The commonest cause of end-stage renal failure (ESRF) in children and young adults is congenital malformation of the kidney and urinary tract. In this retrospective review, we examine whether progression to ESRF can be predicted and whether treatment with angiotensin converting enzyme inhibitors (ACEI) can delay or prevent this.2 with at least 5 years of follow up (median 143 months). 48 patients received ACEI. We explored potential prognostic factors that affect the time to ESRF using Cox-regression analyses.We reviewed 78 patients with asymmetric irregular kidneys as a consequence of either primary vesico-ureteric reflux or renal dysplasia (Group 1, n = 44), or abnormal bladder function (Group 2, n = 34). Patients (median age 24 years) had an estimated GFR (eGFR) < 60 ml/min/1.73 m2, mean proteinuria 144 (14) mg/mmol creatinine (1.7 g/24 hrs). Of 78 patients, 36 (46%) developed ESRF, but none of 19 with proteinuria less than 50 mg/mmol and only two of 18 patients with eGFR above 50 ml/min did so. Renal outcome between Groups 1 and 2 appeared similar with no evidence for a difference. A benefit in favour of treatment with ACEI was observed above an eGFR of 40 ml/min (p = 0.024).At start, mean (SE) creatinine was 189 (8) μmol/l, mean eGFR 41 (1) ml/min 1.73 mThe similar outcome of the two groups supports the nephrological nature of progressive renal failure in young men born with abnormal bladders. There is a watershed GFR of 40–50 ml/min at which ACEI treatment can be successful at improving renal outcome. Nearly half the children and young adults who develop end-stage renal failure (ESRF) have asymmetric irregularly shaped kidneys . This apSuch patients fall into two broad groups. Firstly, there is a group who appear to have normal bladders without outflow obstruction and normal calibre ureters when not micturating, described as having either primary VUR or primary renal dysplasia. Secondly, there is a group with some form of bladder outflow dysfunction which causes a secondary VUR and dilated upper urinary tracts, of which a posterior urethral valve (PUV) in males is the most common cause.99 mTc-dimercaptosuccinic acid (DMSA) renography [The primary group have a bimodal presentation. Commonly they present in childhood with UTI; the rest present in early adult life with renal insufficiency and often with no preceding history of UTI -6. Tradinography . In thisnography ,4,5. In nography .progressive renal failure indicates glomerular capillary hypertension (glomerular hyperfiltration) and progressive focal and segmental glomerulosclerosis (FSGS) [The appearance of proteinuria and s (FSGS) ,13. Risks (FSGS) ,4,5. PatIn this retrospective observational review, from a large, single centre nephro-urological practice, we have examined the natural history and progression to ESRF of patients with primary and secondary reflux with asymmetric irregular kidneys and moderate to severe renal insufficiency. We have tested the null hypothesis of no difference in renal outcome between patients with primary and secondary reflux.2 were identified from a review of the records of outpatients and of patients receiving renal replacement therapy at the Renal Unit of the Middlesex Hospital . Most patients had been referred, as adolescents, from the nephrology and urology clinics at the Great Ormond Street Hospital for Children. All patients had renal scarring confirmed by DMSA or 99 mTc-mercaptoacetyltriglycine (MAG-3) renography, although most patients had undergone extensive investigations.Patients with bilaterally scarred kidneys and glomerular filtration rate (GFR) 15–60 mls/min/1.73 mFor inclusion in this study, patients had:51Cr-edetic acid (EDTA) GFR < 60 ml/min/1.73 m2; or estimated GFR < 60 ml/min/1.73 m2• an isotopic • apparently stopped growing and with a steady body weight , and• data for at least 5 years of follow up.Patients specifically excluded from this study were those with bladder exstrophy, neuropathic bladders, or any form of urinary diversion (conduit or reservoir). In our analysis, the patients were divided into two broad groups:Group 1: those with normal calibre ureters and normal bladders (Primary group)Group 2: those with megaureters, hydronephrosis and abnormal bladders (Secondary group).Glomerular filtration rate (GFR) was estimated by single exponential analysis of the plasma clearance of 51Cr-edetic acid (EDTA) following a single intravenous injection with blood samples taken after 2 and 4 hours [ 4 hours . Plasma GFR was estimated by different formulae and compared with the isotopic GFR. The Jelliffe formulae (I and II) ,16 have 2) [Jelliffe I (ml/min/1.73 m2) :- "(100 2) [Jelliffe II (ml/min/1.73 m2) :- " from a range of 12–60 ml/min/1.73 m2 were found to have no significant bias (-0.34 ml/min/1.73 m2 with a 95% CI of -1.19 to 0.51 ml/min/ 1.73 m2) and an agreement within limits of -11.0 to 10.3 ml/min/1.73 m2.We found that a mean of these 2 formulae gave closer approximations to measured isotopic GFR than the other methods. We have termed this mean value `estimated GFR' (eGFR). All measured values of Normal bladder: patients presenting after adolescence were considered to have a normal bladder if they had no bladder outflow symptoms, a normal urine flow rate (> 15 ml/sec) and no residual urine volume seen by ultrasound after voiding.Declining renal function: the rate of progression of CRF, -delta GFR (`-ΔGFR'), was calculated as the rate of change of eGFR and is shown as ml/min/year.Proteinuria: was initially measured as the amount of protein (g) in a 24-hour urine collection. Since 1995 proteinuria was more commonly measured on a random (spot) sample of urine at clinic visits with the proteinuria expressed as mg protein/mmol creatinine . As all 24 hour urine data (Uprot) included creatinine excretion (mmol/24 hours) we have been able to calculate protein/creatinine ratios (Up/Cr). Using the data from 161 separate 24-hour collections, we assessed how proteinuria in g/day predicts protein/creatinine ratios. Paired values ranged from 0.1–8.6 g/day and 8–700 mg protein/mmol creatinine, with a high correlation (r = 0.90). The regression equation was [Up/Cr = 90.3 × Uprot0.94].Hypertension was defined as either blood pressure consistently > 140/85 mmHg, or patients receiving blood pressure lowering therapy.End-stage renal failure (ESRF): was taken to be the date when the patient began dialysis. To calculate changes in renal function with time the eGFR was assumed to be 8 ml/min at this time.Outcome: Renal outcome was defined as having reached ESRF or not at last review.Since June 1986 some patients were started on ACEI therapy when anti-hypertensive therapy was required. In addition, some anti-hypertensive regimens were changed to ACEI therapy. A small group with blood pressure <140/85 were started on ACEI therapy because of increasing proteinuria. Some patients never received ACEI because ESRF was reached before the use of ACEIs in renal insufficiency had become routine.Patients, who were started on ACEI for hypertension, were advised to restrict their salt intake and the initial aim was for a blood pressure of ≤ 130/70. If ACEI alone did not lower the blood pressure to the target a diuretic was added. The latter was not always possible in Group 2 patients who might already have features of hypovolaemia secondary to their renal tubular pathology. No patient ever received any immunosuppressive drug.Only data from the start and end of the study are presented from all 78 patients. Of the 48 patients who were treated with ACEI, we also report data on 28 of the patients (for whom it was available for at least 18 months before and 48 months after the introduction of ACEI.) at the start of ACEI therapy and again at 2 years after start of therapy.Means were compared within groups by paired samples t-test, and between groups by Wilcoxon rank-sum test. The time scale was time since birth, since the setting was of a congenital disease eventually leading to renal failure. It was checked graphically that there was no obvious pattern to loss to follow up over time. Renal outcome (reaching ESRF or not) was compared between groups using Kaplan-Meier survival plots. Outcomes were quantified as the median survival outcome in months . This is equivalent to the median time for 50% of the group to reach ESRF. Differences in renal outcome over time were tested using log-rank tests. For graphical examination of the proportionality, continuous variables were grouped into approximate tertiles. The Cox proportional hazards model was chosen for further analysis. Continuous variables were centred on the mean. Protein/urine creatinine ratios were log-transformed for further analyses. Treatment with ACEI was entered as a time-changing variable to take account of the variable start of treatment after referral. Univariable regression models estimated crude (unadjusted) effects of the prognostic variables. Since it is possible that the effect ACEI depends on the GFR at start of treatment (entered as continuous variable), especially in patients with moderate to severe renal insufficiency, an interaction between those variables was fitted. Variables were entered in the multivariable model in a stepwise forward fashion. Analyses were performed using SPSS for Windows v10.1. and Stata 8 (Stata Corporation, Texas, USA).Data from 78 patients, who were first seen between December 1969 and February 1988, were analysed. Demographic details are presented in Table Group 1  were patients who had primary VUR or primary renal dysplasia. Twenty two patients  presented in childhood with a UTI. In each case, MCU performed at a median age of 7 years showed reflux which was either bilateral (82%) or unilateral (18%). In contrast, the remainder (n = 22) presented at a median age of 24 years. Only 32% were female and they almost invariably presented either with hypertension after starting a contraceptive pill or with complications during pregnancy. Only 2 had had a MCU performed and neither showed VUR.Group 2 patients  had the following diagnoses: PUV (n = 15), prune belly syndrome (n = 2), single dysplastic kidney with megaureter (n = 2), renal dysplasia with abnormal bladder function (n = 2), bilateral megaureters (n = 1), megacystis and megaureters (n = 4), and finally a group (n = 8) in whom the initial diagnosis (pre-1979) had included "bladder neck obstruction". Six of these had megacystis and megaureters and might now be termed `pseudo-prune belly syndrome'.By Group: The median survival time of Group 1 versus Group 2 was compared by log rank test: 231 months (95% CI: 153–309) vs. 162 months (95% CI: 135–189) respectively, p = 0.35. There was no evidence for a major difference in renal outcome between these patients with primary and secondary reflux. Thus for subsequent analyses the data from all 78 patients was combined.By eGFR: We compared renal outcome for all patients after they were stratified by initial eGFR into four groups (15–30, 31–40, 41–50, and 51–60 ml/min/1.73 m2)   after the start of the study, by which time their median eGFR had fallen from 46 (range 15–60) to 36 (10–60) ml/min/1.73 mTable We examined the effect of ACEI on 28 patients with deteriorating function for whom data was available for at least 18 months before and 48 months after the introduction of ACEI. ACEI reduced the rate of loss of renal function during the first 24 month period of follow-up, but the benefit was greater in the subsequent follow-up period with the rate slowing from a median of -1.86 before ACEI to -1.48 ml/min/yr (p = 0.007). ACEI treatment was associated with a reduction in proteinuria after 24 months of therapy. However, proteinuria had increased at last follow up owing to loss of the anti-proteinuric effect in half the group Fig .Analysis of 30 patients who did not receive an ACEI provides indirect support of benefit from this treatment. The median rate of loss of renal function for 25 of these patients who started with a eGFR ≤ 50 ml/min was 2.80 ml/min/yr and if initial proteinuria was ≥ 50 mg/mmol, (n = 23) the rate of loss of renal function was 3.0 ml/min/yr.At the start of the study 18 (41%) Group 1 patients and 5 (15%) Group 2 patients were hypertensive. Group 2 patients tended to be normotensive and some were started on an ACEI for proteinuria. At ESRF or last follow up, all patients were on conventional anti-hypertensive therapy or ACEI, except for two Group 2 patients.and proteinuria have progressive renal failure, that the rate of decline of function is proportional to the magnitude of the proteinuria, and that angiotensin antagonists both slow the rate of progression and reduce proteinuria [There is a consensus that patients with renal insufficiency teinuria -20. Our While VUR patients with abnormal bladders almost invariably present in early childhood, patients with normal bladder function have a bimodal presentation. In one series from New Zealand, 42 patients (36 adults) had ESRF with reflux nephropathy. Many had presented with advanced renal insufficiency, hypertension, and proteinuria, and only 22% of males and 58% of females had a history of UTI. Similarly, in our study, VUR had been proven in 50% of patients with primary reflux nephropathy and these patients  had almost invariably presented with an UTI in childhood (median age 7.0 years). In contrast, the other half  presented at a median age of 24 years with advanced disease and persistent reflux was not demonstrated in the 2 patients who underwent a MCU. Similar to the New Zealand experience ,22, nearAlthough reflux nephropathy is frequently viewed as a disease of little girls with recurrent UTIs , our datIn 1978 Kincaid-Smith and her colleagues  reportedIn an Italian study , 80 patiIn a UK study from Newcastle, proteinuria and renal insufficiency (plasma creatinine >130 μmol/l) were present from presentation in 21% and 13% of 125 patients respectively, and with time (mean 5.9 years) a further 21% developed proteinuria and 22% renal insufficiency. In all the 16 patients with progressive renal failure, the decline was linear. In a subsequent report, progressive renal failure did not develop in 138 adult patients with normal function at the start (plasma creatinine < 90 μmol/l) [2 nephropathy rarely progresses, but disease progression is invariable when function is worse. Nakashima et al. similarly reported that an isotopic GFR less than 49 ml/min predicted decline to ESRF [Our data support the established relationship between the risk of progressive nephropathy and renal insufficiency with proteinuria, but suggests a watershed range for renal function as a predictor of outcome. When the eGFR exceeds 40–50 ml/min/1.73 m to ESRF .The other determining factor of poor renal outcome is proteinuria, and we find that deterioration can be expected when proteinuria exceeds 50 mg/mmol (0.5 g/d). In a Japanese study, serial biopsy samples from patients with reflux nephropathy confirmed the close association between the degree of renal scarring, the extent of the glomerular pathology, and proteinuria ,26. Once2 at outset [In a 10-year follow up study of 52 children, randomised to medical or surgical management of severe bilateral VUR (grades III-IV) between 1985–1989, progressive renal failure developed in only 4 children (2 from each group) all of whom had GFRs at or below 40 ml/min/1.73 mt outset .Despite the few long-term studies of adult patients with primary VUR and reflux nephropathy -5, therein utero may not prevent progressive renal damage [absence of proteinuria, then some other cause (such as obstruction) must be sought.Progressive renal damage due to congenital outflow tract obstruction may be averted by urological intervention. This is not, however, always successful and even treatment l damage  and the l damage . Most bol damage  althoughApart from small numbers, the limitations of this study are the usual ones in observational research with effect estimates that are potentially confounded. We believe, however, that it would not now be possible to design a prospective study in which ACEI therapy was with held from one group. In this study, ACEI therapy improved renal outcome although non-ACEI patients were generally from an earlier period and not necessarily seen in a specialist clinic. The analysis demonstrated a long-term benefit for ACEI both in slowing the rate of loss of function and in reducing proteinuria. However, ACEI therapy appeared to be ineffective if started when the eGFR was already = 30 ml/min.We have studied a group of patients whose renal pathology is not immunological and whose residual functioning tissue is not homogenously distributed. The pathophysiology is similar to experimental sub-total nephrectomy which results in proteinuria, progressive glomerulosclerosis and renal failure ,31. LikePatients with a GFR of <60 ml/min need careful follow up and we would recommend that anyone with increasing proteinuria, or proteinuria >50 mg/mmol (0.5 g/d) is started on an angiotensin antagonist to reduce proteinuria and slow the rate of progression of the renal failure.GHN has been a consultant and lectured for MSD regarding both ACE inhibitors and angiotensin II receptor blockers. G Thomson, D Nitsch, RG Woolfson, JO Connolly, and CRJ Woodhouse have no conflict of interest.GN was responsible for the study design, management of patients, and writing of the report. GT collected clinical data from medical records; DN contributed to analyses and writing of the report; RW and JC contributed to patient management and writing of the report. CW was responsible for the continuing urological supervision of the patients and writing of the report. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Fibrin D-dimer levels have been advocated as an useful clinical marker of thrombogenesis.We hypothesized that i) there is a hyperclotting state after the return of atrial fibrillation to sinus rhythm, ii) the measurement of plasma D-Dimer levels might be a good screening tool of this clotting status, and iii) the duration of arrhythmia influences the haemostasis measured by plasma D-Dimer levels.Forty-two patients with atrial fibrillation undergoing cardioversion were divided into two groups: in Group A  the duration of atrial fibrillation was 72 hours or more (142.7 ± 103.8 hours), in Group B  the duration of atrial fibrillation was less than 72 hours (25 ± 16 hours). Plasma fibrin D-dimer levels were measured by enzyme immunoassay before, and 36 hours after, cardioversion. The change of plasma D-dimer levels 36 hours after cardioversion was calculated as delta-D-dimer.There were no significant differences in demographic, clinical, and echocardiographic data, and the success of cardioversion between the two groups. Compared to the control, the baseline D-dimer levels were significantly higher in both groups. The delta D-dimer levels were significantly higher in Group A than in Group B (p < 0.005). Furthermore, plasma D-dimer levels 36 hours after cardioversion (r = 0.52, p = 0.0016) and delta-D-dimer levels (r = 0.73, p < 0.0001) showed significant correlations with the duration of atrial fibrillation.The longer duration of the atrial fibrillation episode could lead to a more prominent cardiovascular hyperclotting state after cardioversion, and the mean changes of plasma D-Dimer levels could be used as an useful clinical marker of the clotting state after atrial systole return. Atrial fibrillation is the most common sustained arrhythmia in clinical practice. It is associated with an increased risk of thrombus formation, resulting in substantial morbidity, with the augmented risk of stroke being the most serious. This could be explained by haemostasis conditions favouring thrombosis: previous studies have demonstrated that in most patients, AF is a high risk factor for hypercoagulability, irrespective of underlying structural heart diseases or aetiology -8.In addition, it is well known that the direct current cardioversion of atrial fibrillation, especially if persisting >48 h, carries a great risk of thromboembolism, which extends to 5% of cases not receiving anticoagulant therapy. The mechanism and pathogenesis of thromboembolic episodes after restoration of sinus rhythm in these patients is not completely understood.There is some evidence that the prothrombotic state associated with atrial fibrillation might contribute towards the risk of thromboembolism following cardioversion, but reports are not clear. In this context, having a marker of coagulation activation would be useful in identifying patients at highest thromboembolic risk. Indicators of hypercoagulability, such as D-dimers, which are indicative of a prothrombotic state, might also be indicative of thromboembolic risk . D-dimerWe therefore hypothesized that i) there is still a hyperclotting state after return of sinus rhythm, ii) the measurement of plasma D-dimer levels pre- and post-cardioversion might be a good screening tool of this clotting status, and iii) the duration of arrhythmia could be a good predictor of thromboembolic events after cardioversion, due to the influence on haemostasis measured by plasma D-dimer levels.Over a period of 18 months, we studied 42 consecutive patients, aged between 39–68 years old, with non-valvular atrial fibrillation who underwent successful electrical cardioversion and who remained in sinus rhythm at the one-month visit. Exclusion criteria were other acute causes of atrial fibrillation (for example, thyrotoxicosis, pneumonia or other infections), acute cardiovascular or cerebro-vascular events  occurring within five months, valvular heart disease, malignancy, connective tissue disease, infectious or inflammatory conditions and chronic renal/hepatic disease. The patients were divided into two groups. In Group A , the duration of atrial fibrillation was 72 hours or more (142.7 ± 103.8 hours). In Group B  the arrhythmia had a duration of less than 72 hours (25 ± 16 hours). We included only patients treated with anticoagulant-coumadin for chronic prophylaxis. There was not a statistically significant difference between the mean duration of anticoagulation treatment between the two groups (14 ± 4 months for group A and 12 ± 6 months for Group B). Prothrombin time to an INR  of 2.5–3 was considered as a necessary inclusion criterion for all patients. The total population had a history of drug refractory atrial fibrillation, with a serious number of arrhythmia episodes. We only analyzed the documented arrhythmia episodes. The total number of documented episodes of paroxysmal atrial fibrillation in Group A was 33, and in Group B the patients had 36 confirmed arrhythmia episodes. There were no significant differences in age, sex, hematocrit, hemoglobin, plasma fibrinogen level, underlying heart disease, success ratio of electrical cardioversion, echocardiographic data, presence of diabetes mellitus or hypertension between the two groups. The clinical characteristics of the patients are shown in Table An intravenous line was placed and blood samples for D-dimer measurement were taken from the patients immediately before cardioversion, and 36 hours after recovery of sinus rhythm. Citrated plasma was obtained from venous blood by centrifugation at 2,500 rpm for 15 min at 4°C. Aliquots were stored at -70°C to allow batch analysis. The plasma D-dimer levels were measured by the enzyme-linked immunosorbent assay method. The measurements were obtained with the use of a quantitative sandwich immunochromatographic technique . For every blood sample, measurements were done twice. The investigators and attending physicians were blinded to the D-dimer test results. Inrta-assay coefficients of variation for assays were <5%, inter-assay variances were 10%. The changes of plasma D-dimer levels 36 hours after cardioversion were calculated as delta- D-dimer.Echocardiographic examinations were performed in all patients, immediately prior to the procedure and 36 hours after successful cardioversion. Transthoracic echocardiographic two-dimensional imaging and guided pulsed wave Doppler recordings were obtained. Transmitral Doppler inflow velocities were recorded from the apical four-chamber view.Peak velocities of early fillings (E) wave and atrial filling (A) wave were determined. The inter- and intra-observer variability was <5% for these measurements. We did not detect the presence of thrombi in the left atrium. However, the absence of thrombus on transthoracic echocardiography does not preclude the real absence of thrombus.Clinical variables are expressed as the mean value ± SD. The effects of duration from the onset of atrial fibrillation on the measured indexes were analyzed by two-way repeated measures analysis of variance (ANOVA). Sequential data pre- and post-cardioversion were analyzed by Friedman's repeated measures analysis of variance. Correlations were performed by Spearman's rank correlation method. Stepwise multiple regression analyses were performed to determine independent predictors for plasma D-dimer levels, using age, sex, left-atrial size, left ventricular dimensions (diastole, systole) presence of underlying medical disease, smoking status, and the presence of atrial fibrillation. A p value < 0.05 was considered statistically significant. Analyses were performed with SAS for Windows 8.02 (SAS Institute Inc., Cary, North Carolina) and GraphPad Prism, version 3.00  statistical software packages.The baseline D-dimer levels of each group are shown in Table The patients' sinus rhythm was restored by applying electrical cardioversion in all study patients. Delta D-dimer levels were significantly higher in Group A than in Group B. (p < 0.005).There were no significant differences in plasma D-dimer levels before, and 36 hours after, cardioversion between the two Groups .Two embolic stroke events were recorded during the six hours after cardioversion in Group A (8,33%) and none in Group B. The embolic events occurred in two women with an INR of 2.6 and 2.9 respectively. At the onset of the event one patient had D-dimer levels of 112.2 ng/ml while the second patient had D-dimer levels of 109.8 ng/ml. Fortunately, these were transient events. The computerized tomography detected non-extentend thromboembolic areas.In the present study we analyzed D-dimer levels as a screening index of a hyperclotting state after cardioversion of atrial fibrillation. It would be more useful if we used the term abnormal haemostasis, because the fibrin D-dimer is a cross-linked degradation product, resulting from the balance between thrombogenesis and the fibrinolysis process.Fibrin D-dimer levels have been established as a useful clinical marker of thrombogenesis.  The use In "normal" patients, elevated D-dimer levels have been associated with a higher risk of developing cardiovascular disease.  Also, suPatients with long-lasting episodes of atrial fibrillation or chronic atrial fibrillation are characterized by increased levels of plasma D-dimers ,22, platIn the present study, the plasma D-dimer levels decreased in both groups after successful cardioversion, but the mean change in D-dimer levels pre- and post- cardioversion was significantly lower in Group A than in Group B, and D-dimer levels continued to be high, even 36 hours after the procedure in Group A. There were reported embolic events in 8.33% of Group A patients, with the higher delta D-dimer.These data confirm the existence of an abnormal clotting state after the cardioversion of atrial fibrillation, which could be the cause of the thromboembolic events observed after the return to sinus rhythm, even under anticoagulation.The mechanism of thromboembolism is debatable. The results we found could suggest an embolism might be caused by detachment of a formed thrombus during the phase of passage from AF to sinus rhythm, due to being heavily compromised by stunning the mechanical function of the left atrium and left atrium appendage after sinus rhythm restoration. The stunning of the left atrium and left atrium appendage might attenuate the thrombogenetic activation which our result showed.In the present study we also provided evidence that this hypercoaguable state after successful cardioversion of atrial fibrillation related directly to the duration of the arrhythmia episode. It has been accepted that chronic atrial fibrillation is characterized by increased levels of plasmatic D-dimers, with a wide inter-individual variability, depending on the patients and therapeutic characteristics. However, it has not been established if this level could also be characteristic of paroxysmal or persistent atrial fibrillation in patients, and whether it could be a predictive factor for the risk of thromboembolic events after cardioversion to sinus rhythm.Our results show that longer duration of atrial fibrillation could lead to a more prominent cardiovascular hyperclotting state after cardioversion and that the duration of the arrhythmia episode might be a risk factor for the high incidence of post-cardioversion thromboembolic events. Importantly, this hypercoaguable state does not appear to be subject to any other clinical variables, nor is it related to whether or not the patient had a lone atrial fibrillation or not, suggesting that the duration of the arrhythmia episode confers a constant prothrombotic state per se, after cardioversion to sinus rhythm, which was independent of the etiology but dependent on the duration of the arrhythmia. Interestingly enough, this hyperclotting state after cardioversion exists even under appropriate anticoagulative treatment. The relation of the markers of accelerated coagulation to clinical or echocardiographic risk factors for thromboembolism is controversial.Our results clearly demonstrate a positive correlation of the based on the arrhythmia duration clinically predicted embolic risk to the mean change of plasma D-dimer levels 36 hours after successful cardioversion. We could not detect any relation to the echocardiographic risk factors, probably due to our inability to perform a transesophageal echocardiography. The present study suggests that even in the absence of clinical conditions causing increased embolic risk, patients with signs of accelerated coagulation are at risk of thrombus formation in the future.In conclusion, a longer duration of the atrial fibrillation episode could lead to a more prominent cardiovascular hyperclotting state after cardioversion, and the mean changes of plasma D-Dimer levels could be used as an useful clinical marker of the clotting state after atrial systole return.Our study might have practical implications for the management of patients with an episode of atrial fibrillation, regardless of the anticoagulative treatment they are receiving: the episode must be terminated as soon as possible, because the pathogenesis of thrombus formation in atrial fibrillation is very complex and not yet completely defined. Further investigations with a large population are needed to define all the pathophysiologic mechanisms of thrombus formation.


Asthma is a common disease and appears to be increasing in prevalence. There is evidence linking air pollution, including that from road-traffic, with asthma. Road traffic is also on the increase. Routine surveillance of the impact of road-traffic pollution on asthma, and other diseases, would be useful in informing local and national government policy in terms of managing the environmental health risk.Several methods for exposure assessment have been used in studies examining the association between asthma and road traffic pollution. These include comparing asthma prevalence in areas designated as high and low pollution areas, using distance from main roads as a proxy for exposure to road traffic pollution, using traffic counts to estimate exposure, using vehicular miles travelled and using modelling techniques. Although there are limitations to all these methods, the modelling approach has the advantage of incorporating several variables and may be used for prospective health impact assessment.The modelling approach is already in routine use in the United Kingdom in support of the government's strategy for air quality management. Combining information from such models with routinely collected health data would form the basis of a routine public health surveillance system. Such a system would facilitate prospective health impact assessment, enabling policy decisions concerned with road-traffic to be made with knowledge of the potential implications. It would also allow systematic monitoring of the health impacts when the policy decisions and plans have been implemented. The prevalence of asthma is increasing and there is concern that the increase may in part be attributable to increasing road traffic related pollution. The concerns relate especially to childhood asthma. In this article, we set out the arguments for using modelled exposure assessment to create a surveillance system that will facilitate routine public health work, such as monitoring and health impact assessment. We first discuss the increasing prevalence of asthma and the effects of air pollution on asthma. We then set out the benefits of monitoring the link between outdoor air pollution related to road traffic and asthma and discuss methods of exposure assessment in some detail. We describe modelling air quality in the UK as an example and then address the implementation of a surveillance system.Asthma is a common disease. Figures from the International Study of Asthma and Allergies in Childhood suggest up to 25.9% of children in Oceania have ever had asthma . Althougth century, air pollution increased greatly alongside the noted increase in the prevalence of asthma. Yet the last decades of the century have seen a considerable reduction in pollutants such as sulphur dioxide (SO2) following a cut back on industrial emissions [Air pollution has been linked to morbidity and mortality of several diseases, including diverse conditions such as coronary heart disease  and Hodgmissions .2) however, still remain problematic due to the increasing number of vehicles on our roads. In fact almost 50% of NO2 is thought to be produced by vehicles and much particulate matter is produced by diesel exhaust fumes [2 exposure increases cell membrane permeability, decreases ciliary beat frequency [3 of NO2 to be associated with a relative risk of 1.175 for asthma admission [x) have also been shown to influence emergency room visits in Israel [10) and NO2 appeared to consistently increase attendances at accident and emergency units with asthma in London [Levels of pollutants such as nitrogen dioxide  to calculate the distance from an individual's residence to a road, most often a main road, carrying over a certain volume of vehicles. In certain cases the distance from a child's school to a main road has been used instead. Examples of the use of this method are studies by Livingstone et al.  and Wilk2 may be high, with levels possibly higher than outdoors if a gas stove is used in the home [2. This however, is not without difficulties, as if one is exposed to traffic there will be a combined effect from a cocktail of pollutants produced by both trucks and cars.Another popular method is considering traffic flow along the street of residence or one in close proximity, as used by English et al. . In a sithe home . Anotherthe home . It coulSome authors  have atA number of studies have used modelling to estimate pollution exposure ,36. A moEven within a model however, accounting for personal day-to-day exposures is still problematic. In order to take previous exposures into account a cohort study would be necessary . Certain2 and PM10. The model could be used to estimate exposures on all the streets within a certain radius of the home or place of work as dispersion of pollutants from these streets may also be affecting the individual. In a sophisticated model it may be possible to make adjustment for the height of an individual's residency or place of work in high rise buildings to account for the vertical dispersion of pollutants. Such a system could also be used to estimate exposures at previous residences, work places or schools of an individual so that an assessment of lifelong exposure could be made as accurately and practically as possible. However, the latter might be too complicated for a routine monitoring system.Despite limitations, a model would appear to be the most practical way of assessing traffic-related exposure where routine surveillance is concerned. Information such as vehicle density, type of vehicle, risk of traffic congestion, presence of bus stops and street crossings, distance of residences to roads, street width, type of street, building presence and type and meteorological conditions  could be collected routinely for use in a variety of models for predicting exposure to NOThe UK Government's current policy on air quality within the UK is set out in the Air Quality Strategy for England, Scotland, Wales and Northern Ireland published in January 2000 pursuant to the requirements of Part IV of the Environment Act 1995. The Strategy sets out a framework for improving air quality and for ensuring that international commitments are met. It is designed to be an evolving process that is monitored and regularly reviewed. The Strategy sets standards and objectives for ten pollutants that have an adverse effect on human health, vegetation or ecosystems and target dates for achieving them. The standards generally set concentration limits above which sensitive members of the public (e.g. children, older people, people who are unwell) might experience adverse health effects. In early 2003 an Addendum to the Strategy was published introducing standards and objectives for a new pollutant and revising those for three others.2, PM10, SO2, ozone (O3), NOx and polycyclic aromatic hydrocarbons. The predominant source of most of these pollutants is road traffic, but industrial and domestic sources are also contributors.The pollutants currently specified in the Strategy now include benzene, 1,3 butadiene, carbon monoxide, lead, NO2), there is both an annual mean guideline limit and a short-term mean guideline limit. These reflect the varying impacts on human health of exposure to some pollutants over differing time periods, .The air quality standards or guideline limits are long-term benchmarks for ambient pollutant concentrations which represent negligible or zero risk to human health, based on medical and scientific evidence reviewed by the Expert Panel on Air Quality Standards (EPAQS) and the World Health Organization (WHO). For some pollutants, . The latest available guidance is Policy Guidance LAQM.PG(03) and Technical Guidance LAQM.TG(03). Air quality modelling is key to assessing the future potential for attainment, or not, of the objectives. Part IV of the Environment Act 1995 requires a local authority to designate an Air Quality Management Area (AQMA) covering any part of its administrative area where air quality objectives are not likely to be achieved by, or at any point beyond, the relevant objective's target date at locations where the general public might reasonably be exposed. These AQMAs have been determined by modelling future scenarios. For each AQMA the local authority has a duty to draw up an Air Quality Action Plan (AQAP) setting out the measures the authority intends to introduce to deliver improvements in local air quality in pursuit of the air quality objectives. Local authorities are not statutorily obliged to meet the objectives, but they must show that they are working towards them. As of June 2004, there were 120 designated AQMAs in the UK, with 80 AQAPs produced outlining how air quality would be tackled in these areas.A routine surveillance system would be one which links modelled air quality data, such as those derived in the UK described above, with routinely collected health data. There are a number of issues regarding the technical aspects of linking spatial information on air quality with health information, typically carried out using GIS. These are discussed in detail elsewhere . The infThe majority of studies examining the link between asthma and road-traffic pollution have concentrated on the prevalence of asthma, for example studies by Ciccone et al. , JedrychA few of the studies examining the link between asthma and road-traffic pollution have used information that is readily available. For example studies by English et al.  and Lin A routine surveillance system recording spatial variation in pollutant levels would allow improved understanding of the link between road-traffic pollution and asthma, or indeed other diseases and could be used to help predict future health impact, particularly in cities and towns. The results of such assessment would allow local policy decisions concerning the routing of traffic around residential areas or schools and plans to reduce congestion to be made with knowledge of the implications of the decision on the health of the local population. It would also allow systematic monitoring of the health impacts when the policy decisions and plans have been implemented.We should point out here that to examine acute effects  using daily time series analyses, monitoring data would be required as modelling would probably be too insensitive to detect daily variation in outdoor air pollution levels. However, time series analyses are complicated research methods that are not within the realm of routine public health practice. What we have argued for here is a surveillance system that looks at spatial variation in pollution and asthma which would highlight problem areas and could monitor the effects of interventions to reduce pollution in these areas.We believe that a routine surveillance system which links modelled outdoor air pollution data to health data would provide a useful tool for facilitating routine environmental public health work. Such a system would be especially useful for monitoring the health effects of traffic related pollution and for aiding health impact assessment. Implementation of the system will require close collaboration between public health and environmental health departments, protocols for sharing data and investment in training to develop the necessary technical expertise to set up and maintain the surveillance system. Of particular importance will be the ability of high level management to interpret surveillance information within a wider policy context.RM proposed the idea for the article. ECF wrote the first draft, supervised by RM. MD contributed the section on modelling air quality in the UK. RM edited subsequent drafts.


Difficulty of reconstruction of the eyelids arises from the need to reconstruct different supporting and covering structures in a single operation. Defects in the anterior lamella of the eyelids can be readily repaired with skin grafts or flaps but posterior lamellar reconstruction needs more complex applications.We performed posterior lamellar eyelid reconstruction with posterior parts of the temporalis fascia, since their anatomical and histological features are very similar to the defects. Nine patients with skin tumors located on the periorbital region were treated with local skin flaps and deep layer of the temporalis fascia.Grafts were harvested very easily. There was no complication related with graft or donor site. Biopsy was performed in three cases and normal conjunctival elements were seen. Functional and acceptable aesthetically results were achieved in all patients.Ideal reconstructive material for replacement of the posterior lamina is still lacking. Tarsal reconstruction can be made with deep temporalis fascia with success since the thickness of the both tissues are very similar and also since the loose areolar layer of the temporalis fascia is very thin and highly vascularized, this layer can be used in reconstruction of the conjunctiva. According to our knowledge this is the first report of using of the posterior part of temporalis fascia as a composite graft in the literature. Reconstruction of eyelid defects after tumor excision should aim at obtaining full globe protection without visual disruption and restoring the area to an appearance as close to normal as possible . ReconstTarso-conjunctival grafts, buccal mucosa, hard palate mucosa and amniotic membrane have been used in the reconstruction of the conjunctival defects and all techniques were reported with individual advantages and disadvantages. Temporalis fascia has a specific and complex anatomy -6. MainlNine patients with lower eyelid defects after removal of malignant tumors were treated with local flaps combined with temporalis fascia grafting in the Department of the Plastic and Reconstructive Surgery, Adnan Menderes University Hospital. Data of the patients were summarized in Table Ages of patients were ranged from 21 to 71. Full thickness defects measured from 15 × 5 mm to 50 × 15 mm. All patients were operated under the general anesthesia. The follow up periods ranged from 6 months to 24 months. After ethical approval from our department and patient consent, biopsy performed in three cases to evaluate the technique.Tumor excision was performed with safety surgical margins in all patients. Mustardé cheek flap was prepared in four patients, forehead flap and tri-lobed flap in two patients and one bi-lobed flap were designed. "Y" skin incision was performed for harvesting of the temporalis fascia Figure  and 1c.Against possible hair damage we did not use solution containing of epinephrine for haemostasis. The scalp is incised at angle that follows the direction of the hair follicles, which is facilitated by not shaving the hair. The incision is made through the scalp to the superficial fascia. Superficial fascia was incised to the temporalis muscle in dimensions 40 × 20 mm. This layer was elevated above the loose areolar tissue as distal based flap and loose areolar layer and deep temporalis fascia was dissected and harvested  this layer is thin and will conform to the shape of underlying soft tissue or cartilage with aesthetically pleasing fidelity,(b) well vascularized, and if handled with care, will readily support split and full thickness skin graft,(c) can be harvested easily, with minimal donor-site morbidity.We used this anatomical structure for conjunctiva reconstruction. Conjunctiva is a mucous membrane that covers the posterior aspect of the eyelids  and the anterior surface of the globe (bulbar conjunctiva). Defects larger than 25% of the eyelid usually require a free graft to make for the loss of specialized tissue. Conjunctiva harvested from another lid is the ideal match and physiologically but it is thin, difficult the handle, has tendency to contract, and can only be harvested sparingly to avoid interfering to donor fornices. In addition this technique requires two operations when it is performed as a lid sharing procedure. Oral mucosa is abundant and simple to remove but tends to contract and infection. Nasal mucosa is easier to handle, and minimal contraction but this procedure has some problem of poor access and thickness. Today, most performed techniques are hard palate mucosal graft, amnion membrane, chondormucosal Septum -20. TarsOne of the most popular grafts in posterior lamella reconstruction used to come from the chondromucosal nasal septum. Major disadvantages of this technique are the difficulty of the shape and adapt to the eyelid. Palatal mucosal grafts were widely used. Such grafts meet both the mucosal and supporting requirements. The use of hard palate mucosal grafting in lower eyelid reconstruction was first described by Siegel . Hard paIn our series we did not observe irritation signs and symptoms.It is agreed among most authors that the ideal reconstruction should use identical or similar tissue to that of the original structure. Undoubtedly, reconstructions of the posterior lamella with original tissue i.e. free tarso-conjunctival grafts or flap is the best treatment modality. If the donor sites of the tarso-conjunctival grafts or flap were not suitable or enough, deep temporalis fascia grafting would be an alternative in the reconstruction of the posterior lamella.We believe that application of the deeper part of the temporalis fascia for the reconstruction of the posterior lamella has many advantages: easy to perform, single composite graft for two layers, without or minimal donor site morbidity, no infection risk, no shrinkage of the graft, easy to adapt, wide donor site, no irritation and excellent cosmetically results. There is no data about the using of the posterior part of the temporalis fascia in reconstruction of the tarsus and conjunctiva in the literature.In conclusion, loose layer of the temporalis fascia is ideal tissue for the growing of the conjunctiva and the thickness of the deep layer of the temporalis fascia is very similar to the tarsus. Both tissues can be used in reconstruction of the posterior lamellar reconstruction of the eyelids with success.None declaredEC conceived of the study, and participated in its design and coordination. NS participated in design of study. All authors read and approved the final manuscript.


Quality of care from the perspective of users is increasingly used in evaluating health care performance. Going beyond satisfaction studies, quality of care from the users' perspective is conceptualised in two dimensions: the importance users attach to aspects of care and their actual experience with these aspects. It is well established that health care systems differ in performance. The question in this article is whether there are also differences in what people in different health care systems view as important aspects of health care quality. The aim is to describe and explain international differences in the importance that health care users attach to different aspects of health care.Data were used from different studies that all used a version of the QUOTE-questionnaire that measures user views of health care quality in two dimensions: the importance that users attach to aspects of care and their actual experience. Data from 12 European countries and 5133 individuals were used. They were analysed using multi-level analysis.Although most of the variations in importance people attach to aspects of health care is located at the individual level, there are also differences between countries. The ranking of aspects shows similarities. 'My GP should always take me seriously' was in nearly all countries ranked first, while an item about waiting time in the GP's office was always ranked lowest.Differences between countries in how health care users value different aspects of care are difficult to explain. Further theorising should take into account that importance and performance ratings are positively related, that people compare their experiences with those of others, and that general and instrumental values might be related through the institutions of the health care system. Large differences between countries exist in the use, costs, quality, and accessibility of health services . Also laQUality Of care Through the patients' Eyes – that distinguishes two quality of care dimensions: performance and importance [In this study we did a secondary analysis on surveys of patient views on quality of health care. Patients' views were measured using the QUOTE-questionnaire – with the acronym QUOTE standing for portance . PerformTo select relevant quality of care aspects, a general and a disease-specific approach was followed, using focus group discussions . With thIn this article we first compare the importance dimension of QUOTE across several European countries and Israel to gain insight in the similarities and differences in people's views on quality of care. Secondly, we will look at the relationship between importance and performance ratings as part of an explorative analysis to explain differences in importance ratings between patients and/or countries. The general research question is:Do patients in different European countries think differently about the relative importance of various aspects of quality of care, and if so, how can these differences be explained?This general question is divided into the following separate questions:a. To what extent do the importance judgements of patients cluster within countries when individual characteristics of patients are taken into account?b. Does the ranking of importance judgements vary between countries?c. What is the relationship between the average performance of health care systems, as judged by patients, and the individual importance judgements?When we compare the importance judgements of patients between countries, we will take into account individual characteristics of respondents to rule out differences in the composition of the groups of respondents. With respect to the relationship between importance and performances scores it might be anticipated that in general people attach more importance to those aspects that they actually experience less often. Analogous to the economic mechanism of decreasing marginal utility, e.g. quick service without waiting time in the doctor's office might be valued as less important, if in general services are quick and people don't have to wait long. However, at the same time it can be hypothesized that it's no use aspiring to something that nobody has. If quality of care ratings, as seen through the eyes of the patient, are low on the average and if there is small variation in these performance ratings between individuals, people will probably not find these aspects important. This idea is based on a mechanism of social comparison .The First Dutch QUOTE-questionnaires (for disabled persons, COPD, arthritis and frail elderly people) served as a starting point for our database ,12. ThesThe QUOTE-questionnaires have been translated in the context of different projects. In all but two cases backward-forward translations have been used. Answering formats of importance items were: Not important (1); Fairly important 2); Important (3); and Extremely important (4). The answering formats for the performance items were: No (1); Not really (2); On the whole, yes (3); and Yes (4). The equivalence of the answering formats in different languages has not been assessed. The wording of the importance items that were used in the QUOTE-questionnaires are presented in tables ; ImportaTable All 5133 health care users reported for each of (maximum) ten items their importance and performance ratings. The importance ratings are dependent variables in a series of statistical analyses with patients hierarchically nested in countries. In contrast to traditional forms of analysis of variance in which factors have 'fixed' effects, countries are considered to have 'random' effects. Such a variance component model is preferred over traditional analysis if the number of categories exceeds ten ,18. The The ICC is statistically defined as the variance between countries divided by the total variance. An ICC of zero therefore implies no variance between countries, indicating the absence of differences between countries in patients' importance ratings. Age and sex were included as covariates to take into account differences in the composition of responder groups in the different countries, because of their association with importance scores ,10,21-23In order to explore the relationship between importance and performance ratings Pearson correlations were calculated between the performance items, both at the individual level and aggregated to country level, and the importance rating on user level. In the introduction we have put forward two hypothetical relations between variation of performance within the countries and the importance ratings. To look at the relation between variation of performance and importance ratings, a distinction was made between countries with large variation in experienced health care quality and countries with smaller variation. Based on the mean standard deviation (SD) of all ten performance items, the countries were equally split into: Denmark, Italy, Belarus, Ireland, Ukraine and Portugal (mean SDs ranging from 1.17 to 1.40) indicating countries with high variation and Greece, Finland, Israel, Norway, Netherlands and UK (mean SDs ranging from .82 to 1.08) indicating countries with low variation. Furthermore, explore the relationship between variation in performance at country level, individual respondents performance experience and their importance ratings, we have divided the individual respondents into those who experienced high performance and those who experienced low performance. To keep these distinctions conveniently arranged in one table, we recoded the individual performance scores from the four point scale to a two point scale, with the combination of 'No' and 'No, not really', indicating poor quality, versus 'On the whole, yes' and 'Yes'.We start the presentation of the results with a description of the overall importance that respondents in all twelve countries attached to the different aspects and the clustering of their answers within countries. We then move to the differences in the ranking of aspects between countries. Finally, we will present results for the relationship between the actual experiences of respondents, both individually and aggregated to an average for each country, and the importance they attach to the different aspects.As shown in table In order to explore differences between user groups, we have computed intra-class correlation coefficients for user groups within the Netherlands only. These coefficients are on average higher than those regarding countries. We also analysed the differences between countries within the IBD patient groups. These differences are much like the figures of table The variation between the countries for each aspect is illustrated in table In order to look at the consistency of user views across the different countries, the ten importance aspects were ranked according to their mean value within each country. Table Looking at the relationship between importance and performance ratings by means of correlation coefficients, table If we take into account the variation in performance ratings within countries, the positive relationship between importance and performance ratings is somewhat stronger in the 'high variation' mode compared to the 'low variation' mode. This can be seen by comparing the difference between the first two columns of table Overall, importance scores are somewhat lower in countries with high variation in performance ratings as compared to countries with low variation in performance scores.The objective of our study was to gain insight into similarities and differences in the value users of health care in different countries attach to aspects of care. As an indicator of these values, importance scores of the QUOTE-questionnaires were used. These scores reflect what is important in evaluating health care quality according to users. Our results show that health care users in different countries to some extent think differently about the relative importance of various aspects of quality of care. Intra-class correlation coefficients were calculated to measure the difference between countries. They range from low to high. Sex-age adjusted intra-class correlation coefficients were only slightly lower. This means that demographic differences between the groups that filled in the questionnaires in different countries cannot explain the differences in average importance between the countries.Although there are differences between countries, the importance rankings of the aspects also show consensus. 'My GP should always take me seriously' is nearly always ranked highest, while the item about waiting time is always ranked as least important. Since we only analysed a small sample of countries, it is difficult to generalise this result. However, it might say something about a hierarchy of these instrumental health care values, suggesting that values concerning respectfulness are seen as more important than service aspects, such as waiting time. This is in line with the findings of Grol et al. . There aIn general, there is a positive relation between what people find important and their experiences, both on an individual level and related to the average experience in a country. The positive relation between importance and experience could probably be explained by a general tendency of cognitive consistency  or alterBy looking at the variation in the performance scores, we have tried to include social comparison mechanisms into the analysis. It can be argued that if people's individual experience indicates low performance for certain aspects in countries, they will value these aspects as more important. However, such a hypothesis has to be rejected on the basis of the results presented in this article. A contrasting hypothesis, that in countries with low variation in actual experiences, people who experience low performance themselves, will not aspire to something that is apparently (from their own and others' experience) out of reach is only partly supported by our findings. Although people in this low variation condition have significantly lower importance scores for half of the items, still the differences in the high variation condition are higher.Looking at the individual aspects, it can be argued that people don't find issues important if they are more or less guaranteed by the health care system. An example for this is the issue of prescribing pharmaceuticals that are fully covered by the health care insurance plans of patients. On the basis of the material presented in this article this hypothesis too has to be rejected. People in countries with low levels of cost sharing in this field, found this item more important than people in countries with higher levels of cost sharing. However, an alternative explanation for this finding could be that structural aspects of the health care system, e.g. on the dimension public – private, reflect general values ,29. If tIn general, we believe that further theorising about differences between health care systems in what people find important, might start from the positive relation between importance and experience, from the idea that people compare their experiences with those of others, and from the idea that general and instrumental values might be related trough the institutions of the health care system. Hofstede  has idenThe analysis presented in this article has its shortcomings. The number of countries is small. The analysis of differences between countries is based on only twelve countries, even though large numbers of respondents were involved. The number respondents increase our confidence in the averages per country, but this does not solve the problem of small numbers at the country level. Differences between user groups could not be taken into account because of the small number of groups for all countries except the Netherlands, although one might expect these differences to exist .The multilevel model now contained two levels, respondents and countries. However, as table We used existing data, collected in different studies with different aims and methods. The response rates differed across studies. The user groups in the surveys refer to are very different, ranging from GP-patients in Belarus to disabled people in the UK and IBD patients in Israel. Apart from the apparent differences between user groups, there are also differences between countries in the position and tasks of GPs. The situation in Ukraine and Belarus was transitional, even ten years after the fall of the Iron Curtain . This maThe QUOTE-questionnaires provide a general framework, and researchers have adapted them to their own aims. Against the advantage of flexible adaptation to different research aims and populations stands the disadvantage of reduced  comparability. For  comparisons more standardisation is very important. Apart from that, the ten QUOTE-aspects we used in our analyses cover different dimensions of the Quality of care concept and can be understood as being comprehensive enough for this explorative type of research.In conclusion, we believe it is important to continue to do research into health care related values because of the increasing importance of user views, both in the health policies of European countries separately and in the international debate about the performance of health care systems. There is not much ground for strong cultural relativism, saying that what is important in the eyes of health care users is so different that it is not possible to develop performance measures that can be used in a wide range of countries.There are differences between countries in the importance people attach to aspects of health care. Most of this variation is related to individual differences, but there is also significant variation between countries. The ranking of aspects shows similarities between countries. In nearly all countries, people ranked the item that their GP should take them seriously as most important, while an item about waiting time was always ranked lowest. It is difficult to explain the variation between countries. Further theorising should take into account that importance and performance ratings are positively related, that people compare their experiences with those of others, and that general and instrumental values might be related through the institutions of the health care system.The author(s) declare that they have no competing interests.PG conceived the study and wrote the first drafts of the article; JK performed the statistical analysis; HS provided data and wrote the final draft of the article; WB provided data; IvdE provided data.The pre-publication history for this paper can be accessed here:


Despite the sophisticated cross sectional image techniques currently available, a number of biliary stenosis or obstructions remain of an uncertain nature. In these pathological conditions, an "intrinsic" parietal alteration is the cause of biliary obstruction and it is very difficult to differentiate benign from malignant lesions using cross-sectional imaging procedures alone. We evaluated the efficacy of different endoluminal techniques to achieve a definitive pathological diagnosis in these situations.Eighty patients underwent brushing, and or biopsy of the biliary tree through an existing transhepatic biliary drainage route. A subcoort of 12 patients needed balloon-dilatation of the bile duct and the material covering the balloon surface was also sent for pathological examination . Pathological results were compared with surgical findings or with long-term clinical and instrumental follow-ups. Success rates, sensitivity, specificity, accuracy, confidential intervals, positive predictive value and negative predictive value of the three percutaneous techniques in differentiating benign from malignant disease were assessed.The agreement coefficient of biopsy and brushing with final diagnosis was calculated using the Cohen's "K" value.Fifty-six patients had malignant strictures confirmed by surgery, histology, and by clinical follow-ups. Success rates of brushing, balloon surface sampling, and biopsy were 90.7, 100, and 100%, respectively. The comparative efficacy of brushing, balloon-surface sampling, and biopsy resulted as follows: sensitivity of 47.8, 87.5, and 92.1%, respectively; specificity of 100% for all the techniques; accuracy of 69.2, 91.7 and 93.6%, Positive Predictive Value of 100% for all the procedures and Negative Predictive Value of 55, 80, and 75%, respectively.Percutaneous endoluminal biopsy is more accurate and sensitive than percutaneous bile duct brushing in the detection of malignant diseases (p < 0.01). Bile duct dilatation and increasing jaundice are often onset symptoms of a number of either malignant or benign pathological conditions.In most cases, common cross-sectional imaging techniques such as ultrasonography (US) or spiral-CT or cholangio-pancreatico-biliary magnetic resonance (MRCP) are highly capable of depicting the causes of obstruction by simply showing extrinsic masses in case of infiltrating tumors or benign causes of jaundice, like stones .These non invasive techniques, however, can still yield uncertain results in some particular benign or malignant pathological conditions.When stones are too small for example, or when bile duct dilatation is limited. For final confirmation or exclusion of endobiliary stones ERCP is unavoidable before the subsequent therapeutic steps.There are also some pathological conditions where an "intrinsic" parietal alteration is the cause of biliary obstruction and it is very difficult to distinguish benign from malignant lesions using cross-sectional imaging procedures alone figure  - 5.A biliary dilatation may also occur after surgical interventions involving the biliary system, like bilioenteric anastomoses for gastric or pancreatic neoplasms or cholecystectomies. It is not always possible to distinguish between a recurrent disease or a fibrotic post-surgical stenosis, especially if it occurs early and if inflammatory alterations were already present during surgery.A number of obstructions remains therefore unexplained because the aforementioned imaging modalities do not show any extrinsic compressing or infiltrating mass, nor a calcolous disease.In these cases, only the intrahepatic bile ducts dilation and the level of the obstruction can be determined, but additional diagnostic procedures should be performed for a diagnosis of the real nature of the obstruction .Patients with obstructive jaundice often undergo percutaneous biliary cholangiography and drainage (PBD) for decompression of the biliary tree.Although relatively invasive, not even PBD allows to achieve a definitive differential diagnosis between malignant and benign pathologies.Tissue sampling becomes therefore essential for the histological characterization of parietal alterations and for planning their appropriate treatment .Bile cytology, although easily feasible either through a transhepatic or an endoscopic route, does not accomplish adequate pathological diagnoses in most cases -7.In our study, three different endoluminal sampling techniques for the characterization of biliary strictures of uncertain nature have been reviewed and comparatively evaluated with the purpose of determining which one of them is the most accurate for differentiating between benign or malignant pathology.Our investigation was performed on a population of 80 patients who, from January 1992 to September 1999, underwent endoluminal brushing and/or biopsy for biliary stenosis or obstructions of uncertain nature. A retrospective evaluation of the efficacy of these techniques was carried out by comparing the pathological findings on one hand and radiological findings, clinical long-term follow ups, and/or post-surgical specimens, on the other.Patient population included 43 men and 37 women, with a mean age of 62 years (range 37–87 years). All patients presented jaundice as a common symptom, weight loss was present in 20 cases (25%), and itching in 12 cases (15%).At admission, all patients presented biliary dilation, but no masses were identifiable by imaging procedures such as US, CT, MRCP. ERCP had been performed in 23 patients with middle-low common bile duct stenosis but the nature of obstruction could not be determined nor a drainage could be placed.Obstruction were located at the biliary bifurcation in 18 cases (22.5%), the common extrahepatic bile duct in 50 (62.5%), the right (2) and left (2) hepatic duct in 4 cases (5%)Eight patients with bilioenteric anastomoses (10%) were also evaluated in order to determine the nature of the stricture. The patients came to the interventional unit needing for a biliary drainage. PBDs were performed using standard interventional techniques.The percutaneous approach was right lateral in all patients but 25 of them required also an anterior subxyphoid approach.The procedures for cytological and/or histological samples were performed in any case 3–5 days after placement of the biliary drainage in order to operate on a decompressed biliary system.One hundred and two endoluminal procedures were included in this study. Twenty-one patients underwent cytologic brushing only, 25 endoluminal biopsy only, and 22 both brushing and biopsy. A total number of 43 brushings and 47 biopsies were performed.In 12 additional cases, we obtained cytological and tissue samples from an angioplastic balloon used for the bilioplasty of strictures of uncertain nature  with techniques that will be described.Sixteen patients underwent brushing only, because the cholangioscope was not available yet and five because the diagnosis of malignancy achieved with brushing was considered sufficient, thus not requiring further diagnostic workups to planning the appropriate therapy.All the specimens were collected after PBD thus after translesional advancement of a 10 French catheter; in 12 particularly heavy stenosis a preliminary balloon dilatation was also accomplished.Brushing was performed according to the following technical steps:- the indwelling biliary drainage catheter was exchanged over a guide-wire with a 7/9-F. introducer sheath without valves at the proximal end ("peel-away", William Cook, Europe)- a flexible probe Fig.  with a c- the brush was then carefully pulled back to be removed from the patient into the sheath, to avoid malignant spreading through the transhepatic tract-samples were then placed on a glass slide, fixed with Sprayfix , immediately submitted for cytological examination and stained by the standard Papanicolau technique.Endoluminal forceps biopsy was performed under direct visualization with a 5-mm. cholangioscope (Olympus URF. Type P, Japan) Fig. . Sometim- the biliary catheter was replaced, over a guide, by a 18-F "peel-away" introducer sheath through which the cholangioscope was advanced until it was close to the lesion;- a flexible forceps :- once deflated, the balloon (8–10 mm., Meditech, Boston, USA) was pulled back into the sheath and removed from the patient;- the balloon was then placed in a saline solution with 10% of formalin, inflated and agitated several times to facilitate detachment of samples, which were then immediately delivered to the pathology laboratory.Pathological specimens from 14 patients were compared with open surgery findings and post-surgical pathological reports. The pathologists, hystologists and cytologists, were blinded as to corresponding results.The follow-up of the patients undergone to surgery stopped after the operation. Patients not candidate to surgery were treated with interventional procedures only such as bilioplasty, biliary drainage, interstitial radiotherapy and/or with chemotherapy or just a supportive therapy. This group of unoperated patients was followed-up on the basis of clinical and radiological data obtained by case-record reviews and by correspondence with their referring clinicians and general practitioners. The follow-up period ranged from 3 to 48 months. A minimum of 12 months of healthy negative cytological-histological diagnosis was necessary because either a clinically benign stenosing lesion or a cytohistological diagnosis negative for malignancy must be confirmed by a prolonged survival, as well as by clinical and radiological findings.Calculations of success rate, sensitivity, specificity, positive predictive value, and negative predictive value for each technique were based on the number of biopsy procedures n = 102) rather than on the number of patients (n = 80),  were determined for brushing and biopsy groups assuming a P value of .01 by using the Geigy Scientific Table (Geigy, Florence, 1984). The agreement coefficient between biopsy or brushing and final diagnosis was calculated using the Cohen's "K" value using SPSS 8.0 for Windows (SPSS, Chicago, Illinois, 1997).A final diagnosis of malignant disease was confirmed in 56 (70%) cases and a final diagnosis of benign disease in 24 (30%) cases for an overall of 80 patients.Final diagnoses in the malignant group included: cholangiocarcinoma (n = 31), adenocarcinoma (n = 6), metastatic adenocarcinoma (n = 5), pancreatic carcinoma (n = 13) and malignant endocrine tumor (n = 1). Final diagnoses in the benign group included: iatrogenic stenosis (n = 9), sclerosing cholangitis (n = 12) and primary (N = 2) and secondary biliary cirrhosis (N = 1).Thirty-nine of the 43 brushing biopsies procedures were technically adequate for the diagnostic evaluation. Four cases were considered "poorly cellular" by the pathologists, with an overall success rate of 90.7% Table . These 4Malignant cells were detected by brushing in 11 cases including: adenocarcinoma n = 2), cholangiocarcinoma (n = 6), pancreatic carcinoma (n = 2), and metastatic adenocarcinoma (n= 1)  Table .Endoluminal forceps biopsy was performed in 47 cases. Thirty-five of these were interpreted as containing malignant cells Table : cholangThree cases were erroneously interpreted as benign  but the clinical follow-up revealed 2 pancreatic carcinomas and 1 adenocarcinoma Table . With 35CIs were reported in Table As previously discussed, 12 samples were obtained in as many patients with an angioplastic balloon after dilation of biliary strictures . This technique demonstrated malignant cells in 7 58.3%) cases and benign cells in 5 41.7%). The final clinical diagnosis of the malignant group included adenocarcinoma (n = 1), cholangiocarcinoma (n = 5) and pancreatic carcinoma (n = 1) , iatrogenic stricture (n = 1) and biliary cirrhosis (n = 2) and 6 malignant diseases, such as cholangiocarcinoma (n = 3), pancreatic carcinoma (n = 2), and metastatic adenocarcinoma (n = 1) were included. All concordant diagnoses were confirmed by clinical or surgical follow-up. In the group of 6 discordant diagnoses, cholangiocarcinoma (n = 4) adenocarcinoma (n = 1) and pancreatic carcinoma (n = 1), were included. All the 6 malignancies misdiagnosed by brushing were correctly diagnosed by biopsy.Transient hemobilia (spontaneously reversed from 1 to 12 hours after the procedure), was observed in 5/47 (10.6%) patients who had undergone biopsy.In 4 of them, particular angulations of the access route was present and there were difficulties in negotiation of the stricture.No major complications directly related to the brush cytology or the endoluminal forceps biopsy procedures occurred.The evaluation of patients with biliary tract obstruction without evidence of any intrahepatic or extrahepatic growing mass has traditionally involved a variety of diagnostic imaging techniques . UltrasoThese imaging modalities, are however limited in depicting intraductal anatomy and, sometimes, in exactly determining the level and the cause of the obstruction ,9. MagneThe assessment of the level of obstruction also has been reported as highly accurate -19. HoweFine-needle percutaneous biopsy (FNPB) and fine-needle aspiration (FNA) has been reported poorly valuable in absence of a lesion clearly identifiable ,22. The Treatment protocols require pathological diagnoses for palliative or possibly curative therapy in almost all these types of conditions. In addition, the surgical technique itself can be different if a malignancy is present or not. Some Authors, when liver transplant is still indicated, suggest a large excision associated with gastrectomy, pancreatectomy and a transverse ascending colectomy .Although the efficacy of this surgical approach is still under debate, the role of a preoperative diagnosis is extremely important.Malignant cells surrounding the biliary ducts may continuously exfoliated into the bile, especially in the case of tumors which breack through the mucosa, and become available for the cytological examination when the bile is collected either percutaneously or by ERCP. Cytodiagnosis is easy to be performed, atraumatic in nature, with less potential risk and associated with relatively low charges. This technique has shown low sensitivity 15–28%) and accuracy (48–58%) rates, due to an early cellular degeneration after bile collection and to "poorly cellular" specimens. In addition, some pathological aspects can affect the efficacy of the procedure, such as in case of lesions extrinsically compressing the bile duct wall without a complete transmural infiltration or an adequately wide mucosal disruption . Endolum% and accAccording also with our cholangioscopic experience, biliary tumors may remain intramural causing an annular constriction of the biliary duct ,29 withoIn this review only patients not suitable for ERCP or coming from a failed drainage or other type of retrograde endoscopic intervention were evaluated, thus the percutaneous and endoscopic techniques can not be compared. Whenever possible especially if skilled endoscopists are available, retrograde approach could still to be considered the first step, for its potentially high sensitivity especially if repeated sampling are performed ,28Percutaneous brush cytology, if compared with bile transendoscopic cytodiagnosis, has the potential risk of a malignant spreading of cells through the transhepatic tract. To overcome this risk, in our opinion, the brush should be pulled back and removed from the patient into the introducer sheath. With this technique, in fact, no spreading along the transhepatic tract was observed in our malignant patients at imaging follow-up. Brush cytology is a easy, safe and at relatively low-cost procedure, similarly to bile collection. A single sampling however has a low possibility of detecting a malignancy. The results can improve with multiple samples. Three consecutive negative samples decrease the probability of a malignancy from more than 55% to less than 5% . The absThe differentiation degree of a tumor can affect the accuracy of the histological classification. In those cases of extrahepatic and periampullary biliary tumors, in fact, usually highly undifferentiated, the histological characterization can be difficult, although a generic diagnosis of malignancy can be made.Potential complications due to forceps biopsy, such as disruption of the ductal wall with consequent bile leak and bleeding, cholangitis and pancreatitis, are reported .Endoluminal forceps biopsy especially in patients with hemobilia or cholangitis, should therefore be performed in the remission phase of the disease, and, in any case, at least 5 days after biliary drainage, to avoid the complications related to manipulations into the biliary tree. No major complications were observed in this series, neither from percutaneous brushing nor from forceps biopsy. A transient hemobilia was observed in 5 patients who had undergone biopsy (10.6%). This series, including part of a previously analyzed smaller population  confirmsA high diagnostic value was proven by the simple examination of tissue samplings coming from balloon dilatation of biliary or bilio-enteric anastomotic strictures . Although the number of cases reported in this series is relatively small, it should be considered that it was possible to distinguish benign from malignant diseases in almost all the cases. Our suggestion, therefore is to associate a tissue collection from the balloon to bilioplasty, as a standard procedure when screening for malignant pancreatobiliary diseases is required. In this way. it is possible to save time and avoid risks related to further endobiliary procedures.Patients with obstructive jaundice, who are candidates for biliary drainage, often come to the interventional radiologist still without a definitive diagnosis of the real nature of their disease, even after high-level cross-sectional imaging procedures, such as abdominal MR, MRCP or abdominal spiral-CT. When the clinical diagnosis needs to be histologically confirmed for further therapeutic choices, the transhepatic route can be successfully used for the intraductal sampling. Forceps biopsy is highly accurate under cholangioscopic guidance. As an alternative, repeated brushings can be performed under fluoroscopy. If a balloon blioplasty, for any reason, is performed, it is advisable to collect the tissue fragments on the balloon surface and send them for pathological evaluation.None declared.MR carried out the interventional procedures, participated in the design of the study and drafted the manuscript, FMS carried out the interventional procedures, VC defined the design of the study and performed the statistical analysis, LG collected the results of the procedures, LG participated in the histological analysis, AR participated in the design of the study and drafted the manuscript,, GG participated in the imaging evaluations, EP performed the patients follow-up, VD supervised the drafting of the studyThe pre-publication history for this paper can be accessed here:


There is ample clinical evidence that inherited severe AAT deficiency predisposes to chronic obstructive pulmonary disease. Augmentation therapy for AAT deficiency has been available for many years, but to date no sufficient data exist to demonstrate its efficacy. There is increasing evidence that AAT is able to exert effects other than protease inhibition. We investigated whether Prolastin, a preparation of purified pooled human AAT used for augmentation therapy, exhibits anti-bacterial effects.Human monocytes and neutrophils were isolated from buffy coats or whole peripheral blood by the Ficoll-Hypaque procedure. Cells were stimulated with lipopolysaccharide (LPS) or zymosan, either alone or in combination with Prolastin, native AAT or polymerised AAT for 18 h, and analysed to determine the release of TNFα, IL-1β and IL-8. At 2-week intervals, seven subjects were submitted to a nasal challenge with sterile saline, LPS (25 μg) and LPS-Prolastin combination. The concentration of IL-8 was analysed in nasal lavages performed before, and 2, 6 and 24 h after the challenge.In vitro, Prolastin showed a concentration-dependent (0.5 to 16 mg/ml) inhibition of endotoxin-stimulated TNFα and IL-1β release from monocytes and IL-8 release from neutrophils. At 8 and 16 mg/ml the inhibitory effects of Prolastin appeared to be maximal for neutrophil IL-8 release (5.3-fold, p < 0.001 compared to zymosan treated cells) and monocyte TNFα and IL-1β release (10.7- and 7.3-fold, p < 0.001, respectively, compared to LPS treated cells). Furthermore, Prolastin (2.5 mg per nostril) significantly inhibited nasal IL-8 release in response to pure LPS challenge.in vitro and in vivo, and provide scientific bases to explore new Prolastin-based therapies for individuals with inherited AAT deficiency, but also for other clinical conditions.Our data demonstrate for the first time that Prolastin inhibits bacterial endotoxin-induced pro-inflammatory responses  AAT is The pulmonary emphysema that is associated with inherited AAT deficiency is intimately linked with the lack of proteinase inhibitor within the lungs that is available to bind to, and inactivate, neutrophil elastase. On the basis of clinical observations involving patients with inherited AAT deficiency and various experimental studies, the elastase-AAT imbalance hypothesis became widely accepted as the explanation for lung tissue destruction in emphysema ,21. TherBased on the protease-antiprotease hypothesis, augmentation therapy of emphysema with severe AAT deficiency was introduced during the 1980s . Intravein vivo [in vitro, that both native (inhibitory) and non-inhibitory (polymerised and oxidised) forms of AAT strongly inhibit lipopolysaccharide-induced human monocyte activation [in vitro, and suppresses nasal IL-8 release in lipopolysaccharide-challenged individuals, in vivo.There is growing evidence that AAT, in addition to its anti-proteinase activity, may have other functional activities. For example, AAT has been demonstrated to stimulate fibroblast proliferation and procollagen synthesis , to up-rin vivo ,38. We rtivation . AAT app® (Lot 26N3PT2) was a gift from Bayer (Bayer Corporation, Clayton, North Carolina, USA). This vial of Prolastin contained 1059 mg of functionally active AAT, as determined by capacity to inhibit porcine pancreatic elastase. Prolastin was dissolved in sterile water for injections provided by manufacture and stored at +4°C. Purified human AAT was obtained from the Department of Clinical Chemistry, Malmö University Hospital, Sweden. Native AAT was diluted in phosphate buffered saline (PBS), pH 7.4. To ensure the removal of endotoxins, AAT was subjected to Detoxi-Gel AffinityPak columns according to instructions from the manufacturer (Pierce, IL, USA). Purified batches of AAT were then tested for endotoxin contamination with the Limulus amebocyte lysate endochrome kit (Charles River Endosafe, SC, USA). Endotoxin levels were less than 0.2 enzyme units/mg protein in all preparations used. The concentrations of AAT in the endotoxin-purified batches were determined according to the Lowry method [α1-antitrypsin (Human) Prolastiny method . Polymerg for 35 min, at room temperature, the cells in the interface were collected and washed 3 times in PBS-EDTA. The cell purity and amount were determined in a cell counter Autocounter AC900EO (Swelabs Instruments AB, Sweden). The granulocyte fractions were less than 10%. Cells were seeded into 12-well cell culture plates (Nunc, Denmark) at a concentration of 4 × 106 cells/ml in RPMI 1640 medium supplemented with penicillin 100 U/ml; streptomycin 100 μg/ml; non-essential amino acids 1×; sodium pyruvate 2 mM and HEPES 20 mM (Gibco, UK). After 1 h 15 min, non-adherent cells were removed by washing 3 times with PBS supplemented with calcium and magnesium. Fresh medium was added and cells were stimulated with lipopolysaccharide  in the presence or absence of various concentrations of Prolastin (0–16 mg/ml), constant concentration of native or polymerised AAT (0.5 mg/ml) for 18 h at 37°C, 5% CO2.Monocytes were isolated from buffy coats using Ficoll-Paque PLUS (Pharmacia, Sweden). Briefly, buffy coats were diluted 1:2 in PBS with addition of 10 mM EDTA and layered on Ficoll. After centrifugation at 400 Human neutrophils were isolated from the peripheral blood of healthy volunteers using Polymorphprep TM (Axis-Shield PoC AS, Oslo, Norway) as recommended by the manufacture. In brief, 25 ml of anti-coagulated blood was gently layered over the 12.5 ml of Polymorphprep TM and centrifuged at 1600 rpm for 35 min. Neutrophils were harvested as a low band of the sample/medium interface, washed with PBS, and residual erythrocytes were subjected to hypotonic lysis. Purified neutrophils were washed in RPMI-1640- Glutamax-1 medium (Gibco-BRL Life Technologies, Grand Island, NY) supplemented with 0.1% bovine serum albumin (BSA) and resuspended in the same medium. The neutrophil purity was more than 75% as determined on an AutoCounter AC900EO. Cell viability was > 95% according to trypan blue staining.6 cells/ml) were plated into sterile ependorf tubes. Zymosan was boiled, washed and sonicated. Opsonized zymosan was prepared by incubating zymosan with serum (1:3) in 37°C water bath for 20 min. After, zymosan was centrifuged, washed with PBS and re-suspended at 30 mg/ml. Cells alone or activated with zymosan (0.3 mg/ml) were exposed to various concentrations of Prolastin (0–8 mg/ml), and native or polymerised AAT preparations (0.5 mg/ml) for 18 h at 37°C 5% CO2. Cell free supernatants were obtained by centrifugation at 300 g for 10 min, and stored at -80°C until analysisNeutrophils .Seven subjects  of 26–50 (median 38) years of age, non-smokers, non-allergic volunteers participated in the study. All subjects gave written informed consent before participation in the study. None of the subjects has a history of respiratory disease and none took any medication at the study time.At 2-week intervals each subject was submitted to a nasal challenge with sterile saline, LPS and LPS-Prolastin combination. All experimental sessions were done in the same room. On each provocation day, the nose was inspected and cleaned with 8 ml of isotonic NaCl. Between nasal lavages the subjects stayed in the same building and asked to keep away from known sources of nasal irritants. The night was spent in their own homes. All participants completed a symptom questionnaire. In the first session, the baseline lavage was taken after instillation to each nostril of 8 ml of sterile isotonic NaCl. In the next session, the subjects were challenged with LPS from Escherichia coli serotype 026:B6, Lot 17H4042 (Sigma-Aldrich, USA). The provocation solution was prepared prior to use. LPS was added to 8 ml of sterile 0.9% NaCl to obtain a final concentration of 250 μg/ml, and 100 μl of the provocation solution was sprayed into each nostril, using a needle-less syringe. In the third session, the subjects were first challenged with LPS, as described above, and after 30 min with 2.5 mg of Prolastin into each nostril. Lavage samples were taken with instillation to each nostril of 8 ml of sterile isotonic NaCl after 2, 6 and 24 h followed by assessment of symptoms by a questionnaire. All subject completed a symptom questionnaire with questions about nasal and eye irritation, and throat and airway symptoms. None of the participants reported symptoms of nasal, eye or throat irritations, and no general symptoms such as muscle pain, shivering, were mentioned.The procedure for nasal lavage was performed according to a method described by Wihl and co-workers . Each na. Tests showing p < 0.05 were considered to be significant.Statistical Package (SPSS for Windows, release 11.5, SPSS Inc., Chicago) was used for the statistical calculations. The differences in the means of cell culture experimental results were analysed for their statistical significance with the one-way ANOVA combined with a multiple-comparisons procedure (Scheffe multiple range test). The equality of means of experimental results in healthy volunteers were analysed for statistical significance with independent two sample t-test and repeated measures of ANOVA using the SPSS MANOVA procedure Various concentrations of Prolastin (0–16 mg/ml) were added to adherent-isolated human monocytes with or without LPS (10 ng/ml). Cells stimulated with LPS alone served as a positive control, while PBS stimulated monocytes served as negative controls. As illustrated in figures We recently found that simultaneous incubation of monocytes with LPS and either the inhibitory (native) or non inhibitory (polymeric) form of AAT resulted in a reduction in TNFα and IL-1β release compared to the cells stimulated with LPS alone. At 0.5 mg/ml the effects of native and polymerised AAT appeared to be maximal (41). Therefore, we selected a 0.5 mg/ml concentration of Prolastin, native and polymerised AAT, and compared their effects on LPS-stimulated cytokine release at 18 h. As shown in figures The effects of Prolastin (0–8 mg/ml) on human neutrophil IL-8 production are shown in Figure Neutrophils were stimulated with zymosan (0.3 mg/ml) or AATs (0.5 mg/ml) either alone or in combination for 18 h and IL-8 protein determined. As illustrated in figure To assess the effect of Prolastin on LPS-induced nasal provocation, IL-8 levels in nasal lavages were measured. Nasal instillation 25 μg per nostril of LPS alone or in combination with 2.5 mg/ml of Prolastin was performed in non-smoking and non-allergic volunteers . The IL-8 release in response to LPS challenge increased over time compared to baseline levels  and at least two modified (non-inhibitory i.e. polymeric and oxidised) forms of AAT can block the release of an array of chemokine and cytokines from LPS-stimulated monocytes [in vitro and in vivo.There is now, however, ample evidence that serine proteinase inhibitors (serpins), in addition to their well established anti-inflammatory capacity to regulate serine proteinases activity, may possess broader anti-inflammatory properties. Several studies have shown that the biological responses of bacterial lipopolysaccharide (endotoxin) n by LPS ,43. Our onocytes . These se.g. IL-6, IL-1β and TNFα) and the chemokines (e.g. MCP-1 and IL-8) [in vitro. The Prolastin exhibited these anti-inflammatory properties in a concentration-dependent manner. Its maximal effects were observed with 16 mg/ml in the monocyte model and with 8 mg/ml in the neutrophil model, since doubling these concentrations did not significantly modify the intensity of the effects. Indeed, Prolastin markedly prevented endotoxin-induced cell activation at 0.5–4 mg/ml concentrations, implying that these lower concentrations of Prolastin might also be sufficient to inhibit endotoxin effects. It is worth noting that in order to reduce a potential risk of transmission of infectious agents the Prolastin preparation is heat-treated in solution at 60° ± 0.5 for not less than 10 h. Data from in vitro studies show that heat-treatment results in AAT polymerization and loss of its inhibitory activity [Stimulation of human monocytes and neutrophils with bacterial endotoxin results in the release of a range of inflammatory mediators including the pro-inflammatory cytokines (nd IL-8) -46. Togeactivity ,48. Theractivity . Furtherin vivo. In particular, we were interested in concentrations of the neutrophil chemoattractant, IL-8. Endotoxin (or LPS) from gram-negative bacteria is a common air contaminant in a number of occupational conditions, especially those in which exposure to animal waste or plant matter occurs [3 air and may be associated with respiratory symptoms and nasal inflammation in exposed persons [To explore our hypothesis that AAT functions as a potent inhibitor of endotoxin-induced effects, we examined whether Prolastin also inhibits responses to LPS in the nasal airway, r occurs ,49-51. L persons . For exa persons . A numbe persons ,55. In oin vitro and in vivo experiments provide novel evidence that the Prolastin preparation is a potent inhibitor of endotoxin effects. The major concept behind augmentation therapy with pooled plasma-derived AAT has been that a rise in the level of AAT in subjects with severe inherited AAT deficiency would protect the lung tissue from continued destruction by proteinases (i.e. primarily leukocyte elastase) [Pseudomonas aeruginosa lung infection [Thus, data from both lastase) ,56,57. Rlastase) ,58. Furtnfection . Stocklenfection ,60. DataAAT, α1-antitrypsin; COPD, chronic obstructive pulmonary disease; LPS, lipopolysaccharide; ZZ, homozygous AAT-deficiency variant; MM, wild type AAT variant; PBS, phosphate buffered saline; EDTA, ethylenediaminetetraacetic acid; HEPES, 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acidIzabela Nita, performed cell culture experiments, made contribution to acquisition of data;Camilla Hollander, made substantial contribution to patient study design, material collection and analysis; Ulla Westin, contributed to study design and data interpretation; Sabina Janciauskiene, contributed to conception and study design, data interpretation and wrote the article