A major barrier to the use and scale-up of evidence-based interventions are challenges related to training and capacity building. A cost-effective and highly interactive multi-user virtual environment, Second Life (SL) is a promising alternative for comprehensive face-to-face facilitator training.The purpose of this study was to examine the feasibility of using SL to train facilitators from community-based organizations to use ¡Cuídate! (Take Care of Yourself), one of the few evidence-based interventions developed and tested with Latino youth to reduce sexual risk behaviors.We recruited 35 participants from community-based organizations throughout the United States to participate in the SL ¡Cuídate! Training of Facilitators. Preparation to use SL consisted of four phases: (1) recruitment and computer capacity screening, (2) enrollment, (3) orientation to the SL program, and (4) technical support throughout the synchronous training sessions. Technical difficulties, the associated cause, and the mitigation strategy implemented were recorded during each session. Participants completed evaluations including perceptions of self-efficacy and confidence to complete the necessary skills to participate in SL training.Overall, participants reported high levels of self-efficacy for all skills necessary to participate in SL training. Based on an 11-point scale (0-10), self-efficacy to download and access the software was rated the highest: mean 8.29 (SD 2.19). Interacting with items in SL had the lowest mean score: mean 7.49 (SD 2.89). The majority of technical difficulties experienced by participants were related to inadequate Internet connections or computer malfunctions.Our findings support the feasibility of using SL for the ¡Cuídate! Training of Facilitators. The process used in this study to prepare participants to use SL can be used as a basis for other evidence-based intervention training in SL. This study is an important contribution to developing cost-effective and accessible training options for evidence-based interventions. Multi-user virtual environments (MUVEs), such as Second Life (SL), are a promising alternative to face-to-face training for health care program delivery . While rA MUVE is a computer-based, simulated virtual environment allowing users to inhabit an online virtual world and interact with others via self-representations known as avatars in synchronous sessions . The advSL has been previously used for small-scale health-related programs focusing on education and awareness, support, training, marketing, and promotion of health services ,6-11. FoVirtual training presents a number of technical challenges, including computer system capacity and security issues . For exaThe purpose of this study was to examine the feasibility of using SL to train facilitators to use an EBI, ¡Cuídate! (Take Care of Yourself), one of the few sexual risk reduction interventions developed and tested with Latino youth . The parThis is a descriptive study. The study protocol was reviewed by the institutional review board at the University of Michigan and was deemed exempt and not regulated.A virtual training center  was devePreparation to use SL consisted of four phases: (1) recruitment and computer capacity screening, (2) enrollment, (3) orientation to the SL program, and (4) technical support throughout the synchronous training sessions.Community-based organizations throughout the United States were sent information about the SL Cuídate Training of Facilitators opportunity via social media , distribution lists, and newsletters. To ensure agency staff could feasibly participate in the SL training, an online portal and a screening process were established. Community-based organizations submitted contact information and answered screening questions to determine if their computer system capacity met SL’s system requirements. The minimum system requirements for SL include at least a Windows XP or Mac OS X 10.6 operating system, a graphics card model NVIDIA GeForce 6600 or better, an ATI Radeon 9500 or better, or an Intel 945 chipset for three-dimensional functionality, and a high-speed Internet connection . To idenIf registrants had questionable capacity , research staff guided each registrant through an online scanner available from System Requirements Lab, Inc. . If miniOnce an agency met the minimum computer system capacity, they were presented with a Memorandum of Understanding (MOU) that included information on the purpose of the study, responsibilities of participants, and expectations and accountability of the research team. Participants received an enrollment phone call to review the MOU and were provided with an outline of the project activities. Once the MOU was signed, a ¡Cuídate! Implementation Kit  and a unCommunication occurred with 120 different community agencies and entities throughout the United States via recruitment phone calls. Of those, personnel from 59 agencies underwent the screening process previously described. Of the agencies that met computer system capacity, 55% (24/44) committed to the training and completed the tasks required to participate. Details of the recruitment and screening process are reported in Participants were oriented to SL in three steps: (1) self-directed online orientation manual, (2) a one-on-one SL review session with research staff, and (3) a group skill review on SL training day one. In the first step, we developed an online orientation manual that provided instructions on how to install SL, create an avatar, perform basic navigation functions, teleport to different parts of the environment, manipulate camera angles, and use text and voice communication features. The online manual consisted of text and screenshots of steps and guided video demonstrations embedded within the manual.In the next step, one-on-one meetings in SL were scheduled to review and practice basic skills and to introduce participants to more complex skills. These additional skills focused on interactions with three-dimensional objects in the program including seats, working on collaborative Google documents , changinThe third step was incorporated into the first day of the SL facilitator training. This orientation session served as an introduction to the ¡Cuídate! training and provided an opportunity to practice features of the SL environment relevant to training. Best practices in SL were shared to ensure a smooth training experience. The practices included silencing microphones when they were not speaking to minimize distracting noises, ensuring their avatars remained active by participating in discussions, raising their avatar’s hand when they had a question or comment, and how best to view the interactive documents and posters during the training.In the training center, a designated staff member with high SL proficiency was available to provide technical support. Participants were asked to sign in 15 minutes prior to scheduled SL ¡Cuídate! training and to send a message using text chat to the technical staff if they were having trouble during the session. The staff member would either work in the background with the participant or have them teleport (a quick navigation method in SL) to another location to troubleshoot issues, thus minimizing distractions for other participants.To evaluate the process of preparing individuals to participate in SL training, several different descriptive methods were used. Data were gathered from the participant screening survey, technical support sessions, and a post-orientation survey. The surveys were administered using Qualtrics. Data were then categorized in three different areas for analysis: computer system capacity and experience, SL self-efficacy, and participant preparation time.A measure of overall computer system capacity consisted of two components: technical specifications and participant experience with online environments. During enrollment, participants were asked about technical specifications related to their operating system and Internet connectivity. Participants were also asked about previous online learning experiences (Yes/No) and if they had used SL prior to this training (Yes/No). They were also asked to report the frequency of engagement in online and gaming software on a 3-point scale .Self-efficacy to use SL was assessed with nine questions adapted from a scale developed by Gist, Schwoerer, and Rosen, which was developed to measure computer and software self-efficacy . The firTwo questions assessed participants’ estimates of the time spent reviewing the SL orientation manual. Additionally, the research team recorded actual time spent supporting participants in the use of SL or addressing computer issues. Technical difficulties experienced by participants, the associated cause, and the mitigation strategy implemented were also recorded throughout the training and preparation.A total of 35 participants from 24 agencies participated in 1 of 5 cohorts of SL ¡Cuídate! training. The majority of participants were female  and ranged from 20-59 years of age. Most participants had received at least a Bachelor’s degree . Slightly more than half of the participating community-based organizations had fewer than 50 employees , while 10 community-based organizations reported having more than 50 employees .Most participants had Windows Vista or better , while only a few reported using Windows XP , or Mac OSX 10+ . Regarding Internet connections, nearly equal numbers of individuals  reported having a wired connection or only a wireless connection , while a small percentage of participants  had access to both wired and wireless connections.A majority of participants  reported having online learning experience as well as experience with computer and video games, but very few participants  had ever used SL. Of those reporting having played computer or video games in the past 12 months , 2 participants (11.1%) played very often, 3 (16.7%) often, and 13 (72%) had rarely played.Most individuals rated their confidence levels high (no mean scores were below 7) on the SL self-efficacy scale. Participants reported high capability to navigate SL after reviewing written instructions and additional video clips . Participants had high capability scores for skills such as downloading the SL program and creating an avatar , but slightly lower scores for changing the view on their computer screen and interacting with items in SL . See The majority of participants  reviewed both the written instructions as well as the video demonstrations in the SL orientation manual. The amount of time participants spent using the orientation manual ranged from less than 1 hour , between 1 and 2 hours  or more than 2 hours . It is unknown how many more hours were spent using the orientation manual as the scale ended at 2 plus hours.The one-on-one session in SL required an average of 28.8 (SD 11.8) minutes per participant with a range of 15-60 minutes. Troubleshooting technical issues required an average of 28.4 (SD 16.4) minutes per participant for 74% (26/35) of the participants. The shortest troubleshooting time (2 minutes) was used to correct simple settings issues, and the longest (75 minutes) was used to assist participants with installation difficulties.Some participants had issues with SL installation due to either agency policies (n=3) or inadequate skill (n=3). Some agencies had policies prohibiting access to public virtual worlds like SL. The most prominent technical difficulty after installation was headset malfunction and incompatibility with users’ computers. The majority of these issues were corrected by adjusting settings on the operating system or on the SL program itself. For others, there were SL malfunctions such as lags in performance, periodic interruptions to audio or an ejection from the program. Internet connectivity was thought to be the root cause of these performance issues, particularly those with wireless Internet connections. The overwhelming majority of participants who continued to receive troubleshooting during the training reported wireless Internet connections. Technical difficulties and support are highlighted in The purpose of this study was to describe the process and related challenges of preparing individuals to participate in an EBI facilitator training program adapted for SL. The response to initial recruitment for participants was positive despite training being offered in a very non-traditional format (68/120 agencies indicated interest). Throughout the screening process, a variety of agencies were able to meet technical requirements and complete the training, half of which were small community-based agencies (<50 employees). Reasons that agencies did not participate, despite initial interest, were primarily related to inadequate computer system capacity and/or the inability to implement the training within 6 months post training. The variation in computer system capacity and Internet connections of the agencies that participated allowed for the opportunity to test the feasibility of using SL in areas that do not have available technical support staff or high-speed Internet capabilities.In terms of SL skills orientation, the majority of participants reported high confidence levels for basic skills in SL. This supports the feasibility of using a self-directed orientation manual since participants were able to reasonably orient themselves to the SL environment without additional support. Further, the use of a self-directed orientation manual resulted in limited staff time (less than one hour) for SL orientation and limited time necessary for additional troubleshooting. The time spent on orientation is less than previous reported results of Wiecha et al who spent 78 minutes coaching each participant . FindingIn this study, participants did identify technical challenges that impacted facilitator training. Major difficulties encountered included hardware and software compatibility issues and Internet issues (bandwidth) and not with individual ability to use the SL software (ratings for self-efficacy were high and very few troubleshooting encounters were reported requiring assistance with SL program skills). Although system requirements were identified pre-training, further testing is needed to determine specifically what system requirements should be mandated in order to prevent technical hurdles. For some, the use of a laptop interfered with a seamless experience because some laptops are not designed with the capacity  to run even less burdensome three-dimensional environments such as SL. Of these connection-related difficulties, audio input and output malfunctions were most prevalent even when using a standard audio headset and after pre-training audio testing.One unanticipated cause of these issues was the load on an individual’s network and computer system when multiple users were simultaneously logged on to the virtual environment. Smaller training cohorts (fewer than 7 participants) had fewer connection-related issues in the live training. Therefore, providing installation instructions upon initial registration may allow registrants to test their bandwidth by having them enter more populated areas of SL to see if their computers can handle a large number of users. This early bandwidth testing should reduce the number of technical difficulties that may arise in the training program from a lack of bandwidth capacity. One additional approach that may be warranted is to limit the amount of participants per training session to minimize the technical challenges that may occur.Technical support was a vital component of this study. Delivering training in SL requires technical expertise to remotely troubleshoot with participants. Advanced knowledge of both computer hardware and software components is essential for the technical staff who will provide the support before and during training. By having support staff available throughout the training, major interruptions were avoided and participant burden was minimized allowing for the successful retention of all 35 participants across 3 days of training.In summary, preparing participants to use SL for the ¡Cuídate! Training of Facilitators was feasible, and participants were confident in their ability to use the program for training after completing orientation. In addition, we developed processes to decrease technical difficulties prior to and during training. The potential advantages of conducting SL trainers include the ability to access EBI training without the high cost of travel. This is especially relevant for agencies and communities with limited resources. Decreasing access barriers through the use of technology can facilitate the dissemination and use of evidence-based interventions, resulting in improved health outcomes.


We performed a Pubmed search of articles addressing the management of ventilator-associated pneumonia (VAP). Immunocompromised patients, children and VAP due to multi-drug resistant pathogens were excluded from the analysis. When facing a patient with VAP, it’s important to address a few key questions for the patient’s optimal management: when should antibiotics be started?; what microorganisms should be covered?; is there risk for multirresistant microorganisms?; how to choose the initial agent?; how microbiological tests determine antibiotic changes?; and lastly, which dose and for how long?. It’s important not to delay adequate treatment, since outcomes improve when empirical treatment is early and effective. We recommend short course of broad-spectrum antibiotics, followed by de-escalation when susceptibilities are available. Individualization of treatment is the key to optimal management.Ventilator-associated pneumonia (VAP) is one of the most frequent clinical problems in ICU with an elevated morbidity and costs associated with it, in addition to prolonged MV, ICU-length of stay (LOS) and hospital-length of stay. Current challenges in VAP management include the absence of a diagnostic gold standard; the lack of evidence regarding contamination  Ventilator-associated pneumonia (VAP) is one of the most frequent clinical problems in ICU. With an estimated incidence from 5–20 cases per 1.000 mechanical ventilation (MV) days; which has decreased over the last decade with the implementation of care bundles. However it still remains as the most frequent infection amongst critically ill patients and as the main cause of antibiotic prescription in ICU . Despiteet al. have established a new surveillance strategy for the screening of infection-related ventilator-associated complications (IVAC) [sine qua non characteristic of VAP, even in the absence of clear findings in the Rx. IVAC include all patients with 3 or more days of MV; with worsening of oxygenation lasting 2 calendar days, identified as increase in FiO2 or PEEP; which can be classified as possible VAP and probable VAP, depending on the criteria they meet.VAP represents 80% of hospital-acquired pneumonia (HAP) and is defined as pneumonia developing after 48-72 h of MV. Many screening and diagnostic criteria have been used in order to an early identification of VAP and differentiation from ventilator-associated tracheobronquitis (VAT), with suboptimal results since radiological findings in the critically ill lack sufficient sensitivity and specificity. Recently, Centers for Disease Control and Prevention (CDC) and Klompas vs. airway colonization vs. infection; and the increasing antibiotic resistance.Current challenges in VAP management include the absence of a diagnostic gold standard; the lack of evidence regarding contamination .When facing a patient with VAP, it’s important to address a few key questions for the patient’s optimal management: when should antibiotics be started?; what microorganisms should be covered?; is there risk for multirresistant microorganisms?; how to choose the initial agent?; how microbiological tests determine antibiotic changes?; and lastly, which dose and for how long? See Figure 1It has been well documented that delayed effective therapy increases morbidity and mortality rate among patients with VAP ,8. IndeeWe support prompt antibiotic initiation with a short course of broad spectrum antibiotics, followed by de-escalation when susceptibilities are available ; stressiP. aeruginosa because of its high rates of resistance and initial ineffective antibiotic therapy [P. aeruginosa, combination therapy improves appropriate empirical therapy [Combined therapy is a long established practice in ICU, especially in VAP caused by  therapy . Many st therapy ,13-15; m therapy ,17.Pseudomonas aeruginosa and Staphylococcus aureus[S. pneumoniae, S. aureus and H. influenzae. However, a multicenter study showed a high prevalence (50.7%) of potentially resistant microorganisms (PMR) in this subset of patients with no risk factors for PMR [P. aeruginosa, Acinetobacter baumannii, or methicilin-resistant S. aureus (MRSA). Also differences are seen in surgical and neurological patients, where S. aureus is the main pathogen [Overall, VAP’s main causative microorganisms are us aureus. When co for PMR . Late-VApathogen -3.Strategies based on guidelines are accurate for predicting causative microorganism and thus appropriate initial antibiotic in VAP , but also are endotracheal aspirates from samples retrieved 2 days before the onset of VAP .Standard antibiotic dosage has proven to be insufficient (under-dosage) in critically ill patients with severe sepsis, especially when they undergo continuous renal replacement or ECMO therapies ,21. A reA new approach in VAP treatment is the use of nebulized antibiotics. Its main appeal is that allows achieving high local concentration of antibiotics, with fast clearance, which reduces risk for development of resistance, and with minimal absorption that translates into less toxicity. Even though many issues have to be improved, such as effective delivery systems and optimal formulations that are able to reach the alveoli and are well tolerated by the patients ; it poseRecent studies are lacking of robust data, in spite of which, nebulized therapy has shown to be effective. Nebulized monotherapy has proven to be non-inferior to IV therapy; and as adjunctive to IV regimens is associated with higher antibiotic concentrations at target tissue and less number of antibiotics per patient per day -28, and Optimal duration of antibiotic therapy is still controversial. Until recently, it was standard practice antibiotic regimens of minimum 15 days for uncomplicated infections . CurrentOptimization of antibiotics does not mean strictly following guidelines; instead it means empowerment, stewardship and team working. Antibiotic stewardship is a simple and cost-effective way to improve clinical outcomes while minimizing antibiotic side effects and its negative consequences; maintaining quality of care ,34.Research should be directed towards the development of ultra-fast diagnostic techniques that can immediately predict causative microorganism, without the need of specimen processing and also detect multirresistance mechanisms to avoid inadequate initial antibiotic treatment.Getting it right the first time: It’s important not to delay adequate treatment, since outcomes improve when empirical treatment is early and effective. Prompt appropriate therapy, then step-down: we recommend short course of broad-spectrum antibiotics, followed by de-escalation when susceptibilities are available. Individualize always!: regarding dosage, way of administration and duration based on clinical response.S. aureus; MV: Mechanical ventilation; PMR: Potentially resistant microorganisms; VAP: Ventilator-associated pneumonia; VAT: Ventilator-associated tracheobronquitis.CDC: Centers for disease control and prevention; HAP: Hospital-acquired pneumonia; HCAP: Health-care associated pneumonia; LOS: Length of stay; MDR: Multi-drug resistant; MRSA: Methicilin-resistant Jordi Rello has served in the as board and speaker bureaus for Pfizer, Astellas, and Cubicin. Bárbara Borgatta has no competing interest.BB and JR contributed equally to the writing of this manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/211/prepub


Surgical site infection is a major contributor to increased mortality and health care costs globally which can be reduced by appropriate antibiotic prophylactic use. In Palestine, there is no published data about preoperative antibiotic use. This study aims to find the pattern of antimicrobial prophylaxis use by evaluating time of the first dose, antibiotic selection and duration after surgery in three governmental hospitals in North West Bank/ Palestine during 2011.p < 0.01 were further analyzed using logistic regression model.After approval of Institutional Review Board, a prospective cohort study included a total of 400 abdominal, orthopedic, and gynecological operations which were performed during study period. Trained clinical pharmacists observed selected 301 operations and followed the patient’s files for the three intended study parameters. Compliance of prophylactic antibiotic administration was evaluated according to published guidelines of the American Society for Hospital Pharmacist. Data were analyzed using SPSS version 16 applying descriptive methods. Relationship between guideline compliance and selected operation factors such as type of surgery, patient care unit, and hospital shift, in addition to provider’s age, gender, experience, and specialization were examined applying chi square test. The statistically significant factors with P < 0.001), however the proper antibiotic selection was best adhered to for the abdominal surgeries . Male providers were statistically significantly much less adherent to the timing of antibiotic dose , but better adherent in antibiotic selection . Anesthetic technicians showed higher compliance than nurses in timing and duration of antibiotic use.Overall compliance for the studied parameters was very low (2%); only 59.8% received their first dose in appropriate time, 18.5% had appropriate antibiotic selection, and 31.8% of patients received antibiotic in appropriate duration. The OBGYN department had much better compliance regarding timing and duration of antibiotic use (Lack of guidelines explains the low adherence to appropriate surgical antibiotic prophylaxis in Palestine, with high rate of broad spectrum antibiotic use, long duration and inappropriate time of first dose .We recommend adopting guidelines for prophylaxis and training all health care providers accordingly. Surgical site infection (SSI) is an infection that occurs somewhere in the operative field following a surgical intervention. According to Centers for Disease Control and Prevention (CDC), SSI includes incisional and organ space infections . SSI is The risk of SSI depends on patient-related factors such as age, nutritional status and existing infections in addition to surgical factors, such as duration of procedure and the type of operation  ,5. The bSSI prevention is important and is based on a combination of preoperative preparation, surgical techniques, peri operative antibiotic prophylaxis and postoperative wound care . There iIn Palestine, there is no published data about antibiotic use in surgery till the time we started our research. Availability of protocols that illustrate antibiotic use in surgery in the hospitals, and the adherence to these protocols are very important items that need evaluation. This study aims to find the pattern of antimicrobial prophylaxis use by evaluating time of the first dose, antibiotic selection and duration after surgery for patients undergoing abdominal, orthopedic and gynecologic operations in three governmental hospitals in North Palestine during 2011.This observational non interventional prospective study was performed in the largest three governmental  hospitals from January 15 through December 30, 2011. These hospitals are located in the main cities of North West Bank Palestine with a capacity of 213, 105, and 127 beds; all provide orthopedic, general surgery, and Obstetrics &Gynecology (OBGYN) services to the general public. Surgical prophylaxis in the three hospitals is practiced according to general non written guidelines and individual judgment; antibiotics are usually administered by either a nurse (in the ward) or anesthetic technician (in the operating room).Convenient sampling of all emergent and elective operations in these hospitals meeting inclusion criteria was studied. Institutional Review Board (IRB) of An-Najah National University approval in addition to the approval of the General Directorate of Government Hospitals in the Palestinian MoH in the West Bank was obtained to observe peri operative antibiotic use. Following this approval the General Directors of the selected hospitals  also approved the study to be performed in their hospitals. The ethics committee (IRB) waived a formal informed consent for this type of study since it is considered a type of quality assurance whose goal is the improvement of care at the institution.All patients undergoing abdominal, orthopedic, or gynecologic surgical intervention during the study period were chosen to be our study population. Elective and emergent procedures were included to allow for a comparison between the two types of procedures. The researchers followed the CDC wound classification in order to include only the clean (mainly closed uninfected wound) and clean-contaminated  . All conCompliance of prophylactic antibiotic administration was evaluated based on the published guidelines of the American Society for Hospital Pharmacist (ASHP) . The fol1- Time of first dose antibiotic: Antibiotic should be administered within 1 hr before incision to achieve prophylactic level during surgery and optimize efficacy. For vancomycin, the infusion should begin within two hours before incision. Doses should be repeated intra operatively if the operation is still in progress two half lives after the first dose.2- Duration: Antibiotic administration should be discontinued within 24 hours after the end of surgery, to prevent emergence of resistance.3- Antibiotic selection: In general, inexpensive, non-toxic, and limited-spectrum antibiotic should be used; therefore IV Cefazolin is recommended for most of procedures . Cefoxitin is recommended for appendectomy and colorectal procedures; Vancomycin is reserved for patients with beta-lactam allergy.Each observed operation in the study was classified as adherent or non adherent to each of the three mentioned aspects of compliance.Patient studied variables were: type of surgery (elective vs emergent),patient care unit , and hospital shift . Health provider variables were age, gender, specialization of provider administering antibiotics (nurse vs anesthetic tech), and years of experience.Data were collected by two trained clinical pharmacist researchers through frequent visits to the three research sites. Charts of 400 operations which met study criteria were reviewed to collect relevant patient data and compliance data; in addition out of the 400 cases, the researchers were able to observe 301 operations which were carefully selected to represent the three hospitals’ patient care units and shifts. The observation aimed to document incision time, antibiotic first dose time, in addition to health provider characteristics. Data regarding antibiotic selection and post operative antibiotic administration was obtained through file review.All analyses were performed with Statistical Package for Social Sciences (SPSS) version 16 statistical program. Descriptive analysis was used to evaluate performance and demonstrate the characteristics of the study sample. Frequency of operations with appropriate first dose time, appropriate type, and appropriate duration were evaluated.P value ≤ 0.05.Chi-square test was used to examine the relationship between antibiotic administration and factors such as provider’s age, gender, specialization, years of experience, hospital site, patient care unit, hospital shift, and type of surgery; the results were considered statistically significant at p < 0.01. Therefore patient care unit, provider’s age and specialization were entered in each of three logistic regression models for time of antibiotic use, proper antibiotic choice and duration of postoperative antibiotic use.To eliminate confounding factors, multivariate analysis was then applied by building a model of independent variables which were significant in univariate analysis at Table Table Among 301 patients undergoing abdominal, orthopedic, and gynecological procedures, only 59.8% received their first dose with appropriate time (Table p = 0.023). Tables p <0.001) and abdominal procedures . The duration of antibiotic use was also found to be adhered to in OBGYN department much more than orthopedics , and abdominal procedures , however abdominal procedures were more likely to adhere to proper antibiotic choice .Of all studied and observed procedures only 6 (2%) were compliant with surgical prophylaxis studied guidelines altogether ; these six procedures were from the three hospitals and were done in all shifts. When we compared between the three research sites Table , there wp = 0.028), but much less adherent in timing for first dose . Interestingly the anesthetic technicians showed a higher compliance than nurses in timing  and duration  of antibiotic use.Our study findings in Tables The most important finding in this study is the absence of any written agreed upon guidelines for antibiotic surgical prophylaxis in all governmental hospital sites studied. This finding explains the very low adherence to international guidelines found in the study (only six observed ones). Low adherence is shared by other studies in the region; For example the Jordanian study found that none of the observed cardiac operations was adherent to all antimicrobial prophylaxis guidelines with wide variation in adherence to selected parameters studied . The IraEven in USA where following surgical prophylaxis guidelines is an expected practice, a study of medicare in patients undergoing different kinds of surgical procedures demonstrated that 55.7% of patients received their antibiotic dose within one hour before the surgical incision , and antimicrobial prophylaxis was discontinued within 24 hours after surgery for only 40.7% of patients .Only one hospital in our study which is the main site for medical and nursing students’ training had better adherence in the first time dosing of antibiotics, in addition the OBGYN department showed a very high compliance to dosing time. Time of antibiotic administration before surgery is very important issue in prophylaxis and infection prevention, microorganisms are expected to enter body fluids and tissues from the time of incision until the injury is closed, during this time the antimicrobial level must be in the inhibitory level in serum .One of factors associated with poor adherence in time of prophylaxis administration in our study is the administration of antibiotics by nurses on the ward at fixed clock rounds instead of adjusting this to the time before surgery, this is also the cause for inappropriate time documented in a study in a multicenter audit in Dutch hospitals . The timBoth selection of antibiotic for prophylaxis 18.5%) and duration of post-operative use (31.8%) were far from adherence to the guidelines in our study. For most types of orthopedic, abdominal and gynecological operations, single pre-operative dose of the first generation cephalosporin is recommended; further post-operative doses are not needed and the antibiotic should be discontinued within 24 hours post operation .5% and d, the TurThe general surgery department in this study showed a better adherence in selection of antibiotic compared with OBGYN and orthopedic department, a finding shared with a Turkish study which showed that general surgeons use antibiotic prophylaxis more appropriately . On the An interesting finding is the tendency of female providers to be more adherent to the time of first dose and males to show better adherence to the selection of antibiotic, it is difficult to explain this finding since all providers regardless of their gender receive the same training and role in performing their jobs according to their qualification.Although there is no written protocol, it seems that the anesthetic technicians were much more compliant to the time of first dose and postoperative antibiotic duration. This is possibly because the technician's main training and job skills are related to operation room; on the other hand nurses have wider scope of work for patients on the ward.None of the hospitals studied is following guidelines for perioperative prophylaxis. This explains the low adherence to appropriate surgical antibiotic prophylaxis in Palestine, with high rate of broad spectrum antibiotic use; long duration and inappropriate time of first dose.We recommend adopting guidelines for surgical prophylaxis in addition to the need to train all health care providers accordingly. Role of anesthesia technician in administering prophylactic antibiotic seems to be important and needs to be emphasized.The authors declare that they have no competing interests.SM participated in the study design and coordination of the study protocol. HB worked on preparing the background and literature review. Both HB and AO performed the field work of data collection in addition to statistical analysis. SM reviewed the statistical analysis and drafted the results and discussion. HB and SM drafted the manuscript and all three authors reviewed and approved it.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/14/69/prepub


Early HIV studies suggested protective associations of overweight against mortality, yet data are lacking for the era of potent highly active antiretroviral therapy (HAART). We evaluated associations of pre-HAART initiation body mass index (BMI) with mortality among HAART-using women.Prospective study of time to death after HAART initiation among continuous HAART users in the Women’s Interagency HIV Study. Unadjusted Kaplan–Meier and adjusted proportional hazards survival models assessed time to AIDS and non-AIDS death by last measured pre-HAART BMI.Of 1428 continuous HAART users 39 (2.7%) were underweight, 521 (36.5%) normal weight, 441 (30.9%) overweight, and 427 (29.9%) obese at time of HAART initiation. A total of 322 deaths occurred during median follow-up of 10.4 years (IQR 5.9–14.6). Censoring at non-AIDS death, the highest rate of AIDS death was observed among underweight women . In multivariate models, women underweight prior to HAART died from AIDS more than twice as rapidly vs. normal weight women ; but being overweight or obese  was not independently associated with AIDS death. Cumulative incidence of non-AIDS death was similar across all pre-HAART BMI categories.Among continuous HAART-using women, being overweight prior to initiation was not associated with lower risk of AIDS or non-AIDS death. Being underweight prior to HAART was associated with over double the rate of AIDS death in adjusted analyses. Although overweight and obesity may be associated with many adverse health conditions, neither was predictive of mortality among the HAART-using women. Wasting, commonly experienced by people living with HIV early in the epidemic, is now rare , 2 where2) women. Morbid obesity (BMI ≥ 40 kg/m2) was associated with higher CD8+ counts [Among HIV-infected persons, several early studies suggested that being overweight or obese was associated with better, not poorer, prognoses and immunologic profiles and this perception remains today among HIV-infected persons. A report from the Women's Interagency HIV Study (WIHS) indicated that being overweight, obese, or morbidly obese was independently associated with higher CD4+ count, total lymphocyte count, and WBC counts compared to those of normal body mass index (BMI) 18.5–24.9 kg/m kg/m2 wo+ counts –12; it i+ counts . We unde+ counts .The WIHS enrolled 2843 HIV-infected and 975 HIV-uninfected women in 1994–95 and 2001–02 from six sites . WIHS methods and baseline cohort characteristics have been described previously . At semi2 (m2) and categorized using standard BMI categories developed by the World Health Organization and National Heart, Lung, and Blood Institute as: underweight (<18.5), normal weight (18.5 to <25.0), overweight (25.0 to <30.0), and obese (≥30.0) [3, 200–350, or >350); and nadir CD4+ cell count (defined as the lowest CD4+ cell count measured at any visit prior to HAART); last pre-HAART log10 viral load (within 12 months prior to HAART initiation) and peak log10 HIV-1 RNA viral load (greatest HIV RNA level measured at any pre-HAART visit). We adjusted for WIHS site in all analyses.The primary exposure of interest was BMI immediately (~ within 6 months) prior to initiation of HAART, which was determined by dividing body weight (kg) by height (≥30.0) , 18. Use (≥30.0) , 20. Oth (≥30.0) ; self-re (≥30.0) ; CD4+ cePrimary outcomes were times from date of first visit after HAART initiation (index visit) to AIDS death, non-AIDS death, and death from all causes. The first visit after HAART initiation was chosen as the start point since a minimum of two visits with reported HAART use was needed to qualify as a continuous HAART user. Ascertainment and classification of deaths in WIHS have been described previously , 24. ADI3; or the stated cause of death was listed as AIDS and last CD4 count obtained was <200 cells/mm3.Deaths were attributed to AIDS if the stated cause of death was an AIDS-defining opportunistic infection or malignancy; the stated cause of death was non-specific infection or organ failure  with last CD4 count obtained <200 cells/mmDeath was categorized as a non-AIDS death if a non-AIDS cause was identified as the primary cause of death ; or if kidney failure, or cardiovascular, gastrointestinal, or central nervous system disease was the primary cause of death and the last CD4 count was ≥200 cells/mm3.3; the stated cause was AIDS alone and the last CD4 count was ≥200 cells/mm3; or the primary cause of death was kidney failure with a CD4 count <200 cells/mm3. To account for loss to follow-up, women without study outcomes were censored at the earlier of either: (1) two years after their last HAART use visit or (2) December 31, 2010, as ascertainment of death beyond that date may not have been complete.Cause of death was considered to be indeterminate if the available cause of death was nonspecific (i.e. “cardiopulmonary arrest”); or listed cause of death was nonspecific infection or organ failure with the last CD4 count ≥200 cells/mmPlasma HIV-1 RNA was measured by isothermal nucleic acid sequence-based amplification  with a lower limit of detection (LLD) of 80 copies/ml until October 1, 2008 and then by COBAS Taqman HIV-1 assay with LLD of 48 or 20 copies/mL. Lymphocyte subsets were quantified using standard flow cytometric methods in laboratories participating in the NIH/NIAID Flow Cytometry Quality Assessment Program . HCV RNADifference in means and proportions of the potential confounding covariates across BMI categories were determined by exact and rank tests. We performed Kaplan–Meier and Cox proportional hazards models of times to AIDS death and to non-AIDS death by BMI group . For mod2 with an interquartile range of 23.0–31.1 kg/m2; 39 (2.7%) were underweight (BMI <18.5), 521 (36.5%) normal weight (18.5 <BMI ≤ 25), 441 (30.9%) overweight (25 <BMI ≤ 30), and 427 (29.9%) obese (BMI ≥ 30)prior to HAART initiation .In univariate Cox proportional analyses of all-cause mortality, underweight women died more rapidly than did women with normal BMI category , whereas obesity was associated in a reduction in mortality . In multivariate models, neither underweight BMI  nor obesity  was significantly associated with all-cause mortality among continuous HAART users. Overweight was not associated with all-cause mortality in unvariate models  or in multivariate analyses . Factors associated with increased all-cause mortality in multivariate models included age , annual income of $12,000 or less , current smoking ,), depressive symptom burden , diabetes mellitus , and HCV infection , in addition to pre-HAART and peak HIV RNA viral load, and pre-HAART CD4+ count below 200cells/mmWe found that overweight and obesity were neither associated with an increased risk of non-AIDS mortality nor were they protective of AIDS mortality among women regularly receiving long-term HAART. The directionality of the hazard ratios suggests that higher BMI may have a protective association with non-AIDS death, and it is possible that as this cohort of middle-aged women continues to grow older and more likely to develop conditions associated with both obesity and increased risk of mortality, the relationships between overweight, obesity, and mortality in HIV-infected women may become more apparent.2 [A number of studies conducted in the general U.S. population have shown associations between overweight and reduced mortality. In the National Health and Nutrition Examination Survey (NHANES) both underweight and obesity were associated with excess mortality, but overweight was associated with reduced mortality compared to normal weight ; and in 2 . Yet the2 , 32. Som2 . Thus, GThresholds at which BMI confers mortality risk may also vary significantly by race. Several studies have reported a weaker association between higher BMI categories and mortality in black women than in white women, with thresholds for elevated mortality risk as high as BMI of ≥ 40 –42; alth2) had decreased mortality risk compared to those nonobese (BMI <27 kg/m2) and underweight (BMI ≤ 19.5 in men and ≤ 18.5 in women), and a greater proportion of the non-obese group exhibited >25% CD4+ count decline over 18 months compared with obese participants [3; both underweight and normal weight women had an increased risk of progression to AIDS; and underweight women had an increased risk of AIDS-death compared with obese women [Among HIV-infected persons, studies of the relationship between overweight and obesity and immunologic and virologic outcomes conducted in the HAART era have shown conflicting results; however, these studies included only short-term follow-up and did not evaluate mortality endpoints. Several pre-HAART era studies have suggested that excess weight may actually be beneficial in HIV-infected populations in the U.S. In the Miami Intravenous Drug Abuse Study, among predominantly (91%) untreated HIV-infected drug users, obese subjects , these factors were not associated with AIDS death in multivariable analyses and did not account for the association between low BMI and AIDS death. Although some have reported improved immune benefits of being overweight such as greater CD4 response after HAART initiation , others We decided to use pre-HAART BMI rather than time-updated BMI or BMI trajectory in our analyses, because our objective was to determine the relationship of pre-HAART BMI to mortality, and specifically to determine the extent to which BMI prior to HAART initiation predicts mortality in HIV-infected continuous HAART users. Use of post-HAART BMI as a predictor of mortality as a time dependent variable also leads to the issue of reverse causality as many people lose weight shortly prior to death due to end stage consequences of the death process. Thus heavier weight would appear protective because impending death process is leading to reduced weight not that heavy weight in and of itself is being protective. Additionally, rather than model competing causes of death, we decided to stratify analyses based on whether or not cause of death was attributed to AIDS (vs. non-AIDS). We chose this approach because we hypothesized that the relationship between BMI and mortality might differ significantly in AIDS deaths vs. non-AIDS deaths. When we use AIDS death as an outcome then a non-AIDs death is a “competing risk” as death from a non-AIDs cause prevents a death from AIDS; and similarly when non-AIDS death is the outcome then AIDS death is a “competing risk”. We have no basis on which to model when a person who dies of an AIDS death would have died of a non-AIDS cause if they had not died of AIDS first; and similarly, we have no basis on how to model when a person who dies of an AIDs death would have died of a non-AIDS cause if they had not died of AIDS first. Thus, we believe that any attempt to fit such models would introduce more error and bias due to errors in the model assumptions.Our study has several limitations. We did not have measures of energy balance, dietary intake, or physical activity. The WIHS is a middle-aged population and most Americans die at an older age than the women in WIHS; therefore we may not have been able to elucidate the mortality risk associated with excess body weight expected for non-AIDS death, despite the extended time period under study. Although the potentially protective association between overweight and non-AIDS death we observed was not statistically significant, we may have been underpowered to detect a significant association between overweight or obesity and mortality given the relatively few numbers of deaths observed in each BMI category. Accurately classifying obesity-related and non-obesity-related deaths was not possible because specific causes of death were often not identified. Although only certain cancers are obesity-related, even if we assume that all "cancer", "neurological", and "heart"-related deaths were obesity-related, they would account for only 69 of 143 (48%) non-AIDS deaths. Obese women who died from non-AIDS causes were slightly more likely to have died of potentially obesity-related outcomes than either overweight or normal weight women . Although we evaluated and adjusted for markers of socioeconomic status, residual confounding is still possible. As in any observational study, unmeasured confounders may also affect these relationships.In conclusion, we found that in continuous HAART-using women, having higher than normal BMI was not significantly associated with protection from AIDS or non-AIDS death. Being underweight  prior to HAART increased the hazard of AIDS death two-fold in the first two years after HAART initiation, after adjusting for measures of HIV disease severity. Although overweight and obesity may be associated with a number of adverse health conditions, they conferred neither an increased or decreased risk of mortality among middle-aged HIV-infected women receiving long-term continuous HAART. Despite the survival benefits of potent antiretroviral therapy, women with low BMI are at risk for AIDS death for up to two years after HAART initiation.


The paper states results of experimental exposition of concrete test specimens to direct flame. Concrete test specimens made from various mixtures differing in the type of aggregate, binder, dispersed reinforcement, and technological procedure were subjected to thermal load. Physicomechanical and other properties of all test specimens were tested before exposition to open flame: density, compressive strength, flexural strength, moisture content, and surface appearance. The specimens were visually observed during exposition to open flame and changes were recorded. Exposed surface was photographically documented before thermal load and at 10-minute intervals. Development of temperature of the specimens was documented with a thermocamera. After exposition to thermal load and cooling down, concrete specimens were visually observed, network of cracks was photographically documented, and maximal depth of spalled area was measured. Concrete has many properties which are advantageous from the point of view of fire resistance. It is not combustible and its thermal conductivity is low –4. HowevAs regards action of high temperatures on concrete, there are differences between concrete with common strengths and high performance concrete , 3. PoroOne of the factors contributing to explosive spalling is moisture content , 3, becaAs regards influence of high temperatures, aggregate has the key role and it should be taken into account from the very start of designing the concrete mixture. Aggregate takes up about 60–80% of its volume and various types of aggregate can have crucial role for resistance of concrete to high temperatures. Individual types of aggregate react differently to high temperatures; both physical and chemical changes may occur during exposition to heat. The key factor of behavior of thermally loaded concrete is chemical and physical stability of aggregate. For this reason, selection of appropriate aggregate is very important for ensuring thermal stability of concrete.2, which is formed during hydration of cement and decomposes at temperatures around 500°C [If thermal resistance of concrete should be improved by selection of binder, it is necessary to limit Portland cement and use blended Portland cements and other cements with the lowest possible content of Portland clinker. The goal is the lowest possible content of Portlandite Ca(OH)nd 500°C . Using cnd 500°C . The amo2 emissions and it is also connected with other research works focusing on reduction of CO2 emissions during production of binders [Use of blended Portland cements has also positive ecological impact because it helps reduce CO binders .Test specimens of various compositions for experimental works, loading with open flame, had the shape of cubes with dimensions 100 × 100 × 100 mm. Different mixtures were selected, their composition is given in 3. Mixture CEM I - GR-SCC (360 kg/m3 of cement) had increased dose of cement for the reason of achieving higher strengths and self-compacting properties in fresh state. Two cements were used for the purpose of evaluating influence of used type of cement: CEM I 42.5 R  and blast-furnace cement CEM III/B 32.5 N .Dose of cement (with the exception of the mixture CEM I - GR-SCC) was identical for all mixtures: 350 kg/mTo evaluate influence of the type of coarse aggregate, two types of aggregate were used: granodiorite, biotite granodiorite  and basalt .Composition of granodiorite aggregate: 42% plagioclase, 34% quartz, 15% spar, 8% biotite, and 1% other . ComposiTwo types of aggregate were used for small fraction (0/4 mm). In mixtures CEM I - GR-PF, CEM I - GR-SCC, natural mined, and nonwashed aggregate, spar gravelous sand was used . In mixt3, concrete mixture CEM III/B - B-PF and by addition of fine steel fibers with low content of carbon, also recommended for fire resistant concrete by manufacturer, dose 50 kg/m3, and concrete mixture CEM III/B - B-SF. Concrete mixture CEM I - GR-PF used different type of polypropylene reinforcement, made by the same manufacturer as reinforcement used in CEM III/B - B-PF (shorter and thinner fibers) dose was twice higher than recommended, 2 kg/m3. Parameters of dispersed reinforcement used, differing in material of fibers and dimensions, are given in Concrete mixture CEM III/B - B (without fibers) was designed for evaluation of influence of various fibers. This mixture was modified by addition of polypropylene fiber reinforcement, which is recommended for fire resistant concrete by manufacturer, dose 1 kg/mThe amount of mixing water was almost identical in all concrete mixtures with the exception of CEM I - GR-PF. Firstly, dose of water of this concrete mixture had to be increased to achieve optimal consistency of fresh concrete; the reason was higher dose of polypropylene dispersed reinforcement, which worsens consistency of fresh concrete . SecondaLabeling, characteristics, and results for selection of individual mixtures are as follows.Mixture CEM I - GR-PF:use of ordinary Portland cement,use of coarse aggregate, granodiorite,increased dose of dispersed polypropylene reinforcement,achieving of lower strengths of hardened concrete.Mixture CEM III/B - B:use of blast-furnace cement,use of coarse aggregate, basalt,reference mixture for mixtures CEM III/B - B-PF, CEM III/B - B-SF.Mixture CEM III/B - B-PF, CEM III/B - B-SF:use of blast-furnace cement,use of coarse aggregate, basalt,use of various dosages of various types of dispersed reinforcement.Mixture CEM I - GR-SCC:use of ordinary Portland cement,use of coarse aggregate, granodiorite,designed as self-compacting concrete ,specimens prepared without vibrating. EN 12 350-2 testing fresh concrete, Part 2: slump-test , EN 12350-8 testing fresh concrete, Part 8: self-compacting concrete, slump-flow test , EN 12350-10 testing fresh concrete, Part 10: self-compacting concrete, L-box test , EN 12 350-6 testing fresh concrete, Part 6: density  EN 12 350-7 testing fresh concrete, Part 7: air content, Pressure methods .Properties of concrete in fresh state were determined in accordance with the following procedures:Prior to thermal load, all sets of testing specimens were stored in humid area with constant moisture ±80% and constant temperature ±20°C. Thermal load with direct flame was carried out with gas burner Rothenberg, which can develop a flame with temperature up to 1300°C. The aim of thermal exposition was achieving high thermal gradient at the beginning of the exposition until the moment of achieving the temperature of 1200°C. To achieve this extreme thermal load, the development of temperature of flame was regulated so that the thermal curve was as close as possible to the hydrocarbon fire curve , howeverT1,  T2, T3, and T4 labeled TT-K-24-SLE  and recorded in the apparatus Kimo HD 200 (four channel modules with thermocouple sensors). Thermocouples were located on the exposed surface, in various depths from the heated surface and on the surface opposite to the exposed one (T1),T2)therAll test specimens were analyzed before exposition to thermal load; physicomechanical properties were determined . When the specimens were thermally loaded, other test specimens from the same concrete mixtures were placed into drying kiln to determine current level of moisture of tested specimens. Properties of individual sets of test specimens before exposition to direct flame are given in  EN 12 390-3 testing hardened concrete, Part 3: compressive strength of test specimens , EN 12 390-5 testing hardened concrete, Part 5: flexural strength of test specimens , EN 12 390-7 testing hardened concrete, Part 7: density of hardened concrete  ČSN 73 1316 determination of moisture content, absorptivity, and capillarity of concrete .Properties of concrete in hardened state were determined in accordance with following procedures:Test specimens were visually observed during heating and changes were recorded; records are stated in visual observation of the specimen (description given in observation of the network of cracks (cracks highlighted with a marker) and photographed  there is a red point denoting maximal temperature Tmax (°C), which is stated in the frame above the red point as well as the time, when the maximal temperature was achieved (hours:minutes) from the beginning of thermal exposition.Measured values of temperature development of individual test specimens during heating, which were detected with thermocouples and recorded in the recording module, are demonstrated in Figures T1), showed differences up to 200°C because of manual regulation of the gas burner. Maximal temperatures measured by T1 (surface of specimen) were 1140°C–1260°C, T2 (25 mm below exposed surface) 444°C–524°C, T3 (50 mm below exposed surface) 190°C–227°C, and T4 (100 mm far from exposed surface) 63°C–92°C.Curves of thermal load of tested specimens, measured on the surface of the specimen . Specimen from mixture CEM I - GR-SCC showed explosive spalling of a layer of concrete from exposed surface after approximately 60 seconds from beginning of the experiment (current temperature ±1000°C). After another 60 seconds, a second wave of spalling occurred. After that, only escape of moisture from side walls (water) and extensive escape of moisture (water + water vapor) from the top wall of the specimen, where Specimen from mixture CEM III/B - B-PF (moisture content 4.1%) showed the least extent of failures; network of cracks on the exposed surface was apparent. The highest extent of failures was observed at the specimen from mixture CEM I - GR-SCC (moisture content 4.2%), where explosive spalling occurred on the exposed surface and maximal measured depth was 5.1 mm. These observations confirm positive effect of polypropylene fibers combined with thermally stabile basalt aggregate, specimen from mixture CEM III/B - B-PF. Spalling of specimen from mixture CEM I - GR-SCC occurred because of high density of structure (high dose of cement + addition), which prevented escape of heated water vapor. As a consequence, a layer of concrete was blasted off at the depth, where overheated water vapor gathered with no escape way. Specimens made from other mixtures  showed failures in the form of network of cracks on the exposed surface and cracks in side walls.T1 thermocouple was located) was close to hydrocarbon fire curve [T1 thermocouple) was in most cases around 1200°C after 1 minute.The aim of experimental work was verification of behavior of concrete test specimens exposed to direct flame, which can closely simulate behavior of concrete structure at the conditions of real fire. Development of acting temperatures of the gas burner was regulated so that the curve of temperatures actin on the surface of the test specimen .T2 were observed. The greatest amount of failures occurred in specimen CEM I - GR-SCC, where there was spalling from the exposed surface layer to a maximum depth of 5.1 mm observed. The smallest amount of failures occurred on the specimen CEM III/B - B-PF (moisture 4.1%); there was visible network of cracks only in the exposed surface. On other specimens , failures in the form of networks of cracks in the exposed surface and cracks in the side walls were observed after the experiments.On the specimen CEM I - GR-SCC an explosive spalling of the concrete layer from the exposed surface occurred already after about 60 seconds of the experiment . After another 60 seconds, the second wave of spalling occurred. Then, only the escape of moisture from the side walls (water) and a large leakage of moisture (water + steam) from the top wall of the specimen at the point thermocouple It was confirmed that use of fine polypropylene dispersed reinforcement prevents explosive spalling of concrete thanks to “opening” the structure of cement matrix by melting off . As for the effect of addition of polypropylene fibres in mixture CEM I - GR-PF, it must be mentioned, that the higher content of mixing water caused the higher porosity . The better spalling behaviour of CEM I - GR-PF mixture was not only due to addition of PP fibre. The positive effect was reached by combination of the increased porosity and addition of polypropylene fibres.Specimen with fine steel fiber dispersed reinforcement (CEM III/B - B-SF) also showed no explosive spalling on exposed surface. Positive effect of these fibers lies in transferring tension caused by gathered overheated water vapor in concrete structure, which prevents explosive spalling.Fundamental failure of specimen CEM I - GR-SCC  occurred in the first minutes of the experiment (within 3 minutes from beginning of the experiment).Test specimens CEM III/B - B and CEM I - GR-SCC had no dispersed reinforcement and comparable moisture content (±4%); explosive spalling occurred only on the test specimen with higher density of structure (CEM I - GR-SCC) in consequence of higher proportion of fines.The experimental work brought many observations and new information and data about behavior of concrete specimens of various compositions and strengths thermally loaded by direct flame; the most important ones are below.The nondestructive monitoring of the effect of high temperature on concrete specimens of different mixtures was performed. As an important fact to evaluate the resistance of concrete to high temperatures occurs a continuous evaluation of concrete behavior over time when exposed to high temperatures. The photographing of the surface of the specimens at intervals of 10 minutes was performed. Recording of significant behavioral changes of concrete was conducted throughout the experiment. In particular, it is important to record the time interval when explosive spalling occurs. This must be done in order to ensure protection of steel reinforcement in concrete and the possible prediction of structural failure in case of detection of reinforcement due explosive spalling and for the time required for evacuation. Using other methods of nondestructive testing makes it possible to spread information about the processes inside the thermally loaded specimen.The following nondestructive methods for determination of changes and defects inside the specimens after thermal exposition can be used: determination of velocity of propagation of ultrasonic waver, X-ray tomography. As a next step, these tests can be complemented with destructive testing: determination of physicomechanical properties, X-ray, DTA, and porosimetry.Presented results contribute to knowledge about behavior of real concrete structure thermally loaded by direct flame, a fire, which is currently very topical. The paper is valuable for setting the method of testing concrete specimen exposed to direct flame, which proved to be successful. This way of testing concrete specimens of smaller size is flexible, with low requirements for time and resources and it is a suitable early stage for more costly thermal loading of large scale concrete specimens with direct flame.


Increased mesenchymal–epithelial transition factor gene (c-MET) expression in several human malignancies is related to increased tumour progression. The aim of the present study is to explore the relationship between immunohistochemical expression of c-MET in colorectal carcinoma (CRC) and the clinicopathological characteristics and follow up data, to compare the expression of c-MET in primary CRC and its metastasis in lymph nodes and to test its validity as independent prognostic factor.Hundred and thirty-five archival CRC and nodal metastases samples were collected from King Abdulaziz University Hospital, Saudi Arabia. Tissue microarrays were constructed and immunohistochemistry was done to detected c-MET protein expression. Appropriate statistical analysis was performed.p < 0.003) and in left colon subsite (p < 0.05). There was no significant correlation between c-MET protein expression and age, sex, degree of differentiation, tumour invasion, presence of nodal metastasis, lymphovascular invasion, status of surgical resection margin, or presence of distant metastasis. Furthermore, no association between c-MET protein expression and disease free survival. High protein expression of c-MET is associated with the incidence of local disease recurrence (p < 0.012).High c-MET immunostaining was significantly associated with tumour size larger than 5 cm (in vitro and in vivo studies are required to pursue c-MET as potential molecular marker of metastases and test the possibility of its incorporation as a new targeted therapeutic target.c-MET is a new promising target that may help in understanding the pathogenesis of CRC, and to be used as independent prognostic biomarker to predict local disease recurrence in CRC. Further molecular  Colorectal carcinoma (CRC) is among the most common neoplasms affecting the industrialised nations. According to the Saudi Arabian National Cancer Registry, CRC is accounting for 11.3 % of all newly diagnosed cases in year 2009. This cancer ranked first among male population and third among female population –6.One of the most promising biological markers in the pathogenesis of CRC is the proto-oncogenes c-MET  which encodes the tyrosine kinase receptor for hepatocyte growth factor/scatter factor (HGF/SF). Interaction between HGF and c-MET plays a key role in cellular proliferation, survival, migration, and invasion. The HGF/c-MET axis contributes a critical physiological function in embryogenesis, angiogenesis, and wound healing , 8. UndeThe aim of the present study is to explore the relationship between immunostaining of c-MET in CRC and the clinicopathological characteristics and follow up data, to compare c-MET immunostaining in primary CRC and its metastasis in lymph nodes, and to test its validity as independent prognostic factor.The current study involved 135 paraffin blocks retrieved from patient’s materials in the archives of the Pathology Department, King Abdulaziz University, Jeddah, Saudi Arabia covering the period from January 1995 to December 2010. Paraffin blocks were sliced and stained routinely with haematoxylin and eosin to evaluate histopathological characteristics of the tumours as well as for histological grading and staging. Clinical parameters of patients were collected from the patient's medical records and listed in Table A tissue microarray (TMA) was constructed from 135 primary CRC and 49 corresponding lymph nodes showing tumour metastasis. Two cylindrical cores of 1.5 mm in diameter were selected from donor paraffin blocks and arrayed in 6 recipient paraffin blocks using the automated tissue arrayer (MASTER 3D HISTECH). Normal placenta tissue was used as control tissue to help orientation of samples in each TMA block. TMA blocks were sliced into 4-micron meter sections embedded in sialinated slides in order to be stained by immunohistochemical staining.Immunohistochemical staining of CRC samples were using antibody to protein c-MET was performed by avidin biotin procedure following manufacturer's kit instructions. The antibody used was a monoclonal mouse Anti-Human c-MET . IHC procedure was carried out using an automatic immunostainer . In each analysis, positive controls were used consisting of CRC samples previously shown to stain with this antibody. Tris-buffered saline in place of the primary antibody was used as a negative control.c-MET protein positivity appeared as yellow to brown staining in tumour cell cytoplasm and/or cell membrane. The immune reaction was evaluated semiquantitavely according to staining intensity taking into account the percentage of cells staining at a given intensity, following the scoring system given by Takeuchi et al.  on a scaDifferences between two groups of patients on one variable were tested by using Mann Whitney test while between three groups of patients by Kruskal Wallis test was used. Non-parametric chi-square was used to test variance along one variable. Binary logistic regression analysis was used to predict lymph noel metastasis, distant metastasis, surgical resection margins involvement, lymphovascular invasion, and local disease recurrence in relation immunoexpression of c-MET. Estimated odds ratio {exponential (B)}, 95 % confidence interval (CI) for exp(B). The Kaplan-Meier procedure was used to calculate the disease-free survival probabilities and the Log Rank test was used to compare the difference between survivals. Time was calculated from the date of diagnosis to the appearance of disease relapse (or date last seen disease-free). Statistical procedures were performed using SPSS® Release 16.0. Statistical significance was determined at p value of ≤0.05 and was 2-sided.In CRC, c-MET protein expression was observed as in tumour cells, but was negative in inflammatory cells, endothelial cells, smooth muscle cells or fibroblasts. c-MET immunostaining positivity was observed as yellow-brown staining observed in the cytoplasm and cell membrane. Fig.  Cases wiThere was no significant correlation between c-MET expression and age, sex, degree of differentiation, depth of tumour invasion, tumour stage, presence of nodal metastasis, lymphovascular invasion, status of surgical margins and presence of nodal distant metastasis. On the other hand, high c-MET immunostaining was significantly associated with tumour sizes larger than 5 cm and in left colon location Table .Table 3Ap = 0.285) (Fig. The survival curves for high- and low c-MET groups were assessed by the Kaplan-Meier method and compared by a log-rank test which showed no association of c-MET protein expression with disease-free survival (Log rank = 1.142, and CRC remains the second leading cause of cancer-related death worldwide despite recent advances in adjuvant chemotherapeutic regimens . Recent The present study showed that c-MET protein is concomitantly overexpressed in both primary tumours and in nodal metastasis which is similar other studies findings , 18. TheSignificant statistical correlation was identified between c-MET protein overexpression and tumour recurrence. This result is comparable to those of Saigusa et al.  that invIn addition to association of c-MET activation with tumour progression, previous studies demonstrated that the HGF/c-MET signalling pathway plays a role in angiogenesis and lymphangiogenesis by promoting the growth of endothelial cells, increasing the expression of pro-angiogenic mediators, such as vascular endothelial growth factor, and suppressing the activity of thrombospondin 1-a negative regulator of angiogenesis. Considering the relevant role of c-MET in angiogenesis, activated c-MET is considered as adjuvant pro-metastatic gene for many tumour types. Novel therapeutic strategies, which focus on the simultaneous blockade of such proto-oncogene, have been recently proposed to improve the treatment outcome –24.The limitation of the current study includes including missing some follow-up data, short survival time in a number of patients.in vitro and in vivo studies are required to pursue c-MET as potential molecular marker of metastases and test the possibility of its incorporation as a new targeted therapeutic target.In summary, in the present study the association of high c-MET immunostaining with larger tumours supports involvement of c-MET in tumour progression. On the other hand, c-MET is a promising target that may help in understanding the pathogenesis of CRC, and to be used as independent prognostic biomarker to predict local disease recurrence in CRC. Further molecular


Little is known about differences between the characteristics and psychopathological symptoms of heroin users attending TC or MMT in Asia. This study aimed to compare characteristics and prevalence of depressive disorders among male heroin users in TC and MMT program in Nantou, Taiwan.n = 705) comprised male heroin users with heroin dependence recruited from the MMT program and TC program at a psychiatric center in Nantou, Taiwan between 2006 and 2014. Socio-demographic and heroin-related characteristics were obtained from self-report questionnaires. DSM-IV diagnoses of heroin dependence, major depressive disorder, and dysthymic disorder were evaluated by trained interviewers. T-test and chi-square test and multivariate logistic regression were performed to measure the differences on variables between samples of TC and MMT.The study sample (Compared to MMT, TC participants had poorer family support, higher rate of unmarried, higher rate of unemployment, earlier onset of heroin use, longer length of heroin use, and lower daily dosage of heron. MMT heroin users had higher 1-month prevalence of major depressive disorder than TC participants. We found the distribution of current major depression disorder differed between heroin users choosing different treatment models even controlling for other demographic factors, substance related factors and psychosocial factors. The underlying explanations require further investigation.This study found differences in the characteristics and prevalence of psychopathology. Further study to explore the effect of these differences on the outcome between MMT and TC is warranted. Heroin is one of the world’s most widely abused illicit substance . AccordiBesides methadone treatment, therapeutic community (TC) is also effective in reducing substance use  and imprSeveral studies reported that there were ethnic differences in symptom domains, symptom severity, and prevalence of depressive disorder among heroin users between Asians and Caucasians –9. The cAccording to the Narcotics Endangerment Prevention Act in Taiwan, heroin was classified as Schedule I drug. Heroin-using offenders are often granted deferred prosecution if they are willing to receive treatment in hospitals when they were caught for the first time. A positive urine test during this period of time would require them to undergo compulsory abstention in a compulsory rehabilitation institution. They may be sentenced to 6 months to 5 years in prison if they return to use heroin during 5 years after compulsory abstention. The majority of heroin users in methadone maintenance treatment (MMT) or therapeutic community (TC) at Tsaotun Psychiatric Center are under no compulsion to stay in TC or MMT program.TC at Tsaotun Psychiatric Center is the only abstinence-oriented and drug-free residential setting in Taiwan. Heroin users with severe withdrawal symptoms are not allowed to enter TC. They need to go through acute detoxification before attending TC. Participants are generally recommended to stay in TC for 6 months to 1 year. Individuals with positive urine drug screen or disobey rules of TC when attending the community will be expelled. The TC focuses on self-help, peer-support, personal growth, and rehabilitation. Psycho-social interventions include education, counseling, motivational therapy, cognitive-behavioral therapy, and vocational training. The goal of the TC program is to enhance recognition and control of drug use cues, resolve ambivalence about change, develop effective problem-solving strategies, and prevent relapse.The aim of the present study was to compare the socio-demographic characteristics and heroin-related characteristics among male heroin users in TC and MMT in Nantou, Taiwan. In this study, we also investigated the differences in the prevalence of depressive disorders between TC and MMT male heroin users in Nantou, Taiwan.Participants in this study were recruited from the methadone maintenance treatment (MMT) program and the therapeutic community (TC) at Tsaotun Psychiatric Center in Nantou County, Central Taiwan between 2006 and 2014.Due to the restriction of environmental management, the TC at Tsaotun Psychiatric Center only recruits male heroin users. It is known that female gender is an important risk factor for major depressive disorder –15. To aA total of 999 individuals entered the methadone maintenance treatment (MMT) program at Tsaotun Psychiatric Center between 2006 and 2014. After excluding individuals without the diagnosis of heroin dependence, individuals under 20 years old, individuals with illiteracy, and individuals with history of diagnosed intellectual disability, 553 MMT heroin users participated in the study.n = 705.Among the total of 264 individuals entering the therapeutic community (TC) at Tsaotun Psychiatric Center between 2006 and 2014, 173 individuals met the diagnostic criteria of heroin dependence. After excluding individuals under 20 years old, individuals with illiteracy, and individuals with history of diagnosed intellectual disability, 152 TC heroin users participated in the study. The total participating study sample is, therefore, All participants completed a set of self-report questionnaires administered by a trained psychiatric nurse on the first day of the MMT or TC program. Questions included age, marriage, employment, years of education, lifetime number of criminal convictions (substance related and non-substance related), age of onset of heroin use, main route of heroin administration (injection or non-injection), sharing of needles with others , sharing equipment other than needles , and lifetime suicide attempt (yes or no). Heroin in Taiwan is weighed using a traditional measuring unit: Qian. One Qian is approximately equal to 3.75 g. The frequency and dose of heroin they used per day in the past 30 days before entering treatment were asked.The following self-administered questionnaires were approached in this study: The Chinese version of the Severity of Dependence Scale (SDS[Ch]) is a five-item scale measuring psychological dependence experiences over the past year . SDS[Ch]The diagnoses of heroin dependence, major depressive disorder and dysthymic disorder were based on the criteria of Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). Participants were evaluated by trained interviewers using the structured diagnostic interview of Mini-International Neuropsychiatric Interview (M.I.N.I) , which hWe estimated the 1-month prevalence of major depressive disorder, lifetime prevalence of dysthymic disorder, and lifetime prevalence of suicide attempt among study participants.T-test and chi-square test were performed to determine if there were statistically significant differences on continuous and categorical variables between samples of TC and MMT. Differences were considered significant if p < 0.05.Descriptive statistics were used to explore the characteristics of the study sample in the TC and MMT programmes. p value was less than 0.05. Analyses were conducted using SPSS 15.0 for Windows.Multivariate logistic regression analysis was conducted to examine if there is significant difference in the distribution of major depressive disorder in two treatment models after adjusting for demographic and substance-related variables. Differences were considered significant if the The study was reviewed and approved by the Institutional Review Board of the TsaoTun Psychiatric Center. All participants provided written informed consent before participation and were informed of their right to discontinue participation at any time and assurance of confidentiality.The socio-demographic and substance-related characteristics and psychiatric diagnoses of the sample are summarized in Table p = 0.004), higher mean Family APGAR[Ch] scores , higher rate of unmarried , and higher rate of unemployment  compared to heroin users in MMT.In socio-demographic variables, heroin users in TC had significantly more years of education , longer length of heroin use , and lower heroin daily doses   compared to heroin users in MMT.For substance-related variables, heroin users in TC had significantly earlier age of onset of heroin use  and inhalation (24.2 % vs. 25 %) were similar among heroin users in TC and MMT.The mean SDS score, number of substance related criminal convictions, number of non-substance related criminal convictions, and needle sharing rate were similar among heroin users in MMT and TC.Among MMT participants, the 1-month prevalence of major depressive disorder was 32.2 %. The lifetime prevalence of suicide attempts was 26.6 %. Among TC participants, the 1-month prevalence of major depressive disorder was 22.4 %. The lifetime prevalence of suicide attempt was 24.3 %.p = 0.019). MMT and TC participants had similar lifetime prevalence of suicide attempt and dysthymic disorder.Heroin users in MMT had a significantly higher 1-month prevalence of major depressive disorder compared to participants in TC  . HoweverThe prevalence rate of major depressive disorder among MMT participants in our study was within the range of previous studies in United States, Australia, and Spain (ranging from 16 to 54 %) , 28, 29.Compared to males, female heroin users were reported to have 2–3 fold higher prevalence of depression , 34, 35 Compared to TC patients in the present study, MMT heroin users had higher 1-month prevalence of major depressive disorder. We found the distribution of major depression disorder differed between heroin users choosing different treatment models even after controlling for other demographic factors, substance related factors and psychosocial factors. The reasons for this require more studies to detect underlying factors.TC and MMT participants in our study had similar lifetime prevalence of suicide attempt and both were higher than that among general population , 36, andStudies reported that depressive symptoms, injection drug use, sexual or physical abuse histories, female gender, self-harm histories, and poor relationship with family were associated with suicide attempt among heroin dependent patients , 39, 40.Our study had a number of limitations. Gender differences in the prevalence and related factors of depressive disorder are important –15. Due However, the study also has certain important strengths. Recent studies have noted ethnic differences in depressive disorder –9 and thThe present study found that heroin users from TC and MMT in Nantou, Taiwan had different socio-demographic and substance-related characteristics. The distribution of current major depression disorder differed between heroin users choosing different treatment models even controlling other demographic factors, substance related factors and psychosocial factors. Given the high prevalence of current major depressive disorder, active interventions for relieving depressive disorders for heroin users in TC and MMT are warranted. The influence of different characteristics on treatment outcome between TC and MMT warrants further follow-up studies.


Pseudogymnoascus destructans, has been responsible for the mortality of an estimated 5.5 million North American bats since its emergence in 2006. A primary focus of the National Response Plan, established by multiple state, federal and tribal agencies in 2011, was the identification of biological control options for WNS. In an effort to identify potential biological control options for WNS, multiply induced cells of Rhodococcus rhodochrous strain DAP96253 was screened for anti-P. destructans activity.The recently-identified causative agent of White-Nose Syndrome (WNS), P. destructans were exposed to induced R. rhodochrous in a closed air-space at 15°C, 7°C and 4°C and were evaluated for contact-independent inhibition of conidia germination and mycelial extension with positive results. Additionally, in situ application methods for induced R. rhodochrous, such as fixed-cell catalyst and fermentation cell-paste in non-growth conditions, were screened with positive results. R. rhodochrous was assayed for ex vivo activity via exposure to bat tissue explants inoculated with P. destructans conidia. Induced R. rhodochrous completely inhibited growth from conidia at 15°C and had a strong fungistatic effect at 4°C. Induced R. rhodochrous inhibited P. destructans growth from conidia when cultured in a shared air-space with bat tissue explants inoculated with P. destructans conidia.Conidia and mycelial plugs of P. destructans activity is a major milestone in the development of viable biological control options for in situ application and provides the first example of contact-independent antagonism of this devastating wildlife pathogen.The identification of inducible biological agents with contact-independent anti-  To thistructans  was releRhodococcus rhodochrous strain DAP 96253 is a ubiquitous, soil-associated, Gram-positive bacterium with tremendous metabolic and physiological diversity [Rhodococcus rhodochrous has been used extensively in bioremediation as well as in the production of nitrile-containing compounds [P. destructans by R. rhodochrous indicated that, when induced under the protocol outlined in US patents 7,531,343, and 7,531,344 [R. rhodochrous strain DAP 96253 demonstrated significant contact-independent antagonism of P. destructans in vitro. As a result, the principal objective of this was evaluation of R. rhodochrous induced with urea for potential in situ application as a biological control agent for P. destructans.ompounds  and it hompounds . Severalompounds . Initial,531,344 ,11, R. rin vitro analysis of the observed antagonism, the evaluation of the efficacy of induced R. rhodochrous was pursued in order to establish in vivo efficacy at preventing fungal invasion of bat tissue. This goal was accomplished using a bat-skin explant assay. The evaluation of induced R. rhodochrous to prevent or reduce the infective potential of P. destructans conidia was demonstrated by the inhibition of P. destructans growth on living bat tissue. This is the first example of antifungal efficacy on living bat skin for any biological control agent of WNS and represents a major milestone in this effort.In addition to the strong evidence established via R. rhodochrous for potential in situ application, including whole-cell application, non-growth fermentation cell-paste, and fixed-cell catalyst [In order to optimize biocontrol efficacy and reduce potential cross-contamination of karst environments, various whole- and fixed-cell applications were investigated. The evaluation of various application methods of induced cells of catalyst ,12,13, wP. destructans isolates used in the project were acquired from the WNS diagnostic lab at The University of Georgia Southeastern Cooperative Wildlife Disease Study (UGA SCWDS). Initial investigations have shown very low genetic and physiological variability amongst P. destructans isolates [P. destructans cultures were maintained on Sabouraud Dextrose Agar  or in Sabouraud Dextrose Broth  at 4°C, 7°C, or 15°C depending on anticipated usage. P. destructans conidia were harvested from fungal lawns on SDA plates by adding 10 ml of conidia harvesting solution  to the surface of the plate and gently scrapping with a sterile loop to dislodge conidia. The resulting solution was filtered through glass wool and centrifuged at 5000 rpm for 10 minutes. The resulting supernatant was removed and the spore pellet washed with 5 mL of sterile phosphate buffered saline , re-suspended, and filtered through glass wool. Conidia were stored in sterile PBS at −20°C. Conidia were stored no longer than six weeks prior to use based on in-house assessment of conidial viability under these conditions (unpublished data). R. rhodochrous strain DAP 96253 cells were maintained as glycerol stock aliquots (30% v/v) from 10 l fermentations carried out at GSU. Fresh glycerol stocks were used as the source of cells at the onset of each assay. The induction process was performed using the addition of urea or urea and cobalt as described in US patents 7,531,343 and 7,531,344 [All isolates . Accordi,531,344 .P. destructans growth characteristics in the presence of induced cells of R. rhodochrous. A 10 μl inoculum of P. destructans conidia solution (106 ml−1) in a phosphate buffer solution was spread onto SDA in Petri plates (35 mm x 10 mm). Multiply induced cells of R. rhodochrous [R. rhodochrous to inhibit healthy established hyphae of P. destructans was assessed using mycelial plug assays. A lawn of P. destructans was allowed to grow for up to 20 days at which time a 5-mm-diameter transfer tube was used to remove a plug from the mat of fungus. The plugs were then inserted into a similarly sized core removed from an uninoculated culture plate. The plates were co-incubated in a shared air-space as described previously and radial growth from the plug was assessed over time.A single-compartment Petri plate (150 mm × 15 mm) was used for a contained air-space to assess dochrous  were inodochrous , and culP. destructans conidia solution (106 ml−1) were spread across the agar surface. R. rhodochrous-inoculated Petri plates (35 mm × 10 mm) were placed in larger Petri plates (150 mm × 15 mm) and sealed with parafilm. Negative controls consisted of similarly-cultured conidia with no R. rhodochrous exposure. All trials were conducted in triplicate. At 4 and 7 days post-inoculation, conidia were observed in a light microscope at 200X magnification for the presence of germule formation. Germules were defined as single mycelial extensions emanating from conidia with a length equal to or greater than the intact conidia. Control and exposed slides were retained and examined daily for up to 21 days after germule formation was first observed on control slides. Recovery of conidia was determined by removing the R. rhodochrous after 24 hours, 72 hours, and 7 days. Slides were observed for 21 days after removal of control agent to assess recovery.Thin layers (~750 μl) of 10% SDA were applied to standard microscope slides (24.5 × 76.2 mm) and 100 μl of et al. [et al. [P. destructans activity of fixed-cell catalyst and fermentation cell-paste was determined in co-culture assays with P. destructans conidia and mycelial plugs with various amounts of control agent (<1.0 g), as described previously. Efficacy was determined by observation of germule formation as compared to unexposed controls for growth from conidia, and as percent reduction in radial growth of mycelial plugs.Immobilization of whole bacteria was carried out based on the methods of DeFilippi  and Lopeet al. . Refinem [et al. ,11. EvalR. rhodochrous to inhibit fungal growth on bat skin explants was evaluated using an ex vivo model of WNS. A 10-mm-diameter biopsy punch was used to collect full-thickness samples of skin (n = 40) from the patagium of bats (n = 2) immediately after euthanasia. The explants were adhered to a mesh support with tissue adhesive (TissueTek®) so that they would retain their shape and could be supported at the medium surface without allowing media to come in contact with the inoculated surface of the skin. The skin explants were then maintained on Eagle’s modified minimal essential medium supplemented with antibiotics . A suspension of spores was placed onto the center of the explant and allowed to dry. The inoculated explants were incubated in a shared air-space with induced R. rhodochrous. Uninoculated control explants were incubated alone or with uninduced R. rhodochrous. Initial experiments were conducted at 7°C. Anti-infective efficacy was determined by visual and microscopic evaluation of bat wing membrane tissue cultures exposed to induced R. rhodochrous as compared to unexposed and uninduced controls.The potential for induced R. rhodochrous demonstrated complete inhibition of growth from conidia of P. destructans when cultured with a shared air-space at 15°C  on days 8, 12, 16, and 20 across all replicates  when incubated in a shared air-space for up to 21 days at 7°C  [While the efficacy of urea-induced ernacula . The lacR. rhodochrous using ex vivo bat tissue explants as an indicator of anti-infective activity was paramount to establishing R. rhodochrous as a viable biocontrol agent of P. destructans. This was the first demonstration of inhibition of fungal colonization of bat tissue by a biological control agent. This ex vivo efficacy justifies further in vivo studies with live bats and should be pursued vigorously.The evaluation of R. rhodochrous in these environments. However further investigations are needed to confirm the applicability of this approach.The ability of dormant conidia to remain viable in host-free environments increases long-term impacts of fungal pathogens and renders contaminated environments inhospitable to re-colonization . The impR. rhodochrous strain DAP 96253 has demonstrated the tremendous potential of this organism for application as a biological control agent of P. destructans. This is the first and only demonstration of contact-independent antagonism of P. destructans and represents a significant step toward the development of biologically-based treatment tools for WNS.The evaluation of