The right to prescribe drugs remains a contentious issue within the chiropractic profession. Nevertheless, drug prescription by manual therapy providers is currently an important topic. Notably, physiotherapists in the United Kingdom were recently granted limited independent prescribing rights. Reports suggest that physiotherapists in Australia now want those same rights, and as such a review of chiropractors’ general attitudes toward drug prescription is needed.To examine the literature concerning chiropractors’ attitudes toward drug prescription rights and to compare the opinions of chiropractors currently licensed to prescribe medication with those in the profession who are not.This was a narrative review, consisting of a formal literature search and summary of included articles. Electronic databases searched included the Cumulative Index to Nursing and Allied Health Literature, PubMed, and the Index to Chiropractic Literature. Inclusion criteria consisted of prospective studies published in English in peer-reviewed journals. Studies were required to contain data on chiropractors’ opinions toward medication prescription rights.Of 33 articles identified, a total of seven surveys were included in the review. Of these, there was a general split in opinion among chiropractors regarding the right to prescribe drugs in chiropractic practice. Those supportive of prescribing rights favoured a limited number of over-the-counter and/or prescription-based medications such as analgesics, anti-inflammatories, and muscle relaxants. When questioned on full prescribing rights, however, chiropractors were generally opposed. In jurisdictions where chiropractors are currently licensed to prescribe from a limited formulary, such as in Switzerland, the majority perceived this right as an advantage for the profession. Moreover, continuing education in pharmacology was viewed as a necessary component of this privilege.Based on the literature to date there is a general split in chiropractors’ attitudes toward drug prescription rights. This split is most pronounced in countries where chiropractors are not licensed to prescribe medications. Notwithstanding, this is an important topic in chiropractic currently and warrants both further discussion and research to determine future directions and the implications of either pursuit or denial of prescription rights by chiropractors. Future surveys and/or qualitative studies of other chiropractors’ opinions toward gaining prescription privileges would be timely. Since 1999, the World Federation of Chiropractic (WFC) has maintained the following policy statement on the use of prescription drugs: itioner” –14.“Chiropractic is a drug-free, non-surgical science and, as much, does not include pharmaceuticals or incisive surgery” [In or about 1989, four chiropractic-licensing boards in the United States  were actively lobbying for drug prescription rights . In respsurgery” . Howeversurgery” ,4. As a surgery” –9. Numersurgery” –14 and asurgery” –10 the pCurrently, there are only two jurisdictions in the world where drug prescription has been incorporated into the scope of chiropractic practice. Since 1995 chiropractors in Switzerland have been licensed to prescribe from a limited formulary of over-the-counter (OTC) non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics ,16, whildrugs or medicines are defined as prescription and/or OTC pharmaceuticals, and do not include vitamins, minerals, or other nutritional supplements or homeopathic remedies.The purpose of this review is to examine the literature regarding chiropractors’ attitudes toward the inclusion of drug prescription rights in the chiropractic scope of practice. This review also seeks to compare the opinions of chiropractors currently licensed to prescribe medication with those in the profession who are not. The results of this study are important as they may have implications regarding future research and policy discussion relating to this topic. For the purposes of this review, chiropract*’ was combined using the Boolean operator, ‘AND’ with a variety of medical subject headings (MeSH) and text words relevant to the topic , PubMed, and the Index to Chiropractic Literature (ICL) databases, without time limits to October 19, 2013. The searches were limited to human studies published in English in peer-reviewed journals. In all three databases, the truncated word ‘To select potentially relevant papers, the retrieved citation titles were scanned, followed by a review of their abstracts. Full manuscripts of those that appeared to meet the review criteria were then retrieved for further analysis. The inclusion and exclusion criteria for this review are displayed in Table As this was a narrative review, included articles were not evaluated for their quality. However, data was extracted and presented in tabular form. The categories depicted included study location, survey method, number of respondents and response rate, percentage in favour of prescription rights, and percentage opposed to prescription rights. Data pertaining to chiropractic prescribing rights in Switzerland was presented in a separate table, with the last category consisting of attitudes toward existing prescription rights and its application in practice.As this was a narrative review, the results were not to be synthesized.Thirty-three potential articles were identified through the literature searches and retrieved for full paper review. Twenty-two of these articles were identified from literature searches, eight from reference searching, two from secondary searching of unpublished literature, and one from personal contact with authors known to have expertise in this area.A total of seven articles, all surveys, were deemed includable in the review ,20–25. Ret al. [Based on the literature to date there is a general split in opinion among chiropractors regarding the right to prescribe drugs in chiropractic practice. This split in opinion is most pronounced in countries where chiropractors are not currently licensed to prescribe medications Table . For inset al.  surveyedet al.  and Pollet al.  found thet al. . Therefolicensed to prescribe medications is much different . As such, whether practising in Switzerland or elsewhere, chiropractors with attitudes favourable toward drug prescription surveyed in these regions tend to prefer limited prescribing rights within a musculoskeletal scope of practice.The results of three of the surveys indicate that among chiropractors who are supportive of prescribing rights, a limited number of OTC and/or prescription medications are favoured  and muscle relaxants. In fact, the Swiss Chiropractic Association has recently put forth a proposal to the Swiss government, requesting this expansion; and it has been successful . In New Concerning the issue of full prescribing rights, however, evidence from the reviewed literature suggests that chiropractors are generally opposed ,21,23. IThis review has several limitations. First, the literature search was limited to three databases, included only articles written in English, and excluded non-peer reviewed and/or non-scholarly publications such as those from trade magazines. Therefore, other pertinent articles or commentaries on the topic of drug prescription in chiropractic may have been omitted. Second, all of the seven papers included in this review were surveys. However, this study sought information about chiropractors’ general attitudes and opinions regarding drug prescription in chiropractic, and as such inclusion of this study design was appropriate. Third, several of the surveys reviewed were limited by low response rates ,20–24. MThis review identified seven surveys pertinent to the topic of chiropractors’ attitudes toward drug prescription in chiropractic published in the peer-reviewed literature. Of these, there was a general split in opinion concerning the right to prescribe medications. In jurisdictions where chiropractors are currently licensed to prescribe a limited number of medications, such as in Switzerland, the majority perceived this right as an advantage for the profession. Moreover, continuing education in pharmacology was viewed as a necessary component of this privilege. Future surveys and/or qualitative studies of chiropractors’ attitudes toward gaining similar privileges would be timely.


Ultrasound detection of middle ear effusion (MEE) is an emerging technique in otolaryngology. This study proposed using ultrasound characterization of the mastoid to noninvasively measure MEE-induced mastoid effusion (ME) as a new strategy for determining the presence of MEE. In total, 53 patients were enrolled . A 2.25-MHz delay-line transducer was used to measure backscattered signals from the mastoid. The Nakagami parameter was estimated using the acquired signals to model the echo amplitude distribution for quantifying changes in the acoustic structures of mastoid air cells. The median Nakagami parameter and interquartile range were 0.35 (0.34–0.37) for Group I, 0.39 (0.37–0.41) for Group II, and 0.43 (0.39–0.51) for Group III. The echo amplitude distribution observed for patients with MEE was closer to Rayleigh distribution than that without MEE. Receiver operating characteristic (ROC) curve analysis further revealed that the area under the ROC was 0.88, sensitivity was 72.73%, specificity was 95%, and accuracy was 81.13%. The proposed method has considerable potential for noninvasive and comfortable evaluation of MEE. Otitis media, an inflammatory process of the middle ear, is one of the most common infections1367Ultrasound, defined as sound waves with frequencies higher than 20 kHz, is widely used in various medical applications because of its cost efficiency, nonionizing radiation, simple signal processing, and real-time capability. Several studies have reported the advantages of ultrasound in assessing MEE910111213To resolve the aforementioned limitations, ultrasound tissue characterization of the mastoid, which is located behind the ear, may provide a favorable opportunity to achieve noninvasive and routinely usable ultrasound techniques for clinical MEE detection. The rationale for proposing this idea is as follows. Mastoid cells are air pockets in a honeycomb-shaped bone structure and are connected with the middle-ear cavity; these cells are altered in most ears with MEE151618However, using the intensity analysis of ultrasound echo alone may be insufficient to characterize the mastoid because air cells of various shapes and sizes are randomly distributed in the mastoid. In a relatively complex mastoid structure, the interaction between air cells and the incident wave tends to produce ultrasound scattering; thus, the received ultrasound echoes backscattered from the air cells may be considered random signals. Different scattering structures result in different properties of ultrasound backscattered signals22232423242832In this study, we explored the feasibility of using the Nakagami parameter to characterize the mastoid for detecting MEE. We first established a portable single-crystal ultrasound system equipped with a 2.25-MHz delay-line transducer. We enrolled 53 participants, including normal cases (Group I) and patients with MEE (Groups II and III). MEE in participants in Groups I and II were clinically examined through both otoscopy and tympanometry. Furthermore, MEE in patients in Group III was proven according to effusions observed during grommet surgery. For each participant, ultrasound backscattered signals were acquired from the mastoid for estimating the Nakagami parameter. The results revealed that the Nakagami parameter of the mastoid efficiently discriminated between patients without and with MEE. Finally, this study discussed clinical values of the proposed method for the future diagnosis of MEE.r = 0.66; probability value, p < 0.001). The median Nakagami parameter was 0.35 (IQR: 0.34–0.37) for Group I, 0.39 (IQR: 0.37–0.41) for Group II, and 0.43 (IQR: 0.39–0.51) for Group III. This result indicated that the echo amplitude distribution obtained for patients with MEE was closer to Rayleigh distribution than that obtained for participants without MEE. A significant difference was observed between Groups I/II and I/III (p < 0.05).To confirm the observations, ultrasound envelope signals received between 0.01 and 0.03 ms were used to estimate the Nakagami parameter, as shown in p = 0.08); therefore, we combined the MEE data of Groups II and III for ROC analysis. The AUROC at 95% CI was 0.88 (0.79–0.95), diagnostic sensitivity was 72.73%, specificity was 95%, and accuracy was 81.13%. The performance profile for using the Nakagami parameter in MEE assessment is shown in To preliminarily evaluate the diagnostic value of the proposed method in determining MEE, the receiver operating characteristic curves (ROCs) for diagnosing different groups are shown in Ultrasound characterization of the mastoid to determine the presence of MEE is a novel noninvasive approach. In this study, we validated this idea by using clinical data. The results obtained from the participants with and without MEE revealed that the behavior of ultrasound backscattering from the mastoid depends on MEE. Moreover, MEE-induced ME alters the echo amplitude distribution of the mastoid, thus increasing the corresponding Nakagami parameter. According to our review of relevant literature, this study is the first to validate the correlation between the Nakagami parameter (a quantitative estimate of ultrasound backscattered statistics) of the mastoid and MEE. Importantly, by using the mastoid as an acoustic window for ultrasound measurements, the proposed method provides a noninvasive technique for MEE evaluation.The mastoid composed of air cells is one part of the temporal bone. The propagation of an ultrasound wave is more complex through bones than through soft tissues. Soft tissues behave like fluids with weak variations in their material properties36At present, no relevant study or theories have discussed why effusion affects the echo amplitude distribution of the mastoid. We believe that the effusion changes the acoustic impedance, which affects the acoustic interactions between ultrasound waves and the mastoid structures. Effusion in the mastoid reduces the magnitude of the discontinuities in the acoustic impedance between each air cell. Consequently, the degree of the signal fluctuation decreases, which results in a shift of the echo amplitude distribution toward Rayleigh distribution and an increase in the Nakagami parameter, as supported by the present clinical findings . The Nak38Compared with the results of previous studies101113The study has some limitations. First, the performance of the Nakagami parameter on characterizing different types of mastoids  has not been explored. The proposed method may not efficiently determine MEE when the mastoid structures are not completely developed. Second, the Nakagami parameter estimation depends on the frequencyThis study proposed ultrasound characterization of the mastoid as a noninvasive approach for determining the presence of MEE. The acoustic structure of the mastoid is quantified by the Nakagami parameter to reflect effusion-induced changes in acoustic impedance. The clinical results revealed a higher Nakagami parameter for mastoids of patients with MEE than for participants without MEE; this result represents that echo amplitude distributions obtained for patients with MEE tend to be closer to Rayleigh distribution than those obtained for participants without MEE. The ROC analysis revealed that the diagnostic accuracy of the Nakagami parameter in assessing MEE was 81.13%. Furthermore, compared with the conventional ultrasound technique, in which a probe is inserted into the external ear canal, the proposed method based on the Nakagami approach and a single-crystal ultrasound system ensures patient comfort, this increasing its clinical applicability; hence, it may become a routinely usable noninvasive tool for a comfortable evaluation of MEE.Clinical measurements were performed at Chang Gung Memorial Hospital at Linkou, Taiwan, whose institutional review board approved this study. All the experimental methods were carried out in accordance with the approved guidelines. Informed consent was obtained from all patients and their relatives. In total, 53 patients were enrolled in the Department of Otolaryngology–Head and Neck Surgery between April 2013 and April 2014. According to their clinical diagnoses, the participants were categorized into three groups: normal cases  and patients with MEE . MEE for the participants in Groups I and II was clinically examined through both otoscopy and tympanometry by an experienced otolaryngologist. The patients in Group III were scheduled to undergo grommet surgery, which involves effusion draining through a ventilation tube inserted into the eardrum. MEE in the patients of Group III was proven on the basis of observations of effusions during grommet surgery.A delay-line single-element transducer  with a central frequency of 2.25 MHz and bandwidth of 60% was used. The delay-line transducer is a key component when transmitting ultrasound into the mastoid for receiving the backscattered signals. The transducer was driven by a high-voltage excitation signal generated from a pulser and thus the excitation signal and backscattered echo from the mastoid may overlap during data acquisition, complicating the observation of the behaviors of the backscattered signals from the mastoid air cells. Under this condition, a delay-line transducer is highly suitable for mastoid measurementsm associated with the Nakagami distribution as followsBefore each patient underwent MEE examination, ultrasound measurements were performed by an experienced radiologist. The radiologist was blinded to the examination report of each patient. As shown in R is the envelope of backscattered signals and E (·) denotes the statistical mean. For each patient, the estimated Nakagami value was computed by averaging the results obtained from each measurement.Where r and probability value p were calculated to evaluate the correlation between the Nakagami parameter and MEE. Moreover, independent t tests were performed to compare the difference of the Nakagami parameter between each group; p < 0.05 was considered statistically significant. To preliminarily evaluate the diagnostic value of the Nakagami parameter in determining the presence of MEE, ROC analysis at 95% CI was performed to obtain the AUROC. Sensitivity, specificity, and accuracy were also reported. All statistical analyses were conducted using SigmaPlot software .The Nakagami parameters in the three groups were compared to determine the correlation between the Nakagami parameter and MEE. Data were expressed as median and IQR. The Pearson correlation coefficient How to cite this article: Chen, C.-K. et al. Ultrasound characterization of the mastoid for detecting middle ear effusion: A preliminary clinical validation. Sci. Rep.6, 27777; doi: 10.1038/srep27777 (2016).


Objective: To evaluate effects of G-CSF on a cancelled ART cycle due to thin endometrium. Materials and methods: In a nonrandomized clinical trial from January 2011 to January 2013 in two tertiary university based hospitals fifteen patients undergoing embryo transfer and with the history of cycle cancellation due to thin endometrium were studied. Intrauterine infusion of G-CSF was done on the day of oocyte pick-up or 5 days before embryo transfer. The primary outcome to be measured was an endometrium thickened to at least 6 mm and the secondary outcome was clinical pregnancy rate and consequently take-home baby. All previous cycles were considered as control for each patient.Results: The G-CSF was infused at the day of oocyte retrieval or 5 days before embryo transfer. The endometrial thickness reached from 3.593±0.251 mm to 7.120 ± 0.84 mm. The mean age, gravidity, parity, and FSH were 35.13± 9.531 years, 3, 1 and 32.78 ± 31.10 mIU/ml, respectively. The clinical pregnancy rate was 20%, and there was one missed abortion, a mother death at 34 weeks, and a preterm labor at 30 weeks due to PROM.Conclusion: G-CSF may increase endometrial thickness in the small group of patients who had no choice except cycle cancellation or surrogacy. During implantation, blastocyst attach to endometrium in secretory phase . The relThe level of G-CSF in serum and follicular fluid is a prophesier for the success of human IVF . The norStudies show that pregnancy will not happen if endometrium thickness is less than 6mm , 12.Furthermore, thin endometrium causes higher risk of miscarriage . One obvThis study was approved by the ethical committee of deputy research of Tehran University of Medical Sciences and was registered in  IRCT by number: IRCT201012272576N4 and informed consent had been obtained from all patients.Fifteen infertile women have been included. The inclusion criteria were history of IVF cycle cancellation due to thin endometrium. The age of patients ranged from 22 to 45 years old and their characteristics are summarized in the TM , Filgastrim, Amgen Inc., Thousand Oaks, Canada) Was infused slowly in the uterine cavity and after 5 days endometrial thickness was evaluated again.At first, ovaries were stimulated with a standard protocol  or GnRH Antagonist /GONAL-f). When at least two follicles achieved 18mm diameter, Human chorionic gonadotropin  was administered for ovulation triggering. Transvaginal oocyte retrieval was performed at 36 hrs after injection of hCG. The oocytes were fertilized by intra cytoplasmic sperm injection (ICSI) method. The thickness of endometrium was evaluated on the day of oocyte retrieval and a syringe which containing (300mcg/1ml) G-CSF  at the time of infusion, after intrauterine infusion of G-CSF mean of endometrial thickness was 7.12 ± 0.84 . Two patients had history of tubercoulosis endometritis which had been received standard treatment for tuberculosis and after medical treatment hysteroscopy and adheisolysis was done. They had very resistant thin endometrium (3mm) who had 2 times cycle cancellation. After G-CSF infusion endometrial thickness (ET) was 5mm and they referred for surrogacy.Four other patients had infertility due to uterine factor and adheisionolysis was done with hysteroscopy before ICSI cycles, all these four had increased endometrial thickness after intranuterine infusion of G-CSF, but just one of them got pregnant.We transferred 2-3 good quality embryos for 13 patients except two who had endometrial thickness less than 6 mm, with history of endometrial tuberculosis. The clinical pregnancy rate was 20%.There was significant difference between endometrial thickness at the time of G-CSF infusion versus day of embryo transfer in cycle leading to pregnancy (p = 0.002) and those not resulting in pregnancy (p = 0.04).The second patient got pregnant but at 12 weeks, pregnancy was terminated due to missed abortion.The third patient who got pregnant terminated with cesarean delivery at 30 weeks due to premature rupture of membrane and the neonatal weight was 1800 gr.The Δ difference between endometrial thickness before and after intrauterine infusion of G-CSF was 3.53 ± 0.88. Also the Δ difference between past cycle and GCSF cycle was 1.36 ± 1.1, p value = 0.001.In this study, we found that granulocyte- colony stimulating factor may improve endometrial thickness from 3.3 to 6.1mm. Furthermore, it seems that this effect was associated with a higher potential of pregnancy.Actually, G-CSF may increase the thickness of endometrium in the patient with extremely thin endometrium when other methods to improve endometrial thickness are widely inadequate. Another treatments such as low dose aspirin and vaginal sildenafil increase blood supply of uterine rather than expand the thickness of endometrium , 15. AltIt seems that G-CSF may have a role for increasing thickness in association with esteradiol and sildnafil and it may be a useful option in thin endometrium refractory to the other treatments.However others report that in 3 cases G-CSF couldn’t improve thin endometrium to a more fertile level and all failed to conceive in G-CSF cycle but one of them conceived on another cycle without G-CSF and surprisingly with endometrial thickness 4mm , the samIn two another study there was remarkable results , 24 ,in In the second study by Gleicher in 21 patients with thin endometrium the ongoing clinical pregnancy rate was 19.1%, like the present study, but our study reports the results at the end of study . The limitation of current study is the small sample size, and nonrandomized method, due to limited number of patients. We suggest a randomized clinical trial with greater sample size for evaluating the effect of G-CSF on thin endometrium.Infusion of G-CSF in endometrial cavity is a safe and probably effective method to increasing endometrial thickness for patients with thin and unresponsive endometrium.


Severe aplastic anemia (SAA) is a rare disorder leading to bone marrow failure, which if left untreated, is invariably fatal. Conventional therapies with immunosuppressive therapy or allogeneic hematopoietic stem cell transplantation (HSCT) are highly effective. HSCT can offer a greater outcome in younger patients who have an available HLA match-related donor. Recent studies showing the addition of antithymocyte globulin (ATG) to the conditioning regimen improves engraftment and reduces the risk of graft-versus-host disease (GVHD).There are currently two ATG preparations in the USA, equine (or horse) and rabbit ATG. These agents are pharmacologically distinct, having significant differences in their pharmacokinetics and in vivo immunosuppressive effects . Here, we report a case of two monozygotic twins with constitutional SAA that evolved to myelodysplastic syndrome (MDS) who both underwent allogeneic peripheral blood stem cell transplantation (PBSC) from the same single HLA antigen mismatched sibling donor with the only difference in the transplant regimen being the type of ATG used in the preparative regimen; one twin received horse ATG and the other received rabbit ATG during conditioning. This report emphasizes that dramatic differences in donor T cell chimerism and clinical outcomes including GVHD can occur as a consequence of the type of ATG that is utilized in the transplant conditioning regimen. These differences highlight that these agents should not be considered interchangeable drugs when used in this setting. Severe aplastic anemia (SAA) is a rare disorder leading to bone marrow failure which, if left untreated, is invariably fatal. Annually, 300 to 600 new cases of SAA are diagnosed in the United States of America . ConventTwin #1 and twin #2 are two Vietnamese female monozygotic twins who were born prematurely at 8 months of gestation with a birth weight of approximately 1.8 kg each. They were both diagnosed with SAA at 2 years of age when they presented with symptoms related to pancytopenia. Their initial treatment in Vietnam consisted of corticosteroids and RBC and platelet transfusion support. In October 2001, at the age 8, both twins were referred to the NHLBI in the United States of America, for further evaluation and management.2 × 5 days, cyclophosphamide 60 mg/kg × 2 days, and rabbit ATG 3.5 mg/kg/day × 4 days. CSA and MTX were used as GVHD prophylaxis. She had neutrophil recovery on day +15 and platelet recovery on day +9. Her post-transplant course was complicated by CMV reactivation which responded to antiviral therapy and bacterial sepsis which resolved with IV antibiotics. Lineage-specific chimerism studies conducted on multiple occasions from the time of engraftment until day +100 revealed extremely low levels of donor T cell engraftment. After day 100, she was observed to have a rapid decline in her absolute reticulocyte count, which in the context of very low levels of donor T cell chimerism, led to concerns of impending graft rejection. Therefore, on transplant day +113, she received an intravenous infusion of G-CSF-mobilized PBSCs from her original stem cell donor containing 2 × 106 CD34+ cells/kg and 1.4 × 108 CD3+/kg cells. She eventually converted 100 % donor T cell and myeloid chimerism by transplant day +352 . A bone marrow biopsy in October 2001 showed 5–50 % cellularity without evidence of dysplasia or blasts but with trisomy 8 being present in 35 % of metaphases consistent SAA evolution to MDS. Testing for Fanconi’s anemia and paroxysmal nocturnal hemoglobinuria (PNH) were negative. Peripheral blood counts demonstrated an absolute neutrophil count (ANC) of 417 cells/μl, a platelet count of 16 k/μl, hemoglobin of 10 g/dl, and an absolute reticulocyte count of 61 k/μl. She failed a trial of danazol therapy and in April 2002, commenced treatment with horse ATG 40 mg/kg/day for 4 days combined with CSA. Her post-immunosuppression course was complicated by multiple episodes of infection including non-specific ileitis, colitis, bronchitis, pharyngitis, pneumonia, and an ulcerative labial infection. There was no response at 6 months to horse ATG and she remained transfusion dependent. In November 2002 at age 9, she underwent an allogeneic PBSC transplant from her 9/10 HLA match-related brother  after conditioning with fludarabine 25 mg/m352 Fig. . She nevTwin #2 was the second twin diagnosed with aplastic anemia. On presentation to the NHLBI in 2002, she had an ANC of 2100 cells/μl, a platelet count of 45 k/μl, a hemoglobin of 13.7 g/dl, and an absolute reticulocyte count of 80.7 k/μl. Her bone marrow biopsy demonstrated hypocellular marrow with less than 5 % cellularity with a marked decrease in megakaryocytes. At that time, chromosome analysis by metaphase banding of the peripheral blood and skin fibroblasts revealed no evidence of trisomy 8 or any other chromosome abnormality. Testing for Fanconi’s anemia and PNH was negative. Similar to her sister, she failed a 3-month trial of danazol treatment. Two years later, in January 2003, she had a decline in her blood counts: her ANC declined to 996/μl, platelets to 15 k/μl, and hemoglobin to 9.4 g/dl, with an absolute reticulocyte count of 74.2 k/μl. A repeat bone marrow biopsy performed in 2004 revealed 5–15 % cellularity with trisomy 8 now being detectable in 13 % of metaphases consistent with evolution to MDS. In April 2004 at the age 11, she underwent an allogeneic PBSC transplant from her 9/10 HLA match-related brother who had donated PBSCs for her syngeneic twin who had been transplanted 1.5 years earlier . Of note, both twins received similar transplanted allograft doses of CD34+ cells/kg and T cells/kg Table . Her posBoth immunosuppressive therapy and allogeneic hematopoietic stem cell transplantation represent effective therapy for patients with SAA , 12, 13.Here, we report data where syngeneic twins with MDS who underwent allogeneic transplantation from the same donor had dramatically different donor T cell engraftment profiles and transplant outcome as a consequence of using rabbit versus horse ATG in the preparative regimen Fig. . Twin #1Outside of the setting of a transplant, initial treatment of SAA with horse ATG has shown to result in higher responses rates than rabbit ATG . HoweverIn this paired case report, we demonstrate the unique experience of two monozygotic patients with bone marrow failure and MDS who received an allogeneic HPSC transplant from the same donor, with the only difference in the transplant regimen being the formulation of ATG used in the preparative regimen. Remarkably, their T cell engraftment profiles and clinical outcomes including acute and chronic GVHD differed dramatically as a consequence of this difference.Rabbit ATG resulted in superior GVHD prophylaxis in twin #1, which came at the cost of impeding donor T cell engraftment placing the patient at risk for graft rejection. This case highlights that rabbit ATG and horse ATG should not be considered interchangeable drugs, with the need to consider these effects before choosing the type of ATG to be used in the preparative regimen. In the risk where graft rejection is low, one might consider that rabbit ATG might be better suited to be utilized as part of conditioning regimen, with salvage donor lymphocyte infusions being incorporated into transplant regimens to prevent graft rejection in patients with falling or low degrees of donor T cell chimerism. In situations where the risk of graft rejection or failure is high, given its much shorter half-life, the use of horse ATG may have a role in helping to eradicate recipient immunity without leading to significant in vivo depletion of donor T cells. In contrast, in scenarios where the risk of GVHD may be high , the use of rabbit ATG in the preparative regimen may be more appropriate and gives its greater ability to lead to in vivo donor T cell depletion which reduces the risk of GVHD.Informed consent to publish the information was granted from the patients or their guardians.


Treatment against shunt infection by transvenous antimicrobial treatment is difficult, with a high risk of relapse. Consequently, to maintain a sufficient cerebrospinal fluid (CSF) concentration, intraventricular administration is utilized in combination with the transvenous administration of vancomycin (VCM). Few studies have so far investigated the optimum administration dose for newborns and the concentration in the CSF. Therefore, we chronologically measured the VCM concentration in the CSF after VCM intraventricular administration in newborns and attempted to elucidate the optimum administration method.The participants consisted of newborns admitted to Juntendo University Neonatal intensive care unit from March 2007 to June 2011 who underwent interventricular shunting placement. VCM was intraventricularly administered to 10 patients for a total of 13 cases. The CSF concentration of VCM was chronologically measured at 12 to 120 hours following the intraventricular administration of VCM.The intraventricular administration groups with VCM of 20 (n = 6) and 10 mg (n = 2) had a high concentration in the CSF at 24 hours following administration (95–168 mg/L), with the concentration remaining high at 72 hours (13.2–72 mg/L). At the same time, in the 5 mg group (n = 5), the concentration in the CSF 24 hours following VCM administration was sufficiently maintained (33.2–62.9 mg/L), with a sufficient trough concentration still maintained at 72 hours (11.7–16.5 mg/L).The concentration in the CSF is prolonged in newborns, thus allowing a sufficient therapeutic range to be maintained even at an intraventricular administration of 5 mg. It is therefore believed that the monitoring of the CSF is very important regarding the administration interval because the VCM concentration in the CSF differs depending on the case. Shunt infection due to device insertion is 1 major complication following surgery, with hydrocephalus related to shunt infection becoming a major risk factor in the subsequent developmental prognosis. Even when sufficient measures against infections and careful shunt insertion are carried out, the incidence of shunt infection is still high, namely, ranging from 8% to 12%.4In fact, intravenous antimicrobial administration before and following surgery is normally performed with the objective of preventing the occurrence of shunt infection; however, the effect of such treatments remains limited.5 However, the relapse rate following treatment is high, ranging from 22% to 24%.7 Therefore, a variety of investigations have been carried out to suppress relapse. Some studies mention that the relapse rate declines upon secondary treatment involving the reinsertion of the shunt after confirming the negative conversion of bacteria by external ventricular drainage, rather than temporarily replacing the infected shunt.9Early diagnosis, appropriate antimicrobial treatment, and removal of the infected device improve the prognosis of shunt infection.10In many cases, the cause of relapse is incomplete treatment resulting from the suppression of the transfer of drugs to the cerebrospinal fluid (CSF) due to the blood-brain barrier. Moreover, biofilm formation in the shunt may also be another possible cause. In fact, the transfer rate to the CSF by transvenous antimicrobial administration has been reported to range from 20% to 30% in the acute phase, even regarding vancomycin (VCM). However, when inflammation improves as a result of treatment, transition to the cardiac ventricle further declines, thus rendering sufficient maintenance of the drug concentration in the CSF difficult despite transvenous antimicrobial administration according to the degree of meningitis treatment.14Moreover, another method that is sometimes performed involves eliminating bacteria by directly administering VCM into the cerebral ventricle, and thereby maintaining the level of drug concentration in the cerebral ventricle.15 In children, a high VCM concentration in the CSF level tends to be prolonged. As a result, the administration of 5 mg has been reported to be sufficient for intraventricular VCM administration, taking into account the amount of CSF disposal.15 Regarding the optimal dosage, they also mentioned that monitoring the intraventricular VCM concentration is useful because the VCM concentration in the CSF varies depending on the case. However, few investigations into such administration in children exist, with the data further limited regarding newborns.15The literature investigating the drug concentration in the CSF upon intraventricular administration of VCM is limited. In adults, the intraventricular administration of 20 mg is typical. Although administering from 10 to 20 mg at 24-hour intervals is suggested regarding infants, in recent years, some studies mention that a dose of 5 mg at 24-hour intervals is sufficient.Our objective in this study was, therefore, to determine the appropriate intraventricular administration dose along with the interval of VCM for intraventricular VCM administration for shunt infections in newborns.A retrospective investigation was carried out based on the medical records of 10 patients and 13 cases that underwent ventricular shunt placement  at the Department of Neurosurgery upon admission to neonatal intensive care unit of Juntendo Hospital in the 5 years from March 2007 to June 2011.The inclusion criteria were patients undergoing the intraventricular administration of VCM following surgery, in which the measurement of the CSF concentration of VCM was possible. The intraventricular administration dose of VCM was determined by the attending physician. The CSF was sampled from 12 to 120 hours following the last intraventricular VCM administration when absorbing CSF with the objective of alleviating intracranial pressure. The final 2 mL of extracted CSF was used to measure the VCM concentration in the CSF. The CSF was immediately centrifuged for 5 minutes at 3000 revolutions to eliminate the precipitate, then measured by latex agglutination inhibition. Furthermore, regarding the intraventricular administration of VCM, 1 g of VCM was dissolved in 200 mL saline and the required amount was then administered.Ethical approval was not necessary and the requirement of written informed consent was waived because of the retrospective nature of the study.The patient characteristics are shown in Table The patient treatments and prognosis are shown in Table The intraventricular administration of 20 mg was carried out in 6 cases Nos. 1–6) (Table –6 (TableThe intraventricular administration of 10 mg was carried out in 2 cases (Nos. 7 and 8) (Table The intraventricular administration of 5 mg was carried out in 5 cases Nos. 9–13)  mg/L.14Regarding the average VCM concentration in the CSF in adults, some studies mention that the trough level of CSF was 16.5 (10.0–25.4) mg/L16). From the fact that the result of VCM concentration CSF varies depending on the case, the possibility of the concentration significantly declining depending on the patient's condition cannot be ruled out. Therefore, the 5 mg dose is considered to be sufficient regarding VCM administration in newborns, and it is believed that chronologically monitoring the concentration in the CSF is required to determine the optimal administration interval. Therefore, the usefulness of monitoring has been reported in previous studies in the pertinent literature.18Furthermore, regarding the interval of intraventricular VCM administration, administration in 12- to 24-hour intervals is the typical current regimen. The VCM CSF concentration varies greatly depending on the administration dose; however, in this investigation, it was possible to maintain a trough of ≥10 mg/L at 72 hours following administration, even at a dose of 5 mg. Conversely, regarding the conventional administration interval, the possibility of the concentration in the CSF further increasing is of concern due to additional administration being carried out at high concentrations. However, it has been reported that the CSF concentration declines when there is an excessive amount of discarded CSF There are some limitations associated with this study. First of all, the described tendencies could not be investigated by a statistical analysis because the number of cases was small. However, since such cases are rare and this study includes a large number of cases in comparison with previous studies, including low weight infants, these findings are thus considered to be valuable. The background factors varied, thus potentially affecting the results; however, due to the fact that the concentration in the CSF 24 hours following administration was maintained even with respect to cases with excessive CSF disposal, it was believed that a sufficient therapeutic effect may be maintained even when the conventional 20 mg administration is reduced to 5 mg.From the above, it is believed that regarding the intraventricular administration of VCM in newborns, commencing with an administration dose of 5 mg and then determining the optimal interval by monitoring the CSF every 12 to 24 hours will lead to a good therapeutic effect as a result of maintaining an appropriate concentration and reducing the risk of adverse effects due to an excessive CSF concentration. Furthermore, the data for low birth weight infants, such as premature infants, etc., were also limited in this study, and it is believed that the further accumulation of cases is thus required in the future.An investigation was carried out to elucidate the optimal method for performing intraventricular VCM administration in newborns. Sufficient concentrations in the CSF were maintained at an intraventricular administration dose of 5 mg VCM, and the appropriate administration interval may be determined by monitoring the CSF concentration.


Evidence of inflammation has been consistently associated with pathology in Parkinson's disease (PD)-affected brains, and has been suggested as a causative factor. Dopaminergic neurons in the substantia nigra (SN) pars compacta, whose loss results in the clinical symptoms associated with PD, are particularly susceptible to inflammatory damage and oxidative stress. Inflammation in the striatum, where SN dopaminergic neurons project, is also a feature of PD brains. It is not known whether inflammatory changes occur first in striatum or SN. Many animal models of PD have implicated certain inflammatory molecules with dopaminergic cell neuronal loss; however, there have been few studies to validate these findings by measuring the levels of these and other inflammatory factors in human PD brain samples. This study also included samples from incidental Lewy body disease (ILBD) cases, since ILBD is considered a non-symptomatic precursor to PD, with subjects having significant loss of tyrosine hydroxylase-producing neurons. We hypothesized that there may be a progressive change in key inflammatory factors in ILBD samples intermediate between neurologically normal and PD. To address this, we used a quantitative antibody-array platform (Raybiotech-Quantibody arrays) to measure the levels of 160 different inflammation-associated cytokines, chemokines, growth factors, and related molecules in extracts of SN and striatum from clinically and neuropathologically characterized PD, ILBD, and normal control cases. Patterns of changes in inflammation and related molecules were distinctly different between SN and striatum. Our results showed significantly different levels of interleukin (IL)-5, IL-15, monokine induced by gamma interferon, and IL-6 soluble receptor in SN between disease groups. A different panel of 13 proteins with significant changes in striatum, with IL-15 as the common feature, was identified. Although the ability to detect some proteins was limited by sensitivity, patterns of expression indicated involvement of certain T-cell cytokines, vascular changes, and loss of certain growth factors, with disease progression. The results demonstrate the feasibility of profiling inflammatory molecules using diseased human brain samples, and have provided additional targets to validate in relation to PD pathology. Parkinson's disease (PD) is a chronic, progressive neurodegenerative disorder characterized by symptoms of tremor, bradykinesia, ataxia and rigidity, and is the main cause of movement disorders in the elderly. The current estimates of PD are one million cases in the U.S.A. with 60,000 cases being added each year   under contract as the Institutional Review Board of Banner Research. A summary of the demographics of the cases is shown in Table Due to the limited amount of SN tissue available from each case, SN tissue was provided as 15 consecutive frozen (10 μm) SN sections (~6–10 mg) cut from each block with a cryostat and collected frozen. This approach to tissue sample preparation allowed the selection of matched samples containing approximately equivalent densities of SN pars compacta neuromelanin-containing neurons. Frozen striatum samples (20–30 mg) were dissected from putamen at the level of the lenticular nucleus.Both series of tissue samples were extracted in six volumes (w/v) of a proprietary extraction buffer compatible with the Quantibody arrays  supplemented with protease/phosphatase inhibitors (Thermo-Fisher/Pierce). Samples were briefly sonicated in extraction buffer and incubated on ice with constant shaking for 30 min. After centrifugation , the supernatants were collected for further analysis. Protein concentrations were determined using a micro BCA assay (Thermo-Fisher/Pierce). These same extracts were also used to prepare western blot samples.Preliminary analyses of protein extracts were carried out using western blot methods for tyrosine hydroxylase (TH), as a measure of degree of dopaminergic neuron cell loss; for IBA-1, an indicator of microglia abundance; for TLR-2 as a marker for inflammation; and for glial fibrillary acidic protein (GFAP), as an indicator of reactive astrocytosis. We employed our standard published western blot methods using antibodies to TH ; to IBA-1 ; to TLR-2 ; and to GFAP , Walker et al., For the antibody array analysis, samples were processed as a service by Raybiotech . For SN, each sample protein concentration was adjusted to 500 μg/ml, and for striatum, each sample was adjusted to 1000 μg/ml. These were analyzed using 160 protein Quantibody arrays  composed of antibody-coated glass slide arrays for detecting cytokines, chemokines, soluble receptor, and growth factors. Table To characterize features of microglia activation in tissues being examined by antibody array analysis, 40μm paraformaldehyde-fixed tissue sections of SN and striatum from control, ILBD and PD cases were stained using antibodies LN3  and IBA-1 . These are well-established markers for activated microglia (LN3) or pan microglia (IBA-1). Striatum sections were double-stained for TH  using a two-color method. Immunohistochemstry was carried out according to our published procedures  using Graphpad Prism 5 software  without corrections for multiple comparisons. To determine whether age of patient or postmortem interval (PMI) were covariants for each measure, data from each protein was also analyzed by Analysis of Covariance (ANCOVA) with age, PMI, or age and PMI as covariants using Medcalc statistical software . Further analyses included correlation analyses, stepwise logistic regression analyses and receiver operating characteristic (ROC) curve analyses and were carried out using MedCalc. For each measure, P = 0.03). There was significant negative correlation between TH and GFAP levels in striatum . In addition, when platelet derived growth factor (PDGF)-BB levels were corrected for age (P = 0.031—ANCOVA), a significant disease group difference was obtained (P = 0.0323 between ILBD and PD samples).There were four proteins  that gave P = 0.003) with ROC curve analysis for IL-5 with sensitivity of 85.7% and specificity of 62.5% with area under curve (AUC) of 0.81. Further stepwise logistic regression analysis between ILBD and PD values showed a combination of IL-15 and IL-6sR levels gave predictive value (P = 0.0016), with ROC AUC of 0.820, and sensitivity of 85.7% and specificity of 64.7%. These stepwise regression analysis models were not strengthened by inclusion of TH values. Results are summarized in Table Stepwise logistic regression analysis of these four cytokines was carried out to determine if these measures had predictive value between disease groups. Comparing control to PD indicated that only IL-5 values had significant predictive value (P < 0.05). With these corrections, no additional proteins reached statistical significance.A panel of 13 proteins was shown to have significant differences in striatum samples between the disease groups by One-way ANOVA (Table P = 0.0001). Analysis by ROC with all three factors showed sensitivity of 86.67% and specificity of 87.5%, and an AUC of 0.917. As expected, TH values alone had significant predictive value for discriminating control from PD cases (P = 0.0001) with ROC analysis showing sensitivity of 80%, specificity of 85.71%, and AUC 0.914. Including TH values with the 13 proteins in step-wise regression analysis produced a different outcome; CCL28 in combination with TH had significant predictive value (P < 0.0001), with sensitivity of 80%, specificity of 78.7%, and AUC of 0.938. Repeating the logistic regression analysis to determine if any of these measures gave predictive value between ILBD and PD cases identified PDGF-AA, with ROC analysis showing sensitivity of 72.2% and specificity of 62.5% and AUC of 0.722 (P = 0.015). Combining TH values with the 13 proteins showed IL-15 and TH values could discriminate between ILBD and PD (P = 0.0003), with sensitivity of 82.35 % and specificity of 85.71%, and AUC of 0.899. PDGF-AA levels alone gave discrimination between control and ILBD samples (P = 0.0014) with ROC analysis showing sensitivity of 66.67%, specificity of 77.78%, and AUC of 0.811. TH values alone discriminated between control and ILBD samples . Summary of these findings are shown in Table Stepwise logistic regression analysis of these measures identified a combination of the values for ErbB3, IL-2, and PF4 as having predictive value between control and PD cases , but not between TH and GFAP levels for the ILBD or PD groups. There were no correlations between TH levels in SN and levels of IBA-1 or TLR-2 (data not shown).Multiple correlation analyses were carried out for all of the SN measures against TH levels. The significant correlations are shown in Table To follow up on the findings from a recent paper that examined tissue sections of SN from control, ILBD and PD cases and showed early increased expression of TLR-2 . For striatum, the sections were double-stained with antibody to TH (brown) to reveal the location of positive fibers. In control striatum, there were TH positive fibers throughout the structure, while in the PD cases, most of the TH fibers were lost. In Figures We stained tissue sections of SN and striatum from representative control, ILBD and PD cases to characterize activated microglia present in the disease groups. Staining was carried out using antibody LN3, which recognizes the MHCII protein HLA-DR, and antibody IBA-1, which recognizes all microglia. Results show increased immunoreactivity for HLA-DR in microglia associated with neuromelanin-containing neurons in the SN pars compacta, even in control cases Figures , with prOne limitation of human disease-focused studies can be the presence of mixed pathologies within the same tissue samples. For this study, the possible effects of age-associated AD-type pathology, namely plaques and tangles, on the inflammatory environment might be a confound factor. Although the primary diagnoses criteria used for case selection was the presence or absence of PD, along with the absence of AD, age-associated pathology was a feature of many of the cases used Table . As the This work is the first description of large-scale unbiased multiplex quantitative protein profiling of tissue from human SN and striatum to elucidate changes in inflammatory and related molecules that might be involved in PD pathology, though this platform was used to screen sera from patients with Parkinsonian syndromes for inflammatory protein changes -2 . CCL-28 is expressed by epithelial cells and has chemotactic properties for certain immune cells. Increased expression in periphery has been associated with inflammation, however, in brain, it has only been identified in neurons rather than glial cells , while in striatum there was an increasing number of positive samples in the ILBD and PD groups (P = 0.008). Although the values were low, the amount of TNF-α detected in SN was overall higher than in striatum. Mean values in PD SN samples were 10.1 pg/ml compared to 3.5 pg/ml in striatum PD samples.Five of the inflammatory cytokines associated with disease differences were progressively upregulated in striatum between control, ILBD, and PD samples. IFN-γ is a potent proinflammatory cytokine primarily produced by T lymphocytes and natural killer cells rather than by brain resident cells. IFN-γ has been shown to have a central role in mediating dopaminergic cell loss or deterioration of the nigrostriatal pathway in PD animal models  in accelerating PD pathology can be validated in further analyses. One of the problems highlighted in this study is the heterogeneity in disease or aging changes in these carefully selected cases, as well as the presence of other neuropathologies that can affect measures. Variability is inevitable in human samples, but potentially masked some of the disease group differences. The very large range of values found for each of the factors suggests other causes beside PD pathology might be affecting levels of molecules in tissue. The use of correlation analyses along with assessment of disease group differences provided interesting leads to follow up. The strength of this application is the quality of the postmortem tissue used. These were collected and stored under defined conditions with short postmortem delays so the stability of these measured molecules should be assured (Beach et al., DW planned the study, coordinated sample processing and analysis, performed data analysis, manuscript writing, and coordinating with funding agent. LL assisted in these processes. GS and LS selected and dissected the tissue samples used in the study and provided neuropathology consultations. JC and CA provided clinical assessments premortem on many of the recruited subjects in the study. TB provided neuropathology diagnosis, assisted in sample selection and coordinated tissue collection.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The lensing capabilities of a single subwavelength slit surrounded by a finite array of grooves milled into a brass plate is presented. The modulation of the beam intensity of this ultrasonic lens can be adjusted by varying the groove depth. Numerical simulations as well as experimental validations at 290 kHz are shown. The experimental results are in good agreement with the numerical simulations. This system is believed to have potential applications for medical ultrasound fields such as tomography and therapy. The aet al. –11.Motivated by the wave nature of light and sound, the focus of research on electromagnetic waves has been transferred to acoustic waves, taking into account that the electromagnetic wave is a transverse vector while the acoustic wave is a scalar longitudinal wave. In recent years, the study of acoustic transmission through subwavelength apertures has received a lot of attention. The sound transmission through one and two dimensional aperture arrays has been studied theoretically ,13 and cThe purpose of this work is to show, through both simulations and experiments, that a brass plate with a single subwavelength slit surrounded by a finite array of grooves acts as an ultrasonic lens and the beam intensity modulation can be shifted by varying only the groove depth, maintaining the other parameters such as groove width and groove period fixed.2.t = 5 mm and the period of the grooves is p = 5 mm. The width of the central slit and the grooves is w = 2.5 mm. Three different depths of the grooves are considered, d = 1, 2 and 3 mm.The basic structure considered is a brass plate with a subwavelength center-slit surrounded by a symmetric array of 4 grooves on each side of the slit at the output surface, as depicted in 2. The experimental set-up is based on the ultrasonic immersion transmission technique. The sample was placed in a water tank and the alignment and positioning were provided by an automated positioning system built around a water tank, which is capable of sweeping the hydrophone through a 3D grid of measurement points located at any trajectory inside the tank. Two different kinds of transducers were used: a piston transducer  centered at a frequency of 250 kHz with an active diameter of 32 mm was employed as an emitter and a Polyvinylidene fluoride (PVDF) needle hydrophone  with a diameter of 1.5 mm and with ±4 dB bandwidth spans from 200 kHz to 15 MHz as a receiver. The pulse launched by the emitter piston transducer through the inspected plate was detected by the hydrophone and acquired by the pulser/receiver, post-amplified and digitalized by a digital PC oscilloscope . Time domain data were finally analyzed after averaging 100 different measurements. The time window was set to be wide enough to collect only direct transmission through the plate and to avoid indirect transmission due to lateral reflections. Scanning was done using the automated positioning system along a plane normal to the plate, with a spatial resolution of 0.5 × 0.5 mm3.3, 120 × 109 N/m2 and 0.31, respectively. The water density, the bulk and dynamic viscosities values were set at 1000 kg/m3, 2.47 × 10−3 Pa·s and 0.89 × 10−3 Pa·s, respectively. By way of example, the numerical simulation and experimental pressure field maps at 290 kHz are presented in w), groove depth (d) and the period of the grooves (p) by [j = (−1)1/2, k is the wavenumber and xk and zk are the respective X and Z wavenumber components. The cylindrical wave is governed by the thickness of the structure (t) and is related to the Fabry-Perot resonances. The overlapping of both the cylindrical waves and the acoustic surface evanescent waves produces the modulation intensity of the beam. In such a way, the mere presence of groove-grating does not allow the modulation of the beam because the structure only radiates evanescent waves, so the pressure amplitude decays quickly away from the structure surface [The sound pressure maps of the transmission field were simulated by using the commercial software COMSOL Multiphysics 3.5.a . In the simulations, the brass plate was modelled as an elastic solid and the Helmholtz equation for the fluid medium was used together with the usual boundary conditions in the solid/fluid interface. More details about the model equations and boundary conditions can be found in reference . The fre surface . To verix = 0. To quantify the pressure at a certain distance for different groove depths, it is necessary to cut the pressure field maps at 4.In conclusion, both the simulated and experimental ultrasonic beaming effects of a single subwavelength slit surrounded by a finite array of grooves have been shown. The experimental results are in close agreement with the simulated ones. This modulation phenomenon can be explained as an interference phenomenon. At the output side, the slit diffracts a beam into free space and through acoustic surface evanescent waves to grooves. A single groove has cavity modes that depend on the groove depth and width.Each groove couples acoustic surface evanescent waves into other grooves and radiative waves into free space when the phases are matched. The constructive interference of the acoustic waves emerging from the slit and grooves will increase the pressure at a point where the phase difference between the waves is a multiple of 2π. The phase difference depends on the depth of the grooves, and thus the far-field pressure distribution can be modified. This device is believed to have potential applications for medical ultrasound fields such as tomography and therapy.


Background: Significant morbidity is associated with standard open flank living donor nephrectomy. Laparoscopic donor nephrectomy is criticized for a steep learning curve and a tendency to avoid the right kidney. The anterior muscle-splitting technique uses principles or advantages of an open extraperitoneal approach with minimal morbidity and the advantageous muscle-splitting (instead of cutting) procedure.Objective: To compare mini-incision laparoscopic instrument-assisted (MILIA) live donor nephrectomy using a muscle-splitting technique to the standard open-flank donor nephrectomy (ODN) approach for efficacy and safety.Methods: MILIA living donor nephrectomies were performed in 119 donors and compared to a cohort of open-flank nephrectomy donors (n=38) from the same center. Both donor groups were matched for body mass index as well as other personal characteristics.Results: The mean donor age was 35 (range: 18–60) years. The right kidney was procured in 28% of cases. The majority of donors were female (58%) and Caucasian (60%). No differences were observed between MILIA and ODN donors for the age, gender and ethnicity. However, MILIA donors experienced a longer mean±SD operative time  but a shorter hospital stay  and less intraoperative blood loss . No difference was found in the number of units of blood transfused . Right-sided kidneys were almost equally harvested in both groups (29% of MILIA donors vs. 26% of ODN donors). Post-operatively, MILIA donors had a significantly lower mean pain scores at one week and one month after surgery (p<0.001). They showed significant better post-operative recovery—earlier stopping of pain medications and restoration of other preoperative activities. Moreover, they were better satisfied with their scar appearance. Scores on the short form-36 quality of life questionnaire were comparable for both groups.2) and medium-sized (BMI<28 kg/m2) donors. We believe that this technique should be adopted by centers that have limited advanced laparoscopic surgical experience and also it could be used selectively for the right donor nephrectomies, even in centers performing hand assisted donor nephrectomies by including a small patch of inferior vena cava for a better quality of right donor kidney during transplantation.Conclusion: MILIA is a viable option as an alternative for pure laparoscopic donor nephrectomy. MILIA appears to be as safe as open donor nephrectomy and may provide advantages over ODN, such as smaller incision, shorter hospital stay, and less incisional pain. Patient recovery and satisfaction after MILIA are excellent. This technique avoids the possibility of adhesive intestinal obstruction and also improves handling of major complications  of laparoscopic donor nephrectomy. Utilization of this hybrid technique is particularly feasible on smaller (BMI<24 kg/m Based on this particular situation, the donor nephrectomy should be associated with the lowest possible risks and morbidity and, simultaneously, allow the donor a speedy recovery and return to normal activities.Live donor nephrectomy is a unique procedure in which a healthy individual undergoes a major surgery with essentially no therapeutic benefit for the donor. This special circumstance exposes the surgery to unusual and specific challenges: the benefit goes to the recipient and on the other hand the principle of “Laparoscopic live donor nephrectomy has emerged as an alternative to traditional extraperitoneal open nephrectomy, with the potential advantages of decreased post-operative pain, shorter hospital stay, rapid return to normal activities and clearly improved cosmesis. This procedure was originally employed with the goal of expanding the living kidney donor pool by making the procedure more appealing and acceptable .e.g., bleeding), hidden late complications such as post-operative bleeding and cautery-induced bowel injuries. To minimize these potential risks, modifications from the original technique by Ratner, et al, [A recent United Network for Organ Sharing (UNOS) survey indicated that there is a low-risk with endoscopic techniques but greater than that associated with open donor nephrectomy techniques . Inheren, et al,  were int, et al, , retrope, et al, , and fin, et al, . These m, et al, -9. Howev, et al, . Other p, et al, , higher , et al,  and incrConsidering our strong belief in the safety of the living kidney donor, we tried to avoid inherent risks of laparoscopic techniques and instead created a minimally invasive muscle splitting anterior approach for donor nephrectomy. In this technique, we utilize advantages of open and laparoscopic approaches while simultaneously avoid inherent risks and disadvantages of both techniques. This idea was the basis for our hybrid technique of donor nephrectomy, the so-called “mini-incision laparoscopic instrument-assisted (MILIA) live-donor nephrectomy.” The objective of this report was to describe the MILIA technique and our experience with the MILIA approach to donor nephrectomy.From October 2000 through February 2006, the MILIA live donor nephrectomy technique has been used in 119 cases. Early in the initial phases of the MILIA procedure in 2000, data of donors from the same center performed by partner transplant surgeons using the open-flank donor approach were collected for comparative purposes. The surgical technique is described in 2. The mean age of participants was 35 (range: 19–60) years. A majority of donors were female (58%) and Caucasian (57%). The mean BMI of the ODN group was 28 kg/m2 and the mean age was 35 (range: 18 –57) years.The mean BMI was 27 kg/mvs. 197±33 min, a significantly (p<0.0001) shorter hospital stay (4±1 vs. 6±3 days) and less intra-operative blood loss  than the ODN group. No difference occurred in the mean±SD number of units of blood transfused . Right kidneys were almost equally harvested in both groups (29% of MILIA donors vs. 26% of ODN donors). The incision length was significantly (p<0.0001) shorter in the MILIA group (8±1 cm) than the ODN group (12±3 cm). For MILIA procedures, 85% of cases experienced no intra-operative complications, while only 58% of ODN cases were without intra-operative complications (p<0.02). No difference was found in the reported post-operative complications: 85% of MILIA cases were without complications post-operatively compared to 79% of ODN cases, p=0.12). Post-operatively, MILIA donors had lower mean pain scores at one week and one month after the surgery (p<0.001). They showed significantly better post-operative recovery: earlier discontinuation of pain medications and restoration of other pre-operative activities. Moreover, they were better satisfied with their scar appearance. Scores on the short form-36 quality of life questionnaire were comparable for both groups.MILIA donors experienced a significantly (p<0.0001) longer mean±SD operative time  of laparoscopic donor nephrectomy. Utilization of this hybrid technique is particularly feasible on smaller (BMI <24 kg/m2) and medium-sized (BMI <28 kg/m2) donors. This procedure is especially useful in right-sided donor nephrectomies because we can obtain a small rim of caval patch with the right renal vein to maximize the length the right renal vein without narrowing and compromising the diameter of the inferior vena cava.MILIA is a viable option as an alternative for pure laparoscopic donor nephrectomy. MILIA appears to be as safe as open donor nephrectomy and may provide advantages over ODN, such as smaller incision, shorter hospital stay, and less incisional pain. Patient recovery and satisfaction after MILIA are excellent. This technique avoids the possibility of adhesive intestinal obstruction and also improves handling of major complications (


TotheEditor: In this investigation, we found evidence for the apparent effects that a new variant of the rabbit hemorrhagic disease virus (RHDV) is having on native wild European rabbit (Oryctolagus cuniculus) populations on the Iberian Peninsula, and how this virus could threaten the conservation of endangered predators.Historically, European rabbits were extremely abundant on the Iberian Peninsula, which is in their native range. However, during the 20th century, the number of rabbits on the peninsula has declined >90%, mainly because of diseases , and unlike the classical form of RHDV, it kills rabbits as young as 11 days of age and rabbits that have been vaccinated against classic RHDV . The lynx relies on rabbits for survival, because they represent >85% of the lynx’s diet .The European rabbit is a multifunctional keystone species of the Iberian Mediterranean ecosystem, where it serves as prey for >30 predatory animals, alters plant species composition and vegetation structure through grazing and seed dispersal, its excrement and urine have an effect on soil fertility and plant growth and provide feeding resources for invertebrates, and its burrows provide shelter for different species , panel DThe situation described exemplifies how emerging diseases can affect biodiversity conservation. It also highlights the importance of using wildlife monitoring schemes as detection tools for monitoring the impact of stochastic factors, such as the variant RHDV, on wildlife populations. Urgent management actions, designed within an Iberian rabbit conservation strategy that relies on a multidisciplinary framework, are needed to ensure the conservation of this keystone member of the Iberian Peninsula ecosystem and that of rabbit-reliant predators.


APOE effect on Alzheimer Disease (AD) risk is stronger in women than in men but its mechanisms have not been established. We assessed the APOE-by-sex interaction on core CSF biomarkers, brain metabolism and structure in healthy elderly control individuals (HC).The n = 274) and/or 3T-MRI (n = 168) and/or a FDG-PET analyses (n = 328) were selected. CSF amyloid-β1–42 (Aβ1–42), total-tau (t-tau) and phospho-tau (p-tau181p) levels were measured by Luminex assays. We analyzed the APOE-by-sex interaction on the CSF biomarkers in an analysis of covariance (ANCOVA). FDG uptake was analyzed by SPM8 and cortical thickness (CTh) was measured by FreeSurfer. FDG and CTh difference maps were derived from interaction and group analyses.Cross-sectional study. HC from the Alzheimer’s Disease Neuroimaging Initiative with available CSF (APOE4 carriers had lower CSF Aβ1–42 and higher CSF p-tau181p values than non-carriers, but there was no APOE-by-sex interaction on CSF biomarkers. The APOE-by-sex interaction on brain metabolism and brain structure was significant. Sex stratification showed that female APOE4 carriers presented widespread brain hypometabolism and cortical thinning compared to female non-carriers whereas male APOE4 carriers showed only a small cluster of hypometabolism and regions of cortical thickening compared to male non-carriers.APOE4 on brain metabolism and structure is modified by sex. Female APOE4 carriers show greater hypometabolism and atrophy than male carriers. This APOE-by-sex interaction should be considered in clinical trials in preclinical AD where APOE4 status is a selection criterion.The impact of  APOE) genotype is the strongest genetic risk factor for Alzheimer’s disease (AD) . AP. APAPOE)oversial –7]. Mos. MosAPOEoversial –10] but butAPOE)oversial –13] hav havAPOE)ddle age  and evenddle age . The relatrophy,  while seatrophy,  and two 4 allele , 17]..APOE) geAPOE across the lifespan have been described  co coAPOE estudies,  and in astudies, . Howeverpatients . Damoisecontrols .APOE4 and sex on brain structure and metabolism has not been established. This interaction could affect the design and interpretation of prevention trials in preclinical AD in which APOE is a selection criterion . The aim of the present study was to examine the interactions between APOE4 and sex on brain metabolism and structure, based on the hypothesis that the APOE4 allele exerts a differential adverse effect on brain metabolism and structure depending on sex.The interaction between APOE status, MMSE or CSF biomarkers. There were no significant differences in age, APOE status, MMSE or CSF biomarkers between males and females in all three subsets. In the FDG and CSF subsets, males had higher years of education than females (p < 0.001), but in the MRI subset this difference did not reach significance.Demographic and clinical of the participants in the CSF, FDG and MRI subsets are summarized separately in the Table APOE4 carriers had lower CSF Aβ1–42 values than non-carriers in all three subsets (p < 0.001). APOE4 carriers had higher CSF p-tau181p values in the three subsets, but these only reached significance in the FDG and CSF subset which had larger sample sizes (p < 0.001 and p = 0.004 respectively). APOE4 carriers had higher CSF t-tau values in the three subsets, but these only reached significance in the CSF subset (p < 0.05). There were no significant differences in MMSE scores or education between APOE4 carriers compared to non-carriers in any of the subsets. There were no significant differences between males and females in CSF biomarkers. Neither was there an APOE-by-sex interaction on CSF Aβ1–42, CSF t-tau or CSF p-tau181pvalues in the analysis of covariance (ANCOVA) analyses.APOE-by-sex interaction, covaried by age and years of education . Two clusters emerged, one located mainly in the anterior cingulate region and the other in the temporal region. To analyze the directionality, we isolated the temporal cluster, averaged the FDG uptake, and plotted it in box and whisker plots . Similar results were found for the anterior cingulate cluster (not shown).Fig. ots Fig. . As showAPOE4 group analyses for FDG, covaried by age and years of education. Female APOE4 carriers showed widespread clusters of decreased metabolism (p < 0.005) across the whole cerebral cortex in both hemispheres with respect to APOE4 non-carriers  in the precuneus with respect to non-carriers  nor the female APOE4 carriers vs non-carriers comparison  emerged, one in the dorsolateral frontal region and one in the temporoparietal region. To analyze the directionality, we then isolated the temporoparietal cluster, averaged the cortical thickness (CTh), and plotted it in a box and whisker plot . Similar results were found for the remaining cluster (not shown).Fig. lot Fig. . As showAPOE4 CTh analyses, covaried by age and years of education. Male APOE4 carriers showed 3 large clusters (FWE corrected) of increased CTh with respect to non-carriers. Two of the clusters were observed in the left hemisphere, one in the dorsolateral frontal region and another in the temporoparietal, occipital and precuneus regions. The third cluster was observed in the right hemisphere in the parietal and occipital regions. Female APOE4 carriers showed cortical thinning in several regions than female APOE4 non-carriers .Fig. APOE-by-sex interaction on brain structure, we included CSF Aβ1–42 and CSF p-tau181p as covariates in the analyses. The vertex-wise APOE-by-sex interaction analysis across the whole cortical mantle showed a reduction in the significance maps when including CSF biomarkers as covariates, especially Aβ1–42  were included as a covariate . The results were not significantly altered in any case.APOE4 genotype on brain structure and metabolism is modified by sex. We found a significant APOE-by-sex interaction on brain metabolism and structure. Female APOE4 carriers showed brain hypometabolism and cortical thinning with respect to female non-carriers whereas male APOE4 carriers showed only a small cluster of hypometabolism and cortical thickening with respect to male non-carriers. CSF core AD biomarkers had an influence on brain structural results (and to a lesser extent on brain metabolism).This study shows for the first time that the impact of the APOE-by-sex interaction [APOE-by-sex interactions on MRI demonstrated the interaction on resting state functional connectivity but not on gray matter volume [APOE-by-sex interaction on both brain structure and metabolism. The discrepancy on brain structure could be due to the differences in the subject population or technical differences . Our FDunctions .APOE4 genotype. Neglecting a possible APOE-by-sex interaction on brain metabolism could be one of the reasons for the discordant FDG results [APOE4 carriers showed increased CTh and females decreased CTh. The finding of cortical thickening in AD vulnerable areas in middle aged (48–75 years old) APOE4 carriers with respect to non-carriers has already been described [Our metabolic findings suggest that women are metabolically more susceptible to the  results –13]. Ma. MaAPOE4escribed , 17], b, bAPOE4 escribed , 15]..APOE4 ge1–42 would be followed by atrophy once CSF p-tau181p becomes abnormal . T. TAPOE4 us works , [25]. Tnitially . Nonetheomarkers . Accordinical AD .APOE allele modifies the risk for AD have been extensively studied but are not completely understood. Both β-amyloid-dependent . T. TAPOE aAPOE4 status is a selection criterion are underway . Our results emphasize the importance of sex stratification when considering the AD risk and its impact on AD topographical biomarkers  + ageMean cluster FDG uptake (or mean cluster CTh) = âAPOE genotype and sex in CSF biomarker levels.The same ANCOVA approach was used for the CSF analyses to test for an interactive effect of


This article is part of a study to gain insight into the decision-making process by looking at the views of the relatives of potential brain dead donors. Alongside a literature review, focus interviews were held with healthcare professionals about their role in the request and decision-making process when post-mortal donation is at stake. This article describes the perspectives of the relatives.A content-analysis of 22 semi-structured in-depth interviews with relatives involved in an organ donation decision.conditions’, ‘ethical considerations’ and ‘look back’. Conditions were: ‘sense of urgency’, ‘incompetence to decide’ and ‘agreement between relatives’. Ethical considerations result in a dilemma for non-donor families: aiding people or protecting the deceased’s body, especially when they do not know his/her preference. Donor families respect the deceased’s last will, generally confirmed in the National Donor Register. Looking back, the majority of non-donor families resolved their dilemma by justifying their decision with external arguments . Some non-donor families would like to be supported during decision-making.Three themes were identified: ‘The discrepancy between general willingness to donate and the actual refusal of a donation request can be explained by multiple factors, with a cumulative effect. Firstly, half of the participants (most non-donor families) stated that they felt that they were not competent to decide in such a crisis and they seem to struggle with utilitarian considerations against their wish to protect the body. Secondly, non-donor families refused telling that they did not know the deceased’s wishes or contesting posthumous autonomy of the eligible. Thirdly, the findings emphasise the importance of Donor Registration, because it seems to prevent dilemmas in decision-making, at least for donor families.Discrepancies between willingness to consent to donate and refusal at the bedside can be attributed to an unresolved dilemma: aiding people or protect the body of the deceased. Non-donor families felt incompetent to decide. They refused consent for donation, since their deceased had not given any directive. When ethical considerations do not lead to an unambiguous answer, situational factors were pivotal. Relatives of unregistered eligible donors are more prone to unstable decisions. To overcome ambivalence, coaching during decision-making is worth investigation. In the Netherlands, relatives of potential brain dead donors must give their consent to effectuate organ donation. A majority of the Dutch population state that they are willing to be a donor . Yet, onResearch suggests that the difference between general willingness and the actual decisions made by relatives might be caused by a collision of the values of relatives with those of potential donors , and theResearch has also demonstrated that relatives often regret their decision afterwards, especially when they refused consent for donation –13.The aim of this study was to gain insight into the decision-making process by looking at the views of relatives of potential brain dead donors. The ethical considerations i.e. the values, motives and convictions of relatives  that were expressed to reach the best possible decision were explored, as well as if relatives regretted their decision and if they would have liked to have received some support during the decision-making process after the donation request. Offering support in clarifying values is not standard procedure, and it is not known if relatives would appreciate such an offer. This issue was also explored.A qualitative study was conducted by interviewing relatives of 12 cases, in which consent for donation was given, and nine cases , in which consent for organ donation was refused. A semi-structured interview guide was developed , who refused to consent to donation, nine families (14 participants), who gave full consent to donation and three families (eight participants), who did not give permission for donation after brain death (DBD), but only for donation after circulatory death (DCD), whilst DBD was possible  into nine categories, and resulted in three themes Fig. ; Table 3The first theme concerned the conditions for decision-making after the donation request, the second theme related to the ethical considerations in decision-making and justification of the decision. The third theme concerned the look back at the decision and the decision-making process. Illustrative quotes for the categories are presented in italics.The term ‘participants’ refers to the study participants and ‘relatives’ to the whole group (study participants and other persons engaged in the decision-making process).Since most interviews were planned relatively shortly after the death of their family member (median 85 days), many of the participants were in the process of grieving. They explained how their lives were turned upside down by the sudden death of their partner, child, parent or sibling. Participants frequently had some kind of re-experience of the days in the hospital environment, when talking about the event, and sometimes, details of the elapsed time were vague. Some of the participants explicitly told us that the interview had a healing function and turned out to help them cope with the tragic event.urgency;  Thevice versa.In describing their decision-making process and providing justification for the final decision , the participants mentioned different values, motives and convictions – their own and those of the potential donor. Specific considerations can play a very important role in the deliberation of non-donor families, whereas they were irrelevant for relatives who consented to donation (= donor families) and Values are used to justify the decision. The values ‘aiding other people’ or ‘giving people a better life’, ‘small effort, great benefit’ (easy rescue), ‘reciprocity’ or ‘solidarity’ were mentioned by all participants, whereas ‘integrity’ was important for non-donor families only. “We were 99.9 % sure that he did not want that [donation]. Despite our idea that you should help people when you can, it’s still his body”. (R07) ‘Living on in other people’ was seen as a specific consideration to give meaning to organ donation. “We are very proud of her, because she saved the life of three people. This gives me a feeling of support…. she is not really dead. A part of her lives on in someone else.” (R06) Donor families referred to this value sometimes as a kind of comfort or relief in their grief. Participants rarely connected their mentioned values to religious views or spirituality.Motives signify readiness or reluctance to act. Motives were mostly used as a practical objection contra donation: non-donor families said that it was difficult to decide on behalf of another person or words as: “If he had really wanted organ donation, he would certainly have registered”. (R33). Other motives that were mentioned: the donation procedure takes too long; one cannot be present at the moment of visible death; and organ donation interferes with funeral or burial rituals.Convictions signify the authenticity of the decision, but may lack rationality or evidence; they are mostly expressed without any motivation pro or contra organ donation: “Actually, I have to say that, when I turned 18, I received that form , and I did not have to think too much about it. I just signed it , because I think it is a normal thing to do”. (R16). Most convictions lead to a refusal of consent for donation: ‘organ donation is a reason for premature death’; ‘life is needlessly prolonged to obtain organs’ or ‘the potential organ donor has suffered enough’. Some families refused consent for donation, because of the anonymity of the recipient.dilemma, which they could easily resolve, whereas many non-donor families held ambivalent feelings: “I would really love to help people, and I know for sure that my Dad would have wanted that too. But it would be another major blow to let Dad fight for so long and then the organ went to someone, who did not deserve it, in his opinion, or contact [with the recipient] was not possible and we cannot see what good things Dad could still do”. (R27).Reviewing all ethical considerations, donor families sometimes mentioned that the request to consent to donation placed them in a aiding other people’, ‘giving them a better life’ or’reciprocity’ as important values in the field of organ donation. Organ donation offers a kind of comfort to them, because it gives meaning to an unexpected death. “I notice then that it even feels like a kind of comfort. I am not only mourning the loss of my Father, but I also know that he has done a very good deed. I can talk about that with pride, even though my Father has just died. And I feel that to be a tremendous help in the mourning process”. (R38). Non-donor families, on the other hand, emphasise the integrity of the body, both from their own perspective and from that of the eligible donor. They experienced the need to protect the body of the deceased, often combined with the conviction that they have the right to make decisions concerning the dead body.In balancing all ethical considerations, donor families and non-donor families came to different decisions, by giving prevalence to other values, motives or convictions. Rather remarkable is the fact that most donor families endorsed a utilitarian approach of organ donation: they see body parts as worthless after death, so they can easily give them away to someone who needs them (‘easy rescue’). Donor families emphasise ‘“At a quarter to eight, we said…we’re quitting. That was when we heard that there was no longer a coughing-reflex and that they could start the procedure, which could last one and a half day, or maybe two or three and a half days. That was when we decided to pull out.”(R25). The long donation procedure was the primary reason for three out of the twelve donor families to agree with a DCD-procedure, although a DBD was possible, next to their wish to be present at the moment of visible death.Motives mentioned by non-donor families endorsing refusal for consent were also recognised by donor families. Half of the donor families affirmed that the organ donation procedure took too long. However, for donor families the duration was not, by itself, the reason for refusal of consent; a few of the donor families even saw the extra time as an advantage. For one non-donor family though, the long procedure (combined with the anger about the utilitarian approach of the physician) was the compelling reason behind withdrawal of their initial consent: NN felt that the heart had beaten only for his Father, so it should not be reserved for transplantation.” (R37). For non-donor families, the removal of these organs was an extra consideration for refusal of consent. For a few donor families the removal of the heart was the main reason to choose for a DCD procedure, rather than a DBD.Both donor families and non-donor families mentioned the special significance of some organs and tissues, especially those of the heart, skin and eyes: “Important for the decision was (a) the opinion of the eligible donor on organ donation (relatives’ knowledge of that opinion and registration in the register), (b) the opinion of the relatives themselves on organ donation  and (c) the opinion of the participants who must decide about the body or the organs of the deceased: the deceased himself, the relatives or the physician.The interviewed donor families and non-donor families differed on all three points. a) It was known from all but one eligible donor that they were positive about organ donation; the majority had registered as a donor. On the other hand, none of the non-donors had registered. Their opinion on organ donation was mostly unknown; if known their opinions were both in favour of, and against organ donation. b) Only some participants of the non-donor families were positive about organ donation (a few had registered), whereas most donor families were in favour of organ donation (the majority had registered). c) Remarkably, the majority of the non-donor families felt they had more right to decide about donation than the deceased, because they had to live on with the decision, whereas all donor families greatly valued the last will of the deceased.justify their decision for themselves afterwards. Although nearly all participants explicitly stated that they did not regret their decision, half of the non-donor families did not persist in their decision and explained to remain ambivalent on their decision, especially non-donor families, who had experienced the decision as a dilemma. Most of them disclosed that they were incapable of making a well-considered decision and continued to feel ambivalent in weighing their own values against the potential organ donors’ values or weighing the interests of the potential organ donor against those of the people on the waiting list. They thought that they might possibly have given consent if: they had more time; were prepared better; were told in advance that the procedure takes so much time; the donation request would have been posed in a more empathic and less technical way; or if physicians would have emphasised that donation can save other lives. One donor family told that their deceased would not have registered, if he had known what the procedure entails.Most participants could suggestions for improvement of the decision-making process than donor families. Flaws that were most often mentioned included: ‘lack of information’; followed by ‘a short period of time to decide’: “Yes, and that happened in one conversation, in like, five minutes. So I think, well, how can I decide so quickly about that?” (R25). Both donor families and non-donor families stated that the public information about the length of the donation procedure was not clear.Non-donor families came up with more support or counselling around the decision making process, half of the non-donor families gave an affirmative answer, whereas the majority of the donor families would have declined such an offer. Those who would have appreciated support wanted someone like a coach or a buddy to be nearby during the whole stay in the hospital: “When I look back, I would have found it quite nice if they had said like… well, we have a counsellor whom you have met before. He will come too and talk everything through, because these are far-reaching decisions, he will just stop by later to visit you”. (R28).When asked whether they would have appreciated a kind of support for themselves, could easily understand that for others counselling would be helpful, for example, when there is no agreement between relatives, when people are incompetent to decide because of a shock, when they experience little support from their relatives, or when the wish of the deceased is unknown. The kind of support mentioned was mediation (when there is disagreement between relatives), creating a pause for reflection in a crisis, giving information and explanation about organ donation, being a coach in decision-making or during emotional reactions. This task could be attributed to different professions , acting as a confidant.Participants who did not need The discrepancy between general willingness to donate and the actual refusal of a donation request can be explained by multiple factors, with a cumulative effect.pro or contra. Many considerations mentioned by the participants were similar to a number of ‘beliefs’ in the meta-study of Newton [Firstly, half of the participants (most non-donor families) stated that they felt that they were not competent to decide in such a crisis, which is confirmed by other research . The emof Newton , but couf Newton , 19, 20;f Newton . ReligioTo overcome the incompetence to decide, it is suggested to wait with the donation request to give relatives some time to accept the death of their family member. Thus, this study underscores the importance of decoupling, which is advised by literature , 22.Secondly, the majority of non-donor families did not know the deceased’s wishes. Bramstedt et al. reported that when the wish of the deceased is known, families feel themselves ethically obliged to make a decision that represents the values and preferences of those whom they represent . Indeed,Thirdly, the findings emphasise the importance of Donor Registration, because it seems to prevent dilemmas in decision-making, at least for donor families. Nearly all donor families had a hold on the registration in de National Donor Register. Relatives of deceased, who had not registered in the National Donor Register, were more inclined to remain ambivalent in their decision. Their dilemma could not be resolved by weighing values and convictions. In these cases, they justified their decision with arguments derived from the context . Non-donor families did not regret their decision, but half of them remarked that their decision could have been different, provided that the context had been different. This illustrates the instability of the decision, an instability that was also found in other research –13. To rAs separate point, refusal for consent was mostly defended by various considerations against a complete or a partial consent for DBD. The duration of the donation procedure and/or the exclusion of specific organs  and/or the wish to be present at the moment of visible death were, for some non-donor families, a compelling reason to refuse donation, and for three out of the twelve donor families to agree only with a DCD-procedure, although a DBD was possible. In this study, a DCD was not suggested to any of the non-donor families who refused to give consent. Offering the possibility of DCD (when possible), in case the relatives refuse consent of DBD, might facilitate consent in a subgroup of non-donor families, when relatives have objections because of the time needed for a donation procedure, the wish to be present at the visible death, or the exclusion of organs such as the heart.This study adds a new perspective to the literature on decision-making on organ donation, as many non-donor families were interviewed. Although the sample was not representative, a qualitative comparison of donor families and non-donor families could be made to provide a unique insight into the reasons why non-donor families refuse consent for organ donation. The study was retrospective and explorative. To confirm the suggestions made, further research (an intervention study) is required.Discrepancies between willingness to consent to donate and refusal at the bedside can be attributed to an unresolved dilemma: aiding people or protect the body of the deceased. Non donor families feel incompetence to decide and refused donation, whilst their deceased had not given any directive. When ethical considerations do not lead to an unambiguous answer, situational factors were pivotal. Relatives of unregistered eligible donors are more prone to unstable decisions. To overcome long term ambivalence, coaching during decision-making is worth investigation.The protocol was approved by the Institutional Review Board of the Radboud university medical center, Nijmegen the Netherlands (permission was given with number ABR nr NL.21205.091.07 d.d.10 June 2008) before the study commenced and later by the Institutional Review Board of the Sint Elisabeth Hospital, Tilburg the Netherlands (permission was given with protocol number 1106 d.d.25 March 2011) to get additional data.All participants gave their written consent before being included in the study.Not applicable.