This paper considers the problem of shear building damage estimationsubject to earthquake ground excitation using the Kalman filteringapproach. The structural damage is assumed to take the form ofreduced elemental stiffness. Two damage estimation algorithms areproposed: one is the multiple model approach via the optimaltwo-stage Kalman estimator (OTSKE), and the other is the robusttwo-stage Kalman filter (RTSKF), an unbiased minimum-variancefiltering approach to determine the locations and extents of thedamage stiffness. A numerical example of a six-storey shear planeframe structure subject to base excitation is used to illustrate theusefulness of the proposed results. Structural health monitoring (SHM) is a rapidly developing field encompassing technology and algorithms for sensing the state of a structural system, diagnosing the structure's current condition, performing a prognosis of expected future performance, and providing information for decisions about maintenance, safety, and emergency actions , 2. AdvaA building structure may sustain damage during a strong earthquake. Monitoring the structural health of buildings has thus received considerable interest over the last decade. The vibration-based damage detection technique is one of the more promising fields in SHM because it is nondestructive and the vibration signal of a structure is easily measurable using properly deployed sensors , 4. StruAn FRF expresses the structural response to an applied force as a function of frequency. Theoretically, FRFs can be expressed in terms of system properties of mass, stiffness, damping, and modal properties. It is known that damage detection algorithms using FRFs exhibit several advantages, and have been applied to damage detection by many researchers (see  and the Unknown input filtering (UIF) has played a significant role in many applications, for example, bias compensation , 11, manIn this study, based on the equation of motion under ground excitation, a structural damage detection and identification problem is formulated as a standard state-space system with unknown inputs, where the unknown input vector represents the extent of the damage. Treating the unknown input vector as a stochastic process with a given wide-sense representation, and augmenting it with the system state, an augmented state Kalman filter (ASKF) or, equivalently, the optimal two-stage Kalman estimator (OTSKE)  may be uThis paper aims to present some damage estimation methods based on the Kalman filtering approach to determine the location and extent of structural damage under ground excitation. Specifically, the objective of this paper is to design damage detection and identification algorithms for detecting the location and extent of structural damage. In the following section, two damage estimation algorithms are proposed: one is the multiple model approach via the OTSKE, and the other is a specific discrete-time Kalman filtering algorithm, called the robust two-stage Kalman filter (RTSKF) , to deteThe remainder of this paper is organized as follows. n degree of freedom under ground excitation as follows:x ∈ Rn is the displacement response vector and L represents the loading vector, given by L = [1 1 ⋯ 1]T and M, C, and K represent the n × n mass, damping, and stiffness matrices, which are given, respectively, as follows:Consider a one-dimensional shear building with Kd = K + ΔK, where ΔK is obtained from K using the damage substitution ki → kiδki. Define the unknown input vector d asIt is assumed in this paper that the variation of mass and damping matrices are unchanged after the system is damaged. Therefore, the stiffness matrix for the damaged system is represented as s(3)d=δkδk2⋯δknT.T is the sampling period of the sensor. The problem of interest in this paper is then to design an optimal discrete-time unknown input estimator In realizing the well known usefulness of digital technology, the sensor output is obtained by the following discrete-time measurement equation:o system  and measyk=Hdx is therefore unknown, and thus neither matrices Gk or Hk are obtainable. To remedy this problem, the matrices Gk and Hk are implemented alternatively as follows:x(kT), which remains to be determined. Note that wk and vk are viewed as independent processes and measurement white noises with covariances QkX and Rk, respectively.Because the displacement vector follows:G^k=[0−M−k. Using  and 10)x may notdk based on the system T} = Qkdδkl, E{wkdwlT} = 0, and E{wkdvlT} = 0.In this section, we demonstrate the application of the conventional Kalman filtering approach to identify the damage stiffness vector e system . To faciIn this subsection, we show the result of applying the well-known ASKF  to the dUsings , the sysXk∣ka using the ASKF, we obtainSolving  for Xk∣dk and the displacement xk can be estimated, respectively, from the above ASKF asFinally, the damage stiffness vector It is noted that the computational complexity of the ASKF can be reduced using the previously proposed OTSKE . He. He(29)Edk that is unestimable at time k.Next, using the following full-rank factorization: systems  and 30)(32)U^k=UXka and Then, solving  for the dk∣k is given bydk∣k = φkdk∣k   E+ = Ed, using , 46), , a, aH^k=0,us, from , we haveIf the matrix en, from  and 59)H^k is ofloped in . Thus, tloped in , 20.In this section, we demonstrate the application of the previously proposed optimal unknown input estimators to simultaneously detect and identify the damage stiffness of a structurally damaged system.Qkd is unproper, by assuming an improper unknown input model, and thus the damage stiffness may not be correctly identified. Specifically, the estimated damage stiffness of the OTSKE may not work well for the health stiffness; that is, δki = 0, by choosing a large value of Qkd. On the other hand, the damage stiffness may also not be correctly estimated if a small value of Qkd is chosen. To address this problem, a multiple model approach similar to that given in [As will be seen in the numerical example simulation given in given in  may be uQkd, denoted as Qkd = γsIn, in the OTSKE to detect (identify) those places that the stiffness are in health. Let ϵ(γs) be a given dead-zone threshold associated with the small value γs. Then, the ith area with healthy stiffness is declared when the ith output of the unknown input estimator ith output of the unknown input estimator First, we use a small value of Qkd, denoted as Qkd = γlIn, where γl > γs, in the OTSKE to estimate the true damage stiffness, denoted as Second, we use a large value of Dk asDki is given as follows:ith damage stiffness is obtained as follows:Finally, we denote a detection matrix ith component of the signal ith stiffness is healthy, which also signifies that the ith element of the damage stiffness estimate will behave like a zero-mean white noise.First, we address the damage detection issue. Using , 50), , , 56), a, a56), ashown in , under td^k=ψk+Sktion of  the smaller the value of the covariance matrix Qkd chosen is, the more accurately healthy stiffness areas will be detected. With the above observations, if one can correctly identify the places which have damage stiffness, that is, the first three storeys, and identify healthy areas, that is, the 4th to 6th storeys, then one can properly choose Qkd as Qkd = diag{1000I3, 0.001I3}. Qkd, from which we observe that the estimated damage stiffness values of the 4th to 6th storeys are very near their true values, with 0.00, 0.00, and 0.00 reductions of their corresponding true stiffness values. Moreover, the damage stiffness values of the first three storeys are identified with the following respective error percentages: 0.13%, 4.05%, and −15.00%. Nevertheless, it should be stressed that this specific value of Qkd is heuristically chosen and may not work well in practical system design.From the above simulation results, we may draw the following implications: (1) the larger the value of the covariance matrix γs = 0.001, γl = 1000, and ϵ(γs) = 0.03. Qkd = diag{1000I3, 0.001I3}. However, it should be stressed that no information on the damaged storeys is required for the proposed multiple model approach. Note that the feasible value of the dead-zone threshold ϵ(γs) remains to be determined.In order to improve the aforementioned potential shortcoming of the OTSKE, in the following we show an alternative application of the new proposed multiple model approach via the OTSKE in As shown in the previous subsection, the location and the extent of damage stiffness may not be simultaneously identified by a single filter when applying the conventional Kalman filtering approach, for example, the OTSKE. In this subsection, we demonstrate the application of the proposed RTSKF to detect the locations in which the stiffness is healthy and to identify the extent of any damage stiffness.EMB. For the ith damage stiffness, EMBi is given as follows:us is the unit-step function. By choosing ϵ = 1.5, the values of EMB for 1 to 6 storeys are given by 78, 13, 20, 211, 221, and 237, respectively, which gives a more clear indication that the last three storeys have no damage stiffness.First, we show the detection simulation results using the RTSKF. To this end, we illustrate the unknown input estimates, that is, Second, we show the identified extent of the damage stiffness based on the effective mean algorithm . This isIn summary, the above simulation results illustrate the usefulness of the proposed damage detection and identification algorithm through the proposed constrained optimization approach.As shown in the previous two subsections, the Kalman filtering approach serves as a useful means of simultaneously detecting the healthy areas and identifying the extent of any damage stiffness. It should be stressed that, as compared to the substructure-based FRF approach in , this tiIn order to compare the detection performance of the proposed RTSKF with that of the method in , we furtEMB, and the effective means of the damage stiffness estimates given by , to detect areas where the stiffness is healthy and to identify the extent of any damage stiffness. It is shown by a numerical example that the previously proposed OTSKE with a multiple model approach can accurately estimate the damage stiffness and detect healthy stiffness. Moreover, this paper shows that the recently proposed EDKF can also be applied to detecting and identifying structural damage. A special implementation of the EDKF, called the RTSKF, is also proposed in order to reduce computational complexity. Through the RTSKF, the new proposed quantitative measure given by , one can


Croatian Medical Journal are not at all surprising (Nowadays, not only medicine is under the pressure of rapid change and transformation. This is characteristic for every discipline; moreover, the complexity of the changes that are taking place has had the effect on every sphere of life, even the individual sphere. The results are not always positive and the consequences could be harsh and out of control of the affected individuals. The global economy, global warming, global informatization, and other “global” phenomena add to the uncontrollable spin of events generated at the local level. These global-local combinations result in important novel opportunities but also in novel risks for everyone. Although it can seem paradoxical in the time of rapid changes, a possible answer to the increasing challenges could be a retreat toward basic questions. Which basic issues add to the quality of our life? Which basic values are worth preserving? On what foundations can we build the continuous adaptation necessary to cope with the complex changes? I believe that increasing challenges around us should make everybody question the validity of the very basic postulates of our lives. If we adopt this standpoint, the results of the Cover Page study by Radin, Džakula, and Benković in this issue of the rprising . The stuCroatian Medical Journal is also challenged to cope with the time of change, hence it should ask itself what its basic postulates are. Again we believe we should hold on to the basic principles of biomedical research to provide a common ground for the increasing number of topics offered to a general medical journal. Therefore, we will continue assessing the manuscripts not on the basis of whether they are a priority in science, or whether they represent a hot topic everybody would like to publish, but on the basis of their scientific merit, quality of the study design, and well documented results. We strongly believe that only the quality of presented research is the fundamental for the further development of the Croatian Medical Journal, and this is the value with which we face the future of changes. In medicine in particular, the decisions every doctor has to make should be based on the facts, the facts which stem from the research data. Assuring the reliability of these data is the mission of every medical journal.The Croatian Medical Journal has faced another type of change, the change of the Editorial Board and the Editor-in-Chief. Again, the change is a motive for revealing the fundamentals and reaffirming the Croatian Medical Journal’s basic values. These are incorporated in the author-friendly policy of turning valuable research into high-quality manuscripts. Striving for excellence is our constant, which serves to achieve the journal’s progress. If the realization of this approach is successful, the Croatian Medical Journal will prosper. In return, this would grant the people taking care about the journal the deserved satisfaction for their efforts.Behind the curtain of this struggle for scientific quality, with authors and referees acting as the major stakeholders, the


Medical education has a long history in the Netherlands and Flanders. This is not only reflected by the leading role of Dutch and Flemish universities in both undergraduate and postgraduate training, but also by the high number of scientific articles in international journals. A few examples to support these introductory statements.The national Blueprint with objectives of undergraduate medical education was first published in 1994 and contained one of the first descriptions of medical programmes in the world . FurtherWith respect to scientific research in the area of medical education, the Netherlands is among the most active countries. In a bibliometric survey of the number of publications in international peer-reviewed journals in 2010 the Netherlands ranked number 3 after Canada and the UK. Furthermore, the list of most productive authors is led by Dutch colleagues [Finally, there is the very active Netherlands Association of Medical Education  that has become a platform for discussion and for sharing experiences. In 2012 the NVMO will celebrate its 40th anniversary. The association’s 1,200 members represent an important group of clinical and preclinical health care professionals, educationalists, policymakers, students, and other professionals with an interest in health professions education.Perspectives on Medical Education we will be able to offer international authors an additional option for publication. Although we are aware that the number of medical education journals is quite substantial, we believe that this new international journal will have added value, providing Dutch medical education a place in the international arena, and thereby widening the views of both our Dutch and our international readers.With this history in mind, it is obvious that we had a journal for the Dutch-speaking countries, i.e., Tijdschrift voor Medisch Onderwijs . TMO was first published in 1982 and developed into a peer-reviewed journal with six issues published annually. Because the journal was published in Dutch, however, opportunities to reach an internationally oriented audience were inevitably limited. This clearly constituted a barrier to broadening the scope of the journal and diminished its appeal to the increasingly internationally oriented health professions education community. Consequently, after 30 years of having published in Dutch, we have now reached the next step in the development of the journal, i.e., a transformation into an international English-language journal. Moreover, by transforming TMO into PME aims to provide an international platform for innovation and research in health professions education. Submissions that address a wide range of topics—innovation and research in medical education, case studies, practical guidelines, opinion papers—are welcome.Not only the language and the title have changed. Starting in January 2012 the administrative and editorial process of the journal has been taken over by our publisher Bohn Stafleu van Loghum, which is part of Springer Media. Consequently, articles will be published electronically soon after acceptance for publication (free access) and can be found through the PubMed search system. It also means that we have to say goodbye to Geertje Karsten–van der Giessen, who supported the Editorial Board as a secretary of the journal for many years, and Mereke Gorsira, who helped us with the English summaries of the articles of TMO. Both have made an important contribution to the journal, which we highly appreciate.For this first issue of PME the Editorial Board invited international authors who have a link with the Netherlands or Flanders. They either worked or spent a sabbatical in the Netherlands or they have a history of close collaboration with colleagues in the Netherlands or Flanders. All articles of this first issue deal with a specific topic in medical education, some of which by reviewing a general theme, others by referring to a theme of which the development has been promoted by researchers in the Netherlands and Flanders.Perspectives on Medical Education will offer you a handful of interesting topics. Furthermore, we hope that this issue will inspire you to submit manuscripts to PME.We are convinced that this first issue of


The demyelinating disease Multiple Sclerosis (MS) is assumed to be caused by a malfunction of the immune system, maybe due to exposure of genetically susceptible individuals to unknown environmental agent(s) - possibly virus. Our working hypothesis is that these viruses could be endogenous retroviruses, activated by other infectious agents, presumably from the herpes virus group with EBV as the prime candidate. Previously retroviral activity has been monitored by PERT assays. Assays such as flow cytometry enables detection of possible expression of viral epitopes on the surface of PBMCs from MS-patients, and confocal microscopy can show the cellular location of these epitopes.Polyclonal rabbit antibodies against HERV-H/W Env SU- and TM-regions were used in flow cytometry to detect cell-membrane expression of these epitopes on PBMCs from MS patients in different disease states compared with healthy individuals, and patients with other neurological diseases. Monoclonal antibodies against CD-epitopes were used to quantitate the different PBMCs expressing the HERV-epitopes. The rabbit antibodies were also used in labeling of long-term, spontaneously growing, lymphoblastoid cell-cultures from MS patients to localize viral epitopes on the cell surfaces.The flow cytometric analyses detect increased quantities of HERV-H/W Env epitopes on B-cells and monocytes together with increased numbers of B-cells in patients with active MS. Confocal microscopy show expression of viral epitopes on the surface of the lymphoid cell cultures.The findings demonstrate higher expression of HERV-H/W Env epitopes on the surface of some types of PBMCs from patients with active MS.


Previous studies identifying predictors for transmural infarction in patients with ST-elevation myocardial infarction (STEMI) reperfused by primary percutaneous intervention (PCI), especially analyzing the time-dependency of transmural infarction, achieved inconsistent results and are limited due to small and highly-selected study samples. Furthermore it remains unclear whether transmural infarction assessed within the acute phase of STEMI is associated with adverse clinical outcome.STEMI patients reperfused by primary PCI (n=322) within 720 min after symptom-onset underwent contrast-enhanced magnetic resonance imaging (MRI) at a median of 3 days after the index event . Patients were subcategorized into tertiles according to time-to-reperfusion: lower tertile (< 175 min), middle tertile (175-320 min) and upper tertile (> 320 min). Infarct transmurality was assessed by a score with late-enhancement grading as <25%, 25-50%, 51-75% and >75% transmurality analyzing all 17 left ventricular segments. Transmural infarction was assumed if the hyperenhancement extended 75% of wall thickness in at least one segment. Clinical follow-up was performed after a median of 20 months . The primary endpoint was defined as a composite of death and congestive heart failure.Overall, transmural infarction occurred in 50.6% (n=157) of all patients. The infarct transmurality score progressed significantly with increasing ischemic time .Using multivariable logistic regression analysis including parameters such as post-PCI TIMI-flow, ST-segment resolution and maximum creatine kinase levels, time-to-reperfusion was identified as the only independent predictor for transmural infarction .Furthermore, in Cox regression analysis neither the presence of transmural infarction nor the transmurality score were associated with the occurrence of the primary composite endpoint .In STEMI patients reperfused by primary PCI time-to-reperfusion is the only independent predictor for transmural infarction. However, infarct transmurality is not associated with the occurrence of death and congestive heart failure.


Purpose. Aortic stent-graft infection with fistula formation is a rare complication with high mortality rate when treated surgically by stent-graft removal. We report a case of a patient with aortic stent-graft infection, prosthetic-duodenal, and prosthetic-cutaneous fistulas operated without the removal of an infected prosthesis and ineffectively tailored antibiotic therapy. Case Report. A 66-year-old patient with high cardiovascular risk and endovascular stent-graft implantation developed a symptomatic infection of the aortic stent graft 42 months after procedure. It was manifested by iliolumbar muscle abscess and two fistulas: prosthetic cutaneous and prosthetic duodenal. The prosthetic-duodenal fistula was excised and separated from the prosthesis. The perforation within the duodenum was closed in layers. Iliolumbar abscess was removed and drainage was effected .The stent graft was left. The patient received tailored antibiotic therapy. He was readmitted to hospital after 4 weeks with symptoms of infection and leakage of pus discharge in the lumbar area. Despite the antibiotic therapy, the total parenteral nutrition of the patient's clinical status and malnutrition deteriorated and he died of cardiac arrest. Conclusion. The presented case confirms that leaving off of the infected stent graft in the patient with severe comorbidity and treated with a tailored antibiotic therapy may not be effective. The massive gastrointestinal haemorrhage form prosthetic-duodenal fistula is a well-known surgical complication that is rarely observed after endovascular stent-graft implantation . In the We report a case of a patient with two fistulas  diagnosed four years after a stent-graft implantation for having symptomatic abdominal aortic aneurysm and severe comorbidities. The first symptoms of stent-graft infection were lumbar pain and purulent cutaneous fistula. 2). After clopidogrel and salicylic acid premedication , the stent graft—Zenith TRI-FAB— was implanted, without any complication. Within 2 months of procedure, pain complaints related to the aneurysm were subsided. Control Angio-CT performed 6 months after-implantation revealed a complete constriction of the aneurysm sac around the stent graft. The presence of an endoleak was excluded.In 2006, a 66-year-old patient was admitted to our department with symptomatic infrarenal abdominal aortic aneurysm. The patient was qualified for endovascular treatment implantation of stent graft into abdominal aortic aneurysm due to high cardiovascular risk . The preoperative diagnostics was limited to ultrasound examination and selective aortography taking into account the coexisting chronic kidney disease (eGRF MDRD—43 mL/min/1.73 m3). Ultrasound examinations of the abdomen and esophagogastroduodenoscopy revealed no pathology. After the next 4 months, a purulent cutaneous fistula appeared in the lumbar area  the material used , and the patient clinical conditions –8. BergqFew case reports suggest the restriction of the therapy to prolonged tailored-antibiotic therapy , 11, 12.The decision whether to leave the infected stent graft or to remove it surgically should include the comorbidity and anticipated time of patient survival. The majority of patients treated invasively died within a short postoperative period, usually due to cardiac causes, sepsis, or aortic rupture.The presented case confirms that the leaving of the infected stent graft in the patient with severe comorbidity, regardless of tailored antibiotic therapy, may not be an effective therapy.


HIV genomic sequence variability has complicated efforts to generate an effective globally relevant vaccine. Our strategy for HIV-1 vaccine design is to select epitopes that can induce broad and dominant HLA-restricted immune responses targeted to the regions of the viral genome conserved in sequence, three-dimensional configuration, and across time which may represent regions that are constrained due to functional or structural limitations. These “Achilles’ Heel” epitopes would be ideal candidates for inclusion in an epitope-based HIV vaccine.Highly conserved T-cell epitopes were selected using the EpiMatrix suite of immunoinformatic tools. This analysis was first performed in 2002 on 10,803 HIV-1 sequences available at that time and again in 2009 on an expanded 43,822 sequences. Selected epitopes were validated for binding and immunogenicity with PBMCs from HIV-infected donors in Providence, RI and Bamako, Mali.38 highly conserved HLA-A2 candidate epitopes were selected. Analysis done in 2009 revealed surprising stability of 25 of the epitopes selected in 2002 and identified an additional 13 highly conserved HLA-A2 candidates. Thirty-five (92%) of the 38 selected epitopes stimulated IFNg response in PBMC from at least one subject. Twenty-one of 25 peptides selected in 2002 were validated in assays performed in Providence. Eleven (85%) of the 13 peptides selected in 2009 were confirmed in assays performed in Mali. Twelve of 18 peptides assayed in both Providence and Mali were confirmed in both locations.The validation of these selected HLA-A2 epitopes conserved across time (2002-to-2009), geography  and clades supports the hypothesis that these epitopes could provide effective coverage of virus diversity and would be appropriate candidates for inclusion in a globally relevant HIV vaccine.


Patient Safety in Surgery” (PSS) was launched on November 7, 2007, as the first and only open-access, peer-reviewed, PubMed-cited online journal in the field of surgical patient safety [Journal’s mission originated in the summer of 2006 with a group of surgeon colleagues brain-storming about the meaning of the dogma that “good judgment comes from experience which comes from poor judgment”. During our routine weekly morbidity and mortality conferences in Denver and Zurich, we regularly unraveled severe complications generated by younger colleagues on their “learning curve”. Unfortunately, the patient is the one who eventually pays the price for the individual surgeon’s experience. We speculated about new options for sharing root causes of preventable incidents and complications, in order to avoid similar events to re-occur in a different patient in a different hospital. This fruitful debate led to the brainchild of creating a new international “forum” for exchanging case scenarios of specific surgical complications. This forum should be easily accessible, and include discussion of root causes, preventability, and action items needed for resolution and prevention of the future re-occurrence of identical, or similar, adverse events. Our debate also scrutinized the tendency of most standard print journals to publish positive data exclusively, with little room for negative results and reports on surgical failures and poor patient outcomes [http://www.pssjournal.com/about). We further brain-stormed about the most suitable and representative project title for the new journal, and came up with some of the following tentative suggestions:“t safety . Five yeJournal of Poor Judgment in Surgical Decision-Making”● “Journal of Surgical Errors and Preventable Complications”● “Journal of Surgical Complications”● “Journal of Preventable Complications and Patient Safety”● “Patient Safety in Surgery[Ultimately, we decided to omit any negative aspect in the title, related to terms such as “errors” and “complications”, and instead to focus on an exclusively positive message in the final title, n Surgery. With sthttp://www.pssjournal.com), the Journal’s mission is to increase the safety and quality of care for patients undergoing surgical procedures in all fields of surgery. The Journal was designed to complement the more than 200 traditional surgical journals by filling an essential void, through providing a forum for discussion, analysis, and work-up of system and process failures, technical complications, medical errors, and other adverse events in the management of surgical patients in the perioperative setting. This scientific forum was created to lower the threshold for reporting adverse events in all fields of surgery, with the long-term goal of increasing the safety and quality of care for patients undergoing surgical procedures. Ultimately, health care providers from around the world need to be able to safely and openly report anything that does not go well for their patients. As surgeons, we are the only group of people on earth whom other humans give formal consent to render them unconscious and open their bodies with a knife. Thus, we have the highest onus to leave no stone unturned in our quest to do the “right thing” for our patients. We strongly consider public reporting of medical errors and surgical complications an ethical responsibility of our profession. Therefore, we will continue to strive to offer PSS as a vehicle of transparency, trust, and credibility for the public who has a right to know the truth about the quality and safety of surgical care provided around the globe.As outlined on the PSS homepage  has increased from less than 2,000 hits in 2007, to up to 16,000 accesses per month in 2012 .● The top-25 most accessed articles have been viewed through the PSS website more than 500,000 times until present , and is read online in more than 180 countries around the world . This impact factor is calculated by the identical formula as for the Journal Citation Reports (JCR®) and thus reflects a “real” number for the journal’s impact factor, albeit not (yet) officially sanctioned by Thomson Reuters [● PSS has an “unofficial” impact factor of  Reuters .Journal’s webpage more than 16,000 times [Journal continues to publish two editorials per calendar year which address controversial topics in the field . The average time from manuscript submission to a first editorial decision is currently one month (30 days), and the time to a final decision lies around two months from initial submission (40–80 days). The “key” to a successful fast-track management of submitted manuscript lies in the timely appointment of suitable referees, and the reliance on their timely acceptance and commitment to returning their reviews within 14 days. Overall, an average of 88% of all invited referees accept their assignment within less than 5 days from manuscript submission, a statistic which speaks for the quality of the initial reviewer selection by the managing editors  Journal scope / Good prior experience(2) Journal reputation and profile(3) Fast peer review / Speed of publicationOverall, within just 5 years of the initial launch, PSS has been able to solidify its early reputation as an internationally respected journal in the important field of patient safety in the perioperative setting.only a fool will agree to publish a case report on preventable complications which lead to poor patient outcomes”. This notion is based on the rationale that such a document would provide a written testimony (and admission of guilt) which could be used in court against the individual medical practitioner in case of a malpractice claim or lawsuit. The ultimate resolution consisted of introducing a mandatory request for submitting authors to provide a written consent from patients or their legal guardians for any manuscript which provides information on specific identifiable individual patient scenarios .The design and implementation of PSS as a new journal in its field was accompanied by multiple challenges and hurdles. As an anecdotal example, many friends and colleagues  discouraged the founding editors from introducing an article category on “case reports”. The underlying argument was that “Strikingly, we were astonished by the unexpected high submission rate of case reports on surgical complications, preventable sentinel events, and “never events”, starting from the first weeks of the journal’s launch ,7, untilhttp://www.biomedcentral.com/about/apcfaq). A recent commentary published in Science discussed the findings of a large-scale survey on the perceived role of open access online journals among 50,000 researchers [Beyond a doubt, the main barrier which deters authors from submitting their work to PSS  is represented by the extremely high publication fees. For journals published by BMC, these so-called “article processing charges” (APCs) – which have to be carried by the author – range from $1,600 to $1,900 per article  impact factor, which comes at a price of up to $2,000 publication costs, instead of targeting a prestigious high-impact print journal, free of charge? The answer is intuitive.Journal of all times, with more than 23,000 accesses until present [PSS has seen a tremendous start in its first 5 years, and we have successfully resolved some of the initial “childhood diseases” of any new journal. In order to overcome the financial impediment for submission of high-quality articles imposed by the high processing fees, we were recently able to obtain independent grant support for coverage of the APC fees for 30 articles submitted by outside researchers. Pre-submission inquiries for qualification of a waiver for processing fees should be submitted to the editorial board (philip.stahel@dhha.org). Requests will be screened by the managing editors based on objective metrics related to the manuscript’s scientific quality. An anecdotal example of a manuscript which was actively commissioned for PSS, with the authors’ APC fees being waived through extramural grant support, shows that this paper is currently ranked as the #1 most viewed article in the  present . This exUndoubtedly, the open access modality of publishing in PSS provides unprecedented advantages compared to standard print journals. The elimination of financial barriers related to individual or institutional journal subscriptions allows for global and unrestricted free access to all published articles. This proactive modality likely represents the underlying reason for a new journal, such as PSS, being read in more than 180 countries around the world Figure . In addiThe following aspects provide some irrefutable incentives for publishing in PSS:● All articles published in PSS are free to read, copy, distribute, and re-publish in parts or in entirety .● Authors retain the full unrestricted copyright on the entire article. This allows for replicating data and figures in future publications (e.g. review articles or book chapters) without the need for requesting a formal copyright release by the publisher, as long as the original source is adequately cited.● There is no limit to the length of an individual article, including the number of tables and figures.● There are no extra charges for publishing an unrestricted amount of high-quality color figures.● Movie clips can be embedded for instructional purposes at no extra cost, through embedded links in the manuscript (see example: ).● The fast-track publication process allows for short turn-around times of submitted manuscripts and publication within about 2 months of initial submission. All articles are cited in PubMed within less than one week of provisional publication.● All articles published in PSS are archived in public repositories, including PubMed Central, in compliance with the NIH Public Access Policy.American College of Surgeons (ACS) in Chicago, IL. During this meeting, we discussed current challenges and outlined the future vision for the Journal in the next 5 years. One priority is to take PSS from its first unofficial impact factor of 1.19 to an official impact factor in the Journal Citation Reports (JCR®). This goal precludes the prospect of being tracked by Thomson Reuters for an official impact factor. Indeed, selected online open access journals have accomplished the task of “squaring the circle” by achieving high impact factors which are competitive with standard print journals in their respective field. Impressively, one representative open access journal from the “Public Library of Science”, PLoS Biology, has reached an impact factor of 11.45, which ranks the journal #1 in the JCR® category of ‘Biology’ in 2011. Additional examples of selected open access online journals with noteworthy impact factors are listed below (year of launch and current impact factor in parentheses):The first international editorial board meeting for PSS took place on October 3, 2012, at the Clinical Congress of the Journal of Hematology &Oncology ● PLoS ONE ● Molecular Neurodegeneration ● Journal of Neuroinflammation ● Retrovirology ● BMC Biology ● PLoS Biology ● Genome Biology ● Breast Cancer Research ● These selected open access journals serve as pioneer role models with regard to the gradual transition from the “classic” entity of print publication to the future model of open access publishing of high quality science in high impact online journals. Clearly, the impact factor alone does not guarantee the quality of submitted papers, but rather represents a surrogate marker for the scientific renown of a journal in the international community. However, in this day and age of restricted grant funding opportunities, a journal with a (high) impact factor is more likely to be targeted by better quality submissions.International Society for Patient Safety in Surgery”. This new society will further enhance the current global patient safety initiative aimed at increasing transparency about the quality of medical care to the public, who remains the ultimate stakeholder [Another important and challenging goal for the next 5 years includes the plan to inaugurate an “keholder . The oblkeholder .Ultimately, PSS strives to position itself as a landmark journal in the field of patient safety in the perioperative setting, with a global renown for publishing high-quality science in this important field. There is a lot of work ahead of us. We would like to thank our readership, submitting authors, peer reviewers, and our editorial board for their loyalty in the past 5 years, and for their continuing support of the journal’s mission in the future.Journal’s editorial board . They declare no other conflicts of interest.The authors are all members of the PFS, PAC, DH and GN designed this editorial. PFS wrote the first draft of the article. All authors contributed to revisions and approved the final version of the manuscript.


The aforementioned online journal is published by this unique University devoted to Yoga science, combining the best of the East and the West. SVYASA recognized by the Govt. of India, Ministry of Human Resource Development and University Grants Commission in 2002 is part of the nonprofit organization VYASA (Vivekananda Yoga Anusandhana Samsthana) registered as a society in 1986. Over two decades, VYASA has made substantial contributions to yoga research and applications through nearly 70 publications in peer-reviewed journals at national and international levels. With nearly 50 students pursuing their Ph.D. degree and 100 their Master's degree, SVYASA has carried itself as a centre of advanced research in yoga and neurophysiology accredited by the Indian Council of Medical Research (ICMR). Yoga Therapy for Health with a research-based Arogyadhama (wellness home) has treated large numbers of common ailments with fascinating success using yoga therapy as an adjunct to the modern medical system. Thus, it has established the usefulness of the Holistic approach of yoga working at the body, prana, mind, emotional and intellectual levels with a clearly set goal of moving towards perfect health.Modern medical healthcare delivery systems have made tremendous strides in alleviating infectious and contagious diseases as well as the pain, agony and distress of these ailments. However, the exacting scientific rigor of their body-based mechanistic approach has failed to deal with the multidimensional challenge of ailments as asthma, Diabetes Mellitus, coronary artery diseases, cancer etc. Specialization and superspecialization, which became a necessity in this matter-based paradigm led to greater fragmentation but also resulted in ‘no cure’ situations while trying to combat the pandemic of the new era of science and technology. Escalating costs of treatment in modern medicine with no cure and secondary offshoots have made the public move towards alternate complementary and traditional systems of medicine against the advice of modern medical experts. Among CAM and traditional medical systems, applications of yoga have started meeting the needs of evidence-based systems with increasing popularity in India and throughout the world.While yoga is practiced as yogic postures in thousands of centers world wide, therapeutic yoga is hardly used by authentic personnel of healthcare delivery systems. While most CAM have been looking at naturopathy, acupuncture, herbal medicine etc, SVYASA has started this unique research online journal in the field of yoga and its applications under the following five main heads:Yoga—SpiritualityYoga and Life SciencesYoga and Physical SciencesYoga and Management Studies (including education)Yoga and Humanities This journal being edited by an expert team and peer-reviewed by an International Advisory Board containing experts from all fields of yoga applications, would serve as a focal point for contributions from yoga researchers in its widest sense.We invite all levels of yoga personnel to contribute their research findings in this unique online journal so as to not only unearth secrets from ancient texts of yoga but also include modern scientific research articles.


To the Editor: Donor organs for transplantation are in extremely short supply. The increased number of patients with advanced liver disease requiring transplantation has resulted in the expansion of selection criteria for potential donors. Previously unacceptable or marginally acceptable donors, such as those who die from bacterial meningitis, are now donor candidates  and technically difficult, requiring intraoperative blood products (≈25 U), prolonged postoperative mechanical ventilation, blood pressure support, and renal hemofiltration. Pathologic examination of the recipient's explanted liver showed secondary biliary cirrhosis. The recipient was given ceftriaxone before and after transplantation for 7 days. During postoperative week 4, she was also treated for N. meningitidis isolated from the blood and cerebrospinal fluid of the donor was serogroup C by immunoprecipitation, and the lipooligosaccharide (LOS) immunotypes  were L2, L3, L7, and L9.Pathologic examination of the explanted donor liver demonstrated focal acute subcapsular necrosis, large droplet fat accumulation, and mild chronic portal inflammation. The N. meningitidis. Elevated levels of immunoglobulin (Ig) G antibodies    to the g week 4) , panel A week 4) , panel BNeisseria antigens at the time of transplantation. With effective antimicrobial drug treatment, the recipient has little risk for bacteremia after transplantation of organs from donors dying of N. meningitidis infection (N. meningitidis were transplanted with the donor liver. Although we cannot definitively associate these findings with the organ recipient's difficult intra- and postoperative course, this case raises the question of the role of proinflammatory responses to transplanted endotoxin in postoperative condition and graft dysfunction in this critically ill population (The rise in IgM antibodies to LOS L9 and IgG antibodies to group C polysaccharide is consistent with a response to exposure to nfection . Howeverpulation .N. meningitidis infections and may lead to the consideration of additional interventions to mediate the effects of endotoxin exposure.Prospective studies identifying and quantifying endotoxin in the transplanted liver itself and in the recipient may be valuable in assessing the meaning of this finding. An assessment of endotoxin transfer will assist in further defining the risks associated with organ transplantation from donors with


At the time of writing, the New Year has started according to the Gregorian, Julian and Lunar calendars. It is perhaps not too late to wish our readers and contributors a successful new year in 2014.Our journal continues to prosper, thanks to the many people who publish their work in it, those who review manuscripts and those who are involved in the editorial and production processes. Our Thomson Impact Factor is inching its way up, from 1.06 in 2011 to 1.303 in 2012. The impact factor is a measure of something, arguably of quality and importance, but at least it is moving in the right direction.The most significant change in journal policy – I hesitate to call it innovation – was the introduction of a €500 (for Europe) or $660 USD (rest of the world) fee per article accepted for publication, starting in January 2013. Exemption is possible, primarily for manuscripts from developing countries (none of which are in the Arctic), by application to our publisher Co-Action. The assessment of ability to pay is completely separate from the editorial process. The number of submissions has declined from an all-time high of 103 in 2011, to 82 in 2012 and to 56 in 2013. Whether there is a cause-and-effect relationship to the publication fee is difficult to determine, as any epidemiologist can confirm.We have had some interesting statistics to share with our readers. The acceptance rate for articles submitted in 2013 is 57%, virtually unchanged from 2012. These figures, however, are a far cry from percentages in the high 80s in the later years of the previous decade.Since our move from print to an exclusively online journal, beginning in early 2012, the “waiting time” has been much reduced. For articles published in 2013, the average time elapsed from receipt of a manuscript to acceptance is now down to 76 days, compared to over 200 days in the early part of this decade. The average time from receipt to publication in 2013 is 123 days, compared to 382 days in 2011.As expected, almost all our authors are from the circumpolar countries. Based on the nationality of the corresponding author, Canada led the pack with 26%, followed by Denmark/Greenland (21%), Russia (19%), USA and Norway (9% each), Sweden (8%) and Finland (4%). There was one paper each from India and Belgium.Enough statistics. Like books, journals must be “good reads” or we lose our readers to the numerous other diversions that are available. One is now constantly being bombarded by the appearance of new online journals. The editors will not compromise on scientific quality, but we are also looking for reports on studies that are innovative, interesting, relevant and even controversial.And finally, we sincerely thank all the reviewers who took time out of their busy schedules to review manuscripts, without whose dedicated service there would have been no journal.Three cheers to our reviewers:Laura ArbourNick AshboltKenneth AsplundKaren BakkerJames BernerPeter BjerregaardBert BoyerRichard BrownMike BruceLiviana CalzavaraSally CarraherSusan ChatwoodRajiev CherukupalliMary ChipmanMelany CuevaInger Dahl-PetersenShelley DeeksAnne FanningLeanne FindlayJeppe FriborgChris FurgalJoanna GainesTom GleesonNicholas GrayGwen HealeyRobert HegeleBarbara HowardTiina IkäheimoSusan JackCharlotte JeppesenRhonda JohnsonLawrence JosephTommi KarkiJames KellnerJanet KellyMichael KralHarriet KuhnleinJuhani LeppäluotoMonica LindDonna MancaRobert MannLoraine MarrettPaul McDonaldFlorence MyrickSioban NelsonCarmina NgLindasay NicolleNina NielsenGudrun NilsenPeter NilssonLena Maria NilssonJon OdlandPamela OrrLarry PalinkasDavid PhillipsAngela PringlePernille RønnCharlotte ReadingAshley RobertsCelia RoddIwona RudkowskaTorkjel SandangerAmanda SheppardPeter SkoldAudrey SteenbeekVigdis StordahlRosemary WaringSonia WescheLisa WexlerStig Andersen


We describe a successful living donor liver transplantation (LDLT) using a lymphocytotoxic crossmatch highly positive graft. A 41-year-old woman with alcoholic liver cirrhosis was referred as a potential candidate for LDLT, and her husband was willing to donate his partial liver. As the T-lymphocytotoxic crossmatch titer was over 10,000×, the patient was first infused with rituximab for preoperative desensitization, and then five rounds of plasmapheresis were performed. After the third plasmapheresis, the lymphocytotoxic crossmatch test was negative. A left liver graft including the caudate lobe was implanted, and anti-CD25 antibody (basiliximab) was administered on postoperative days 1 and 4. The postoperative course was uneventful except for an episode of mild acute cellular rejection on postoperative day 27. Although the impact of a lymphocytotoxic crossmatch-positive liver graft on acute cellular rejection and graft survival in LDLT remains controversial, perioperative desensitization may provide benefits when using a highly sensitized liver graft. Renal transplantation rates are low among patients highly sensitized to human leukocyte antigen (HLA) because of the high rate of antibody-mediated rejection and subsequent graft loss. It was recently reported, however, that preoperative desensitization using an anti-CD 20 antibody (rituximab) and intravenous immunoglobulin improved transplantation rates in patients highly sensitized to HLA . In contThe recipient was a 41-year-old woman with end-stage liver disease due to alcoholic liver cirrhosis (model for end-stage liver disease score 21). At the age of 20, she was gravida one, para one. She was considered a candidate for liver transplantation because of repeated episodes of encephalopathy. Because of the severe shortage of cadaveric donor grafts in Japan, we planned an LDLT, and her husband was willing to donate his partial liver. The ABO blood type was identical, but the T lymphocytotoxic crossmatch titer was over 10,000× and the B lymphocytotoxic crossmatch titer was 128×  [For preoperative desensitization, the patient was first infused with rituximab 2 weeks before the scheduled surgery . As the antibody to hepatitis B core antigen was positive, entecavir (0.5 mg/day) was administered for 3 weeks preoperatively to prevent a possible hepatitis B virus breakthrough. Five rounds of plasmapheresis were performed. After the third plasmapheresis, the lymphocytotoxic crossmatch test was negative, and was sustained as negative thereafter.A left liver graft including the caudate lobe was implanted. During the LDLT, splenectomy was performed. On postoperative days 1 and 4, 20 mg of anti-CD25 antibody (basiliximab) was administered in addition to the routine methylprednisolone and tacrolimus, as we were anxious about hyperacute rejection. Besides, mycophenolate mofetil  was started on postoperative day 7. The postoperative course was uneventful except for an episode of mild acute cellular rejection (Banff score 3) on postoperative day 27, which responded promptly to steroid recycle therapy. The liver biopsy specimen obtained at the time of the acute rejection showed mild infiltration of lymphocytes in the portal area and around the bile ducts. The clinical course of the recipient is summarized in Fig. The impact of a lymphocytotoxic crossmatch-positive liver graft on acute cellular rejection and graft survival remains controversial, both in deceased donor liver transplantation , 4 and i2 of rituximab 1–3 weeks before the transplant. Following these successful cases, we planned the administration of 375 mg/m2 (500 mg/body) of rituximab 2 weeks before the operation [In this patient, the anti-donor antibodies were assumed to have arisen through pregnancy. Therefore, we applied preoperative desensitization using rituximab and plasmapheresis to reduce the high titer of preformed antibodies and B lymphocytes. As a result, the lymphocytotoxic crossmatch was negative after the 3rd plasmapheresis, and negativity was sustained thereafter. Preoperative desensitization using rituximab was introduced in ABO-incompatible LDLT in 2003 and has dramatically improved the outcomes of ABO-incompatible LDLT. The appropriate dosage of rituximab is still controversial, but many previous studies have reported the administration of 375 mg/mperation , 9. In aIn summary, we report a successful LDLT using a lymphocytotoxic crossmatch highly positive graft. Perioperative desensitization using plasmapheresis and rituximab may provide significant benefits for reducing anti-HLA antibodies.


Cell and Bioscience is on track to receive its first Impact Factor in mid-2013. What is the role of the Impact Factor as a measure of a journal’s success? This methodology is an intriguing endeavor. Time will tell whether it has the same value as, or better value than, some of the stock charting programs used by Wall Street investment advisors to direct investment dollars into various equities.A thought provoking commentary was published recently that proposes the use of several metrics to predict the future H-index of a scientist and accordingly the likelihood of his/her “success”. Using aCell and Bioscience [Cell and Bioscience is the rapid rise of bioscience and biomedical research in Asia[Cell and Bioscience is aptly positioned at the nexus of burgeoning scientific interactions between Asia and the rest of the world.For journal editors, there is unfortunately no innovative proposal to predict a journal’s future success. In 2011, the Society of Chinese Bioscientists in America (SCBA) launched oscience  as the f in Asia. Indeed, in Asia. Cell anCell and Bioscience has been publishing for nearly two calendar years. The journal has been tracked and indexed by PubMed (http://www.Pubmed.gov), Scopus (http://www.scopus.com), and was recently added for tracking by ISI Thomson-Reuters to its Web of Science, science citation index. What this means is that every article in Cell and Bioscience since its launch in January 2011 has now been tracked by Web of Science, science citation index and that the journal will receive its first Journal Citation Report, Impact Factor in mid-2013. The Impact Factor is a measure of the citation frequency of the articles published in a journal and is often used as a proxy to reflect the standing of a journal in its field. There are certain misconceptions about what an Impact Factor number means or does not mean[Cell and Bioscience intend to compete vigorously and successfully in this and other measures of journal excellence.As of this writing, not mean. However


Paediatrics and International Child Health (PCH) is delighted to publish eight papers representing the core of the Proceedings of the Dengue Congress at the 9th International Congress of Tropical Pediatrics in Bangkok in October 2011. These papers have been excellently summarised by Usa Thisyakorn and Krisana Pengsaa in the preface to this supplement.The resurgence and worldwide spread of dengue means that health professionals in temperate climates as well as in tropical regions need to be aware of the condition. In the former, many patients are infected whilst travelling. In sub-Saharan Africa, dengue might be overlooked in institutions overloaded by patients with severe malaria. Medical practitioners in South-east Asia have built a fine reputation in the treatment of dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS), and continue to fine-tune the World Health Organization (WHO)'s dengue case classification and management. In sub-Saharan Africa, DHF might not be recognised amongst other conditions with similar clinical features, and there is a lack of experience of treating it. This is compounded by the need for serial laboratory monitoring, e.g. haematocrit and platelet count, and, in some cases, amino-transaminases. Although there is vast experience of treating diarrhoeal dehydration, it requires less judicious monitoring than when treating DHF/DSS. Conversely, the high prevalence of malnutrition and anaemic heart failure in sub-Saharan Africa means that many paediatricians are more concerned with over-hydration, even in patients with septic shock.international child health part of the title underscores the journal’s interest in the wide spectrum of topics in community child health in developing countries which need to be brought to the attention of readers. Many non-infectious diseases, e.g. obesity, are now international disorders with an alarming increase in prevalence in low-income countries.Over the years, the journal  has taken a keen interest in dengue and, in the near future, will be publishing a number of papers and a commentary on the topic. The first issue of 2012 (volume 32) in February saw the journal relaunched with a new editorial board under the title Paediatrics and International Child Health . The rationale for the change of title has been outlined previously.PCH receives papers from a wide variety of countries and it is expected that the supplement will be read by paediatricians involved in the management of dengue throughout the world. The journal shall continue to take a keen interest in dengue and its development.


Human monoclonal antibodies have been characterized recently that potently neutralize HIV-1 isolates across all clades. These exciting new antibodies (PGT series) were derived from direct functional screening of B cells from IAVI protocol G donors (Theraclone/Monogram) and are unusually potent with binding predicted to be to novel glycan-dependent epitopes on Env.Structures of these new PGT antibodies are being determined by x-ray crystallography and electron microscopy with further characterization using binding and mutagenesis assays.The crystal and EM structures so far have been elucidated for many of these antibodies. Work on the others are in progress, focusing on Fab complexes with glycans, gp120 core and fragment constructs, as well as Env trimers.Structural characterization and biochemical analysis of these antibodies have uncovered novel specificities to new glycan-dependent epitopes and reveal further mechanisms for viral neutralization. These new epitopes provide additional insights for neutralization of HIV-1 and how antibodies can bind and penetrate the glycan shield, a novel framework for structure-assisted vaccine design.This study was supported by the International AIDS Vaccine Initiative (IAVI), Ragon Institute of MGH, MIT and Harvard, and NIH AI84817.


Dear Colleagues,Rambam Maimonides Medical Journal (RMMJ).We are proud and honored to launch the inaugural issue of our new online publication – The Rambam, was one of the greatest arbiters of all times on matters of Jewish law, one of the greatest philosophers of the Middle Ages, a scientist and researcher, a court physician, and a pre-eminent leader in the society of his time. In addition to his monumental work on Jewish law and ethics, his writings on medicine are classic and remarkable even in the present day. Rambam Health Care Campus in Haifa, Israel, which bears with pride the name of Maimonides, the Rambam, and aspires always to act by his guiding principles, is pleased to announce the launching of a new open-access journal, the Rambam Maimonides Medical Journal. This peer-reviewed publication will be sponsored by Rambam Health Care Campus and authored by leading physicians and scientists worldwide.Maimonides, known as the RMMJ will focus on clinically relevant biomedical research and additional issues central to the provision of optimal health care to patients, disease prevention, and public health, and will provide an address for original articles about translational clinical and basic research that moves discoveries from the bench to the bedside and from the bedside to the community. The journal will also publish reviews, “Rambam Grand Rounds”, and symposia reports as well as special essays concerning ethical and societal aspects of medicine.RMMJ will be freely accessible via the Internet for immediate worldwide, open access to the full text of articles. RMMJ applies the Creative Commons Attribution License under which anyone is free to copy, distribute, and display the work (please see full agreement on our homepage). All readers will be able to download and/or print any article at no cost. There will be neither subscription fees nor processing fees for the authors. Authors who publish in the journal will retain the copyright to their article.In the best interests of the medical and scientific community, RMMJ will be guided by the high standards of scientific quality and integrity, professional responsibility, and human compassion that constitute the Rambam’s scholarly and ethical legacy. Furthermore, the scientific standards and impact of open-access journals are no different from traditional subscription-based journals; RMMJ will undergo the same peer-review process and quality control as would any other scholarly journal.The editorial policy of RMMJ will be initially published four times a year with contributions from physicians and scientists worldwide and, fittingly, will be coordinated at Rambam Health Care Campus.Sincerely Yours,Editor-in-ChiefShraga Blazer, M.D. Rambam Maimonides Medical Journal, whose contents in the disciplines of medicine and medical ethics, research, and education aim to follow the legacy left us by Rabbi Moshe ben Maimon (the Rambam). I hope you will agree that this inaugural issue represents a distinguished start for a journal that will feature the cutting-edge ideas of leading thinkers in the above-mentioned disciplines. In an era when medicine and science are advancing together at an accelerated pace, and ethics and science are interacting to create a cultural attitude imbued with insistence on life’s sacredness and dignity, this journal will provide an integrated approach to currently debated health care topics. The format is open access because we at RMMJ strongly believe that presenting its contents to the public with no barriers except for the scientific criteria of excellence and integrity best exemplifies the heritage of Maimonides. We, the editorial team, invite you to be a part of RMMJ by becoming a permanent reader or by contributing articles in your field to future issues.I am honored to be an Associate Editor of the newly launched Associate EditorRafael Beyar, M.D., D.Sc., M.P.H. Rambam – whose scholarly writings encompassed the broad span between general philosophy, Jewish codex of laws, science, and medicine, taught us that while as individuals we may be all different, several principles unite us all. These principles generate a bridge connecting science and technology as a common language that allows us to understand and explore the basic physical, chemical, and biological principles on which our universe is founded on the one hand and the human being with its endlessly complex high functions on the other hand. The walk across the bridge taught us humbleness as we face the complexity of nature, and humaneness and compassion as we treat the suffering man and woman. The RMMJ will walk on the bridge built by the Rambam, unraveling complex biological and pathogenetic mechanisms at the molecular, biochemical, cellular, and model organism level, culminating with the high functions of the human being and their aberrations that cannot be reproduced in faithful models. It will also shed light on aspects of biomedicine unique to Israel, from our unfortunate experience with multiple mass casualties and trauma, through exciting genetic studies exploring the origin and migration of the many ethnic and religious groups that have resided in the region. Last but not least, it will serve also as a bridge to peace, attempting to alleviate political tensions in the region by publishing studies by physicians and researchers from all the neighboring countries, and proceedings and summaries of regional conferences and workshops on subjects unique to this corner of the world.Rabbi Moshe ben Maimon – the Associate EditorAaron Ciechanover, M.D., D.Sc. Rambam, was a multi-faceted individual of numerous accomplishments in varied fields, who also bridged civilizations and religions. He was among the world’s first clinician-scientists, who presciently emphasized the need for evidence in clinical care and decision-making, and realized that scientific knowledge and clinical practice must be promulgated by documentation in order to be open to critical analysis and scrutiny. Accordingly, Maimonides left us with a legacy of scholarly written texts in philosophy, Jewish law, and clinical medicine. We now continue in this tradition, through the auspices of the Rambam Maimonides Medical Journal, an international medical journal based at the hospital bearing the Rambam’s name, and located close to his final resting place. As is evident from the Editor-in-Chief’s statement and the contents of the inaugural issue, the journal will always have at least some content to interest almost every possible reader in biomedical research, clinical medicine, and the allied health professions. We welcome and invite you to share in the Maimonides tradition, by enjoying the high-caliber scholarly research and clinical articles, and also invite you to submit your own scholarly contributions for consideration. This journal will link one of the world’s leading academic medical centers with the international medical community through the shared values enunciated by the Rambam.Maimonides, the Associate EditorKarl L. Skorecki, M.D., F.R.C.P.(C.), F.A.S.N.


External site visits as part of the process of accreditation are an important aspect of quality control of medical education programmes. In 2011/2012 all medical schools  in the Netherlands had such a visit. According to the accreditation system of the Netherlands and Flanders, accreditation has to be renewed every 6 years. The preparation of the site visit starts with the writing of a ‘critical reflection’ describing three aspects of the programme: the intended learning outcomes, the teaching and learning environment and the assessment. Furthermore, the critical reflection should present facts and figures about numbers of staff involved, supportive personnel, study results, etc. Due to changes in the accreditation system, the process of quality control of the programme is no longer part of the critical reflection and site visit. In the new system of accreditation the universities can apply for accreditation of the quality control process of all the programmes they offer [In general, according to the opinion of the visiting committee, the quality of the medical programmes in the Netherlands is good and the graduates of these programmes meet the international standards of quality for medical doctors. However, although Dutch medical schools are very prominent in the area of research in medical education  and are Interestingly, in the process of implementing the CanMEDS model in postgraduate medical specialist training, the same themes have been identified for the education of the ‘intrinsic’ CanMEDS roles . In the Netherlands, current experience with the CanMEDS roles in postgraduate training shows that the role of the medical expert is very prominent in the training programmes. The intrinsic roles, however, do not yet receive sufficient attention in the programmes. Last year, in order to help residents and medical specialist programme directors with the implementation of the intrinsic roles, the CanBetter project was started . Just asPerspectives on Medical Education, the journal of the Netherlands Association of Medical Education. It was the first volume of the journal to be published in English. When we started the preparations for the change from a Dutch into an English journal, the great challenge was to increase the interest of authors and readers. So far, taking the number of submissions into account, the new format is a success. The number of submitted manuscripts has quadrupled and around 25 % of the first authors originate from countries outside the Netherlands and Flanders. At the same time the percentage of rejected manuscripts has increased to 30 %. In summary, after 1 year of experience with PME, it appears that the new format of the journal really appeals to a greater audience and facilitates the improvement in the quality of the journal. The recent inclusion of PME into the PubMed database will definitely contribute to the growth and strength of the journal.The year of 2012 has meant a great change for With respect to the Editorial Board some changes will occur in 2013. According to the journal’s history, at present the members of the Editorial Board originate from the Netherlands and Flanders. However, it is our aim to change the Editorial Board gradually into a more international Board. Furthermore, as you can see in the advertisement in this issue of PME, there will be a vacancy for the position of Editor as—after more than two terms of being the Editor—I will be leaving this position in the course of 2013.


It is expected that in the year 2010, at least 50% of all new approved drugs will come from the biopharmaceutical sector. The discovery and validation process is mostly carried out by new innovative and medium-sized companies. But despite advances in technology and greater understanding of biological systems, drug discovery is still a lengthy process. Specialized drug discovery companies need an ideal business climate, that is, political, economic and social conditions, to be able to cope with the entrepreneurial risks of drug development.Global Pharmaceutical Industry is at the crossroads. On one side, market demand for novel and better medicines is getting redefined and growing due to demographic, economic and epidemiologic trends, but at the same time, pharmaceutical companies are finding it difficult to survive since they are unable to innovate and discover new molecules. The pipeline of the new drug molecules is drying fast due to poor R&D productivity, high failure rate and generic competition.Scientific research proceeds with an infinite variety in the availability of data, the maturity of conceptions and the mix of conviction and uncertainty. Often a major discovery is the culmination of a process with numerous blunders, wrong turns, false hypotheses, missed opportunities, persistent hard work, lucky breaks, rational arguments, insightful conjectures and accumulating knowledge over decades. But none of the failures are being reported or published in the journals and other resources. This part is always ignored because of the publishing style of most of the journals in the pharmaceutical field.Journal of Pharmaceutical Negative Results (JPNR). We are proud to introduce you to a new home for negative results focused on all aspects of Pharmacy. Journal of Pharmaceutical Negative Results concerning failures in techniques and negative or unexpected results in all areas of pharmacy. To achieve this, the Editorial Board of PNR Journal gathers well-known experts from all over the world.[he world. To make Journal of Pharmaceutical Negative Results is published by the open access publisher, Medknow Publications and Media Pvt. Ltd, India.[d, India. When subConsidering all the advantages of this journal, we believe this journal to be of great benefit to the field of pharmacy. We invite you to work together with us to create this new and high-visibility open access forum for the pharmaceutical sciences.


Journal of Medicine and Life is actually upgrading, in order to better support the parameters of evaluation that scaffold the correlation of the local research with the international one, which, in turn, is rapidly developing and improving. Accordingly, the journal itself will better follow the international recommendations as far as the manuscripts evaluations are concerned. This means that a stronger network of external reviewers entered in use, to provide a professional evaluation for each paper submitted and to support the decisions of the editorial team. This, in turn, will improve the quality of the papers published in Journal of Medicine and Life and will raise the prognostic of visibility for each and all the studies published in the journal. The benefit obtained by a modern editorial management is bilateral. On one hand, the journal will benefit from strong papers that will be of great help in raising the indexing level of the journal. On the other hand, stronger journal indexations will be a better offer for those authors in need of good research indicators to support various funding resources or other criteria, professional and administrative. The interdependence loop, journal–to–authors, is complete only if the international criteria for a scientific journal are consistently supported by the authors’ submissions. This is why, we strongly encourage the authors to observe and carefully respect the upgraded Instructions for Authors, which are actually in use. Not complying with this major requirement, means that the submitted manuscripts will be delayed or directly rejected, with or without the chance for a resubmission.Along with the upgrade of the editorial criteria of selection, a better competition between manuscripts will develop, and, only those scientifically strong and technically well prepared will have the chance to be included in the publication. This is not only a competition between the Romanian authors, but also between authors from various international research media, who will increasingly enter the game. Only the best submission will qualify. In accordance with the international trends in research, the journal will pay a special attention to those studies approaching modern topics of large interest, and researches conducted towards various exploratory niches. This will ensure a better entrance on the market of research and funds raising, so, the journal must not be regarded only as an administrative tool which supports promotions.


African and Arab academic and research institutions contribute modestly to the international biomedical literature. Inadequate research funding and limited national, regional and international collaboration are important factors contributing to this deficiency. Furthermore, only few regional journals are covered by major indexing systems such as MEDLINE (Index Medicus), which hampers the international dissemination of research results obtained in African and Arab nations.Libyan Journal of Medicine (LJM) was established in 2006 as an open access journal. Since then, its scientific status has steadily improved. In addition to the less selective databases, it is currently indexed in the most prestigious citations databases: Embase, Scopus, Thomson's Science Citation Index, PubMed Central, and MEDLINE. In a relatively short time, it has gained a promising record of citations compared to its peers (To increase the international visibility of regional research data, ts peers . LJM hasts peers . MoreoveIn 2012, the journal received 250 manuscript submissions, of which only the scientifically most qualified were published: only 15% of the submitted papers were selected for publication. We are thankful to the enormous services provided by our editors, reviewers, and publisher, whose cooperation has enabled LJM to become a well-established and respected channel for publishing research of both regional and international interest from various parts of the world. LJM will continue its policy of publishing only high-quality research that makes significant contributions to the body of knowledge. The editors are keen on attracting even more high-quality papers from regional research groups. To that end, raising the efficiency of the peer review process, expanding the editorial board, and broadening the editors’ collective expertise are essential steps. We have already embarked on that road.Omran BakoushDepartment of Internal MedicineUAE University, UAE & Department of NephrologyLund University, SwedenEmail: omran.bakoush@med.lu.seAmin BredanGhent University, Ghent, BelgiumHani BenamerNeurology Department, New Cross HospitalWolverhampton WV10 OQP, United KingdomMohamed DawUniversity of Tripoli, Tripoli, Libya


Background. Graft pretreatment to limit postoperative damage has the advantage of overcoming a current issue in liver transplantation (LT). The strategic potential of graft pretreatment in vivo by a specific agonist for γ-aminobutyric acid receptor (GABAR) was investigated in the rat LT model with a small-for-size graft (SFSG). Methods. Recipient rats were divided into three groups according to donor treatments and recipient surgeries: (i) saline and laparotomy, (ii) saline and split orthotopic liver transplantation (SOLT) with 40%-SFSG, and (iii) GABAR agonist and SOLT with 40%-SFSG. Survival was evaluated. Blood and liver samples were collected 6 h after surgery. Immunohistological assessment for apoptotic induction and western blotting for 4-hydroxynonenal, ataxia-telangiectasia mutated kinase (ATM), histone H2AX, phosphatidylinositol-3 kinase (PI3K), Akt, and free radical scavenging enzymes were performed. Results. Pretreatment by GABAR showed improvement in survival, histopathological assessment, and biochemical tests. Apoptotic induction and oxidative stress were observed after SOLT with an SFSG, and this damage was limited by GABAR regulation. GABAR regulation appeared to reduce DNA damage via the ATM/H2AX pathway and to promote cell survival via the PI3K/Akt pathway. Conclusions. Pretreatment in vivo by GABAR regulation improves graft damage after SOLT with an SFSG. This strategy may be advantageous in LT. Oxygen is required for cell survival. However, oxygen also poses a potential hazard via reactive oxygen species (ROS) and reactive nitrogen species (RNS), with biological and functional alterations of lipids, proteins, and deoxyribonucleic acid (DNA) –3. Thereγ-aminobutyric acid (GABA), and almost all researchers have focused on GABA or the regulation of GABA receptor (GABAR) in the brain [The predominant inhibitory neurotransmitter in the brain is he brain –8. Currehe brain , 10. In he brain , 7, 8. The brain , 11, 12 he brain , 14 or the brain , 16). Lihe brain . HoweverOrthotopic liver transplantation (OLT) is an accepted therapy for children and adults with end-stage liver disease, and it currently provides long-term survival and quality lifestyle. However, cold ischemia during organ storage and subsequent reperfusion severely damage the transplanted liver . During A small-for-size graft (SFSG) is also an issue in deceased-donor liver transplantation (DDLT) and living-donor liver transplantation (LDLT). An SFSG is defined as a ratio of graft weight against standard liver volume <40% , 21. An ex vivo and in GABAR regulation by a specific antagonist [in vivo by a specific agonist showed a subtle reduction in liver damage in a murine hepatectomy model involving shear stress with portal hypertension [Our laboratory has focused on the effect of GABAR regulation on liver damage by using rodent models –28. We ftagonist , 28. Howrtension  and in artension . Proactiin vivo by a GABAR agonist in the rat SOLT model with a 40%-SFSG, and we examined the possible pathways involved.As a final goal of GABAR regulation in the liver, we investigated the strategic potential of graft pretreatment l) were purchased from Harlan Laboratories, Inc. . Graft donors and recipients were 8–12-week-old rats (approximately 250 g). The experimental protocols were approved by the Ethical Committee of our institution . Rats were cared for in accordance with the institutional guidelines for Animal Welfare based on The National Institutes of Health Guide for the Care and Use of Laboratory Animals.Lewis rats  was used [A dose of 43.56 nmol/g body weight of GABAR agonist /g body weight, 1.0 mL, i.v.) and SOLT with 40%-SFSG.Recipient rats were divided into three groups according to donor treatments and the recipient's surgery as follows: (i) saline  and laparotomy, (ii) saline  and SOLT with 40%-SFSG, and (iii) GABAR agonist . Cell signalings involving cell proliferation, differentiation, and apoptosis were investigated from the early postoperative period [n = 5 in each group).First, a survival study was performed , alanine aminotransferase (ALT), and total bilirubin (T-Bil) levels, and the international normalized ratio of prothrombin time (PT-INR) were measured. Serum AST, ALT, and T-Bil levels were assessed . The PT-INR in plasma was measured by the i-STAT System .μm sections. Morphological characteristics and graft injury scores were assessed after hematoxylin-eosin (HE) staining. The graft damage score (points) has previously been described elsewhere [Liver tissue was fixed in 10% neutral-buffered formalin, embedded in paraffin, and sliced into 4 lsewhere , 34, 35.in situ Apoptosis Detection Kit, S7100, Chemicon International, Inc., Billerica, MA, USA) and cysteine aspartic acid protease (caspase) 3 (cleaved caspase-3 (Asp175) antibody, 9661S, Cell Signaling Technology, Inc., Danvers, MA, USA). TUNEL-positive nuclei were stained brown, and negative nuclei were counterstained light blue. Caspase-3-positive nuclei were stained brown, and negative nuclei were counterstained blue. Slides were scanned with an automated high-throughput scanning system . To quantify the immunohistological findings, positively stained nuclei were counted by Aperio Imagescope software . All nuclei were classified into four color intensity levels, and the higher two levels were considered as positive. The ratio of positively stained nuclei to all nuclei was calculated, and the mean ratio per mm2 was determined.Induction of apoptosis was assessed by immunostaining of terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling (TUNEL)  served as a control. Signals were quantified by using ImageQuant 5.0 software .The primary antibodies for 4-hydroxynonenal (4-HNE) , ataxia-telangiectasia mutated kinase (ATM) , phosphorylated histone H2AX , phosphatidylinositol-3 kinase (PI3K) , Akt , superoxide dismutase (SOD) 1 , SOD 2 , and catalase  were used. Liver samples were collected, homogenized, and centrifuged at high speed for 10 min at 4°C. The supernatant was then collected and used for bicinchoninic acid protein determination  and western blot analysis. Forty micrograms of protein were run on 4–20% Tris-glycine gels and transferred onto 0.45 t-test was used for the comparison of unpaired continuous variables between groups. Survival curves were constructed by the Kaplan-Meier method (log-rank test). Statistical calculations were performed using SPSS Software Version 16.0 . A P value <0.05 was considered statistically significant.The results are presented as mean ± standard deviation. The Student's P < 0.0001), and graft pretreatment by GABAR agonist prolonged survival after SOLT (P = 0.0369).Survival curves in each group are shown in Inflammatory cell infiltration, vacuolization, hepatocyte ballooning, and necrosis were confirmed after SOLT with a 40%-SFSG. Actual histopathological findings in H-E staining are shown in each group in Figures P < 0.0001) and between SOLT with saline and SOLT with GABAR agonist   .P < 0.0001) and between SOLT with saline and SOLT with GABAR agonist   .P < 0.0001) and between SOLT with saline and SOLT with GABAR agonist   .P < 0.0001) and between SOLT with saline and SOLT with GABAR agonist   .P = 0.0001) and between SOLT with saline and SOLT with GABAR agonist   .P < 0.0001) and between SOLT with saline and SOLT with GABAR agonist   .P < 0.0001) and between SOLT with saline and SOLT with GABAR agonist   .P = 0.0068) and between SOLT with saline and SOLT with GABAR agonist   .Actual intensities of ATM and H2AX in each group are shown in P = 0.0131) and between SOLT with saline and SOLT with GABAR agonist   . P = 0.0007) and between SOLT with saline and SOLT with GABAR agonist   .Actual intensities of PI3K and Akt in each group are shown in P = 0.0139) and between SOLT with saline and SOLT with GABAR agonist   . P = 0.0006) and between SOLT with saline and SOLT with GABAR agonist   .Actual intensities of SOD 1, SOD 2, and catalase in each group are shown in P = 0.0445) but not between SOLT with saline and SOLT with GABAR agonist   .P = 0.0361) but not between SOLT with saline and SOLT with GABAR agonist   .P = 0.6904) and between SOLT with saline and SOLT with GABAR agonist   .in vivo [ Based on the current situation in the clinical field, the 40%-SFSG needs to be investigated in detail because successful SOLT overcomes a donor shortage in DDLT, and the shift to a left-lobe graft provides donor safety in LDLT , 24, 30.in vivo , 40. Thein vivo , 40. OurOS mediated by free radicals is defined as an imbalance between the production of ROS/RNS and antioxidant capacity –3. ROS/RFrom the viewpoint of the production of ROS/RNS in the process of OS, Akt also plays a critical role in controlling apoptosis , 46, 47 From the viewpoint of antioxidant defenses, free radical scavenging enzymes, such as SOD and catalase, also play an important role in reducing DNA damage and subsequent apoptosis , 3, 56. in vivo affected graft damage after SOLT. Moreover, immunohistochemistry showed that this pretreatment reduced apoptotic induction after SOLT. In the field of brain research, the effect of GABAR regulation on the prevention of OS has been reported [Our results of the survival study, histopathological assessment, and biochemical assays showed that pretreatment for SFSG by GABAR regulation reported –7. Althoreported , 10. Altreported , the effex vivo  is more suitable for LDLT is unknown. Although our results showed the strategic potential of GABAR regulation in vivo as a pretreatment for liver grafts, we failed to confirm a positive effect of GABAR regulation ex vivo [Any pretreatment in a living donor violates ethical policy and spoils donor regulations. Whether GABAR regulation  ex vivo . Therefoin vivo and in vitro in the process of OS [In previous reports on the brain, many investigators have suggested that GABAR regulation by a specific agonist or antagonist affects the response to reduce OS-induced injury , 7, 8. Tss of OS , 11, 12.ss of OS , 46, 59.ss of OS , 16. Altss of OS , our resss of OS , 16. in vivo works well in the liver, as well as the brain. Even though CIWR injury and shear stress with portal hypertension affect 40%-SFSGs after SOLT and results in fatal OS, graft pretreatment in vivo by GABAR regulation clearly improves graft damage after SOLT. This strategy may be advantageous for overcoming current issues in the DDLT and LDLT fields. The effects of GABAR regulation on graft damage after SOLT with a 40%-SFSG appear to prevent OS by reducing DNA damage via the ATM/H2AX pathway and by promoting cell survival via the PI3K/Akt pathway.In conclusion, regulation of GABAR by a specific agonist


There is an ever-increasing need for organ donations globally. Paediatric kidney transplantation into adult recipients is a well-recognised technique to expand the donor pool. The transplantation can be done either via en bloc kidney transplant (EBKT) or as single kidney transplantation (SKT).2 at four weeks post-transplant.An EKBT from a 18-month-old (15 kg) male patient was transplanted in a 35-year old, 85 kg male with end stage renal failure (ESRF), secondary to Focal Segmental Glomerulosclerosis (FSGS) on haemodialysis. Post-operative recovery was uneventful. Immuno-suppressant drugs used were tacrolimus, basiliximab and prednisolone. Doppler ultrasound scans performed post-operatively showed normal renal resistive indices in both kidneys. Serum creatinine decreased from 1200 to 170 μmol/L 57 with eGFR improving from 4 to 38 mL/min/1.73 mGiven the low incidence of paediatric donors, EBKTs are relatively uncommon and subsequently published series tend to be centre specific with small numbers. The graft survival rates tell us that paediatric kidney donors should not be considered as marginal transplants. The difficulty is in determining when it is more appropriate to perform a paediatric EBKT as opposed to splitting and performing two SKT. Unfortunately there are no widely accepted guidelines to direct clinicians.This case report highlights the first EKBT performed at our institution. The current literature demonstrates that paediatric donors are excellent resources that should be procured whenever available. In 2011, a total of 1099 organs were transplanted from 354 donors, the highest annual amount to date. 606 of these were renal transplants, 129 of which were performed following cardiac death. Despite this, there are still a great number of patients on the waitlist for a renal transplant.Paediatric kidney transplantation into adult recipients is a well-recognised technique to expand the donor pool. There are however, conflicting opinions regarding en bloc kidney transplantation (EBKT) versus single kidney transplantation (SKT).We report our institution's first successful EBKT from a small, paediatric, deceased donor into an adult recipient and summarise the current literature.22) who died of drowning. Only his kidneys were accepted for transplantation for a single recipient. The recipient was a 35-year old, 85 kg male (BSA: 2.05 m2) with end stage renal failure, secondary to Focal Segmental Glomerulosclerosis (FSGS) on haemodialysis. The donor-recipient antigen mismatch was 3/6.The Donor (Maastricht category III) was an 18-month-old, 15 kg male patient . Serum creatinine decreased from 1200 to 170 μmol/L with eGFR improving from 4 to 38 mL/min/1.73 m3The decision of how to best utilise donor paediatric kidneys is difficult. Historically, the main factors that fostered reluctance in using paediatric kidneys included technical difficulties in salvage and transplantation, early graft failure, high rates of graft thrombosis, concern for hyper-filtration injury, frequent rejection episodes, suboptimal nephron mass and a lack of long term graft and survival outcomes.EBKT was originally developed to increase the transplanted nephron mass and to overcome the technical challenges of small calibre vessels in paediatric donors. While it has made the technical aspects of procuring and transplanting small paediatric kidneys easier, challenges are still present and surgical experience and technique has been shown to greatly affect outcomes.Given the low incidence of paediatric donors, EBKTs are relatively uncommon and subsequently published series tend to be centre specific with small numbers. Several authors have reported outcomes using the United Network of Organ Sharing (UNOS) or Scientific Registry of Transplant Recipients (SRTR) registries.P < 0.001).Bhayana et al. used UNOS data (1988–2006) and reported that paediatric EBKT has better longer term graft survival (GS) than paediatric single kidney transplant (SKT) and the best long-term GS over adult standard criteria donor transplant (SCDT) despite higher graft loss during the first 12 months post-transplant.Thomusch et al. recently reported a 20-year graft survival and function analysis from a matched pair study between paediatric EBKT and cadaveric adult donor grafts. With a mean EBKT donor age of 15 months he also reported a higher early graft loss (first post-operative year) but superior long-term outcomes in graft survival and function with EBKT .These graft survival rates tell us that paediatric kidney donors should not be considered as marginal transplants. The difficulty, however, is now in determining when it is more appropriate to perform a paediatric EBKT as opposed to splitting and performing two SKT. Unfortunately there are no widely accepted guidelines to direct clinicians but instead, based on earlier registry analysis <5 years or <20 kg is being crudely used as the cut-off where EBKT is preferential to SKT.More recently, however, Mohanka et al. compared SKT and EBKT from paediatric donors’ ≤15 kg and no significant difference was noted in one-year survival rates between EBKT (79%) and SKT (86%).Similarly, using the SRTR data (1995–2007), Kayler et al. showed that graft survival of ideal standard criteria donors was similar to SKT from donors weighing ≥35 kg and EBKT from donor's ≥10 kg. Between donor weights of 10–34 kg, EBKT had superior outcomes over SCDT. However, the protective benefit was less than half as compared to SKT and so authors concluded that from a resource perspective, splitting these kidneys would increase overall total graft years to the recipient population.Laurence et al. came to a similar conclusion through the creation of a decision analysis model to predict life years gained for patients with ESKD on the transplant waiting list depending on whether they received EBKT or SKT.Graft failure is, however, a major concern for all paediatric donors (EBKT or SKT), with most single centre studies and transplant registries reporting early graft failure at higher rates than those of standard adult donors. After approximately 12 months post-transplant, survival outcomes with EBKT equal that of SCDT, with one study even showing superiority of EBKT over living donor kidneys.The most common causes for early graft failure are vascular complications, with reported rates of vascular thrombosis between 2.5 to 12.5% in small paediatric donors, considerably higher than thrombosis rates for standard adult donors (∼1.8%).Other causes for graft failure include acute or chronic rejection, medication non-compliance, primary non-function, transplant pyelonephritis, graft dislocation and surgical complications.2, P < 0.0001).There have also been concerns about donor recipient weight disparity especially in paediatric to adult transplants. Consequently, kidneys from small paediatric donors have often been primarily transplanted into other children or small adults as a way of matching nephron mass and ensuring functional requirement of recipients are met. The rationale behind this regarded concerns about causing hyperfiltration injury, whereby compensatory changes in the transplant kidney result in hypertension, proteinuria, and glomerulosclerosis and, ultimately, graft failure.Acute rejection is another concern with paediatric kidney donors having high rates of acute rejection compared to standard adult donors.4 Bhayana reported acute rejection rates of 9% in SKT compared to 6% with EBK and similar results have been reported in other series.4In conclusion, the current literature demonstrates that paediatric donors are excellent resources that should be procured whenever available. The decision to perform EBKT or splitting to perform two SKT is difficult. While some centres have reported excellent outcomes with SKT, overall graft survival is inferior to EBKT, especially with lower donor weights with greater technical difficulty. In our institution and throughout Australia, as paediatric donors are uncommon and surgical experiences limited, performing EBKT may be prudent, especially in young paediatric donors.We, the authors declare that there is no conflict of interest.None.Authors confirm that written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.B. Patrice Mwipatayi: study design, data collections, writing and final approval.David Leong Chee Weng: data collection, writing.Pradeep Subramanian: data collection, writing.Alarick Picardo: writing, editing.