Blood coagulation under physiological conditions is activated by thrombin, which converts soluble plasma fibrinogen (FBG) into an insoluble clot. The structure of the enzymatically-generated clot is very characteristic being composed of thick fibrin fibers susceptible to the fibrinolytic degradation. However, in chronic degenerative diseases, such as atherosclerosis, diabetes mellitus, cancer, and neurological disorders, fibrin clots are very different forming dense matted deposits (DMD) that are not effectively removed and thus create a condition known as thrombosis. We have recently shown that trivalent iron (ferric ions) generates hydroxyl radicals, which subsequently convert FBG into abnormal fibrin clots in the form of DMDs. A characteristic feature of DMDs is their remarkable and permanent resistance to the enzymatic degradation. Therefore, in order to prevent thrombotic incidences in the degenerative diseases it is essential to inhibit the iron-induced generation of hydroxyl radicals. This can be achieved by the pretreatment with a direct free radical scavenger , and as shown in this paper by the treatment with oxidizing agents such as hydrogen peroxide, methylene blue, and sodium selenite. Although the actual mechanism of this phenomenon is not yet known, it is possible that hydroxyl radicals are neutralized by their conversion to the molecular oxygen and water, thus inhibiting the formation of dense matted fibrin deposits in human blood. It is well recognized that in the developed countries, thrombotic events are the main cause of death, mostly in the form of strokes and heart attacks. In addition, persistent presence of thrombi is observed in practically all degenerative diseases including rheumatoid arthritis, neurological disorders and cancer -3. The cResistance of fibrin clots to enzymatic degradation, observed in numerous degenerative diseases can now be explained in terms of the effect of hydroxyl radicals (HRs), which convert soluble human FBG into insoluble and plasmin-resistant polymer. Hydroxyl free radicals are, in turn, produced by poorly chelated iron ions accumulating in the circulation from the ingested food and/or hemoglobin leaking from red blood cells (RBC). Hydroxyl radicals cause unfolding of FBG polypeptide chain(s) with the exposure of buried hydrophobic epitopes that form intermolecular bonds resistant to proteolytic degradation. Thus, it can be concluded that the commonly observed thrombolytic resistance of older thrombi might be caused by such a molecular modification induced by HRs generated under conditions of iron overload. In particular, the presence of insoluble fibrin like deposits may contribute to chronic inflammation and predisposition to thrombosis observed in the degenerative diseases. Soluble precursors, in the form of protofibrils, demonstrated in the blood of stroke patients by means of scanning electron microscopy (SEM), may also be responsible for hemorheologic disturbances observed in chronic inflammatory diseases , 9. Human fibrinogen was purchased from Sigma Aldrich (Cat.No. F3879-250MG). This was dissolved by pouring 10 ml of warm PBS  (pH of 7.4) over the content and gently mixed with a glass rod until completely dissolved. This stock solution can be stored at -20°C in 1-2 ml portions in plastic vials. A second stock solution was prepared with fibrinogen concentration of 2,5 mg/ml – which was also stored at -20°C. A working solution was prepared by thawing 2nd stock solution 2 at 37°C and diluting it with PBS to obtain a solution of 0.166 mg/ml. Blood was obtained from 30 healthy control subjects  [Ethical clearance from the University of Pretoria Ethics committee was granted]. These individuals did not have any chronic conditions, did not smoke and did not use any medication. The micrographs from the healthy individuals were compared to our data base of thousands of micrographs, and found to be comparable. 1 and 2).All samples for SEM were prepared using 10 µl of PRP and WB, placed directly on a glass cover slip and mixed with various compounds followed by 5 ul of human thrombin (10U/ml) . Hydrogen peroxide, methylene blue, sodium selenite and salicylate were prepared to various mM concentrations (Table 4). The samples were again rinsed 3x with PBS for five minutes and were dehydrated serially in 30%, 50%, 70%, 90% and three times with 100% ethanol. The material was critical point dried, mounted and coated with carbon. A Zeiss ULTRA plus FEG-SEM with InLens capabilities were used to study the surface morphology of platelets and micrographs were taken 1kV. This instrument is located in the Microscopy and Microanalysis Unit of the University of Pretoria, Pretoria, South Africa.The cover slips with prepared clots were incubated at room temperature for 5 minutes and then were immersed in 0.075 M sodium phosphate buffer (pH 7.4) and finally placed on a shaker for 2 minutes. Smears were fixed in 2.5% glutaraldehyde / formaldehyde in PBS solution with a pH of 7.4 for 30 minutes, followed by rinsing 3x in phosphate buffer for five minutes before being fixed for 30 minutes with 1% osmium tetraoxide (OsO1) shows the mM values and µl volume for all experiments performed with the purified fibrinogen. All experiments were repeated 10 times and 10 ul portions of 0.166 mg/ml purified fibrinogen were placed on a glass cover slip and 5ul of human thrombin (10U/ml) was added to create an extensive fibrin network. (Table 2) shows the mM values and µl volume for all experiments performed with PRP and WB. (Table 1a – f) we show purified fibrinogen, PRP and WB with additional thrombin. When thrombin is added to fibrinogen and PRP samples, an expansive fibrin network is created, where thick fibrin fibers are formed, with thin fibers sparsely distributed among these thick fibers Fig. . In WB smears, red blood cells (RBCs) are entangled with individual thick and thin fibers Fig. (1e). However, when FeCl3 is added to PRP, fibrin fiber morphology is changed Fig. . Ferric iron addition to fibrinogen shows dense matted deposits (DMDs) with thin fibers dispersed in between Fig. (1b). Ferric iron addition to PRP show a nearly solid DMD formation, where nearly no fibers are individually recognized. When ferric iron is added to WB, RBCs fused to DMDs are seen and these RBCs also tend to change form Fig. (1f).In control experiments Fig. (2a – c). In the fibrinogen preparation, thin beaded fibrin fibers are visible, but here the DMD formation is not formed. However, in the PRP sample Fig. (2b), no DMD formation was visible and samples appeared similar to regular control clots. Also, DMD formation was not present in WB smears Fig. (2c). This suggests a possible protective effect of hydrogen peroxide against ferric iron damage.We also added hydrogen peroxide and ferric iron to all three preparations. These are shown in Fig. (3a – c) more subtle changes were noted. In the fibrinogen experiments, thick, beaded fibrin fibers were noted Fig. (3a); however, in PRP samples, an amorphous clot formation was seen Fig. (3b) and WB samples revealed deformed RBC shapes with beaded fibrin fibers Fig. (3c). In samples treated with methylene blue Fig. (4a – c) showed ultrastructure very similar to untreated control samples. Salicylate-treated samples are shown in Fig. (5a – c). In the purified fibrinogen experiments, dense, beaded fibrin fibers are seen Fig. (5a); however, PRP samples compared well to that of controls Fig. (5b) and RBC did not deform Fig. (5c); even with the addition of a lower volume of salicylate. Samples treated with the anti-oxidant sodium selenite Fig. . Iron is a transition metal that plays an essential role in many physiological functions in living organisms. Metabolism of iron in the human body is well controlled, so no large quantities of this metal are released at a given time. However, a certain proportion of iron exists in blood in a trivalent form in the so called labile iron pool . In addiAs showed by us for the first time, ferric ions can generate the most biologically reactive hydroxyl radicals (HR) without any oxidizing agent, according to the following reaction: That, in turn, causes polymerization of fibrinogen in a purified system, in plasma and/or in whole blood . It is iAs shown in this paper, the formation of DMDs and their subsequent fusion to RBCs can be prevented by hydrogen peroxide and certain other oxidizing agents. In the case of hydrogen peroxide this phenomenon may occur by scavenging hydroxyl radical according to the following reaction:4+ to Se2+. This effect is very likely to be responsible for the anticancer properties of certain selenium derivatives, particularly sodium selenite [The inhibitory effect of hydrogen peroxide on the formation fibrin-like deposits, may explain the therapeutic effects of this compound reported in several papers -19. As iselenite -25.The most important conclusion is that the results of this work can explain a well-known fact of failure of the so-called antioxidants in the prevention and treatment of degenerative diseases -28. In f


Results of the study demonstrated the ability of propolis phenolic acids  and vanillin to penetrate into skin epidermis and dermis. The rate of penetration and distribution is affected both by physicochemical characteristics of active substances and physical structure and chemical composition of semisolid vehicle. Vanillin and vanillic acid demonstrated relatively high penetration through epidermis into dermis where these compounds were concentrated, coumaric and ferulic acids were uniformly distributed between epidermis and dermis, and caffeic acid slowly penetrated into epidermis and was not determined in dermis. Further studies are deemed relevant for the development of semisolid topically applied systems designed for efficient delivery of propolis antioxidants into the skin.Antioxidant and free radical scavenging effects are attributed to phenolic compounds present in propolis, and when delivered to the skin surface and following penetration into epidermis and dermis, they can contribute to skin protection from damaging action of free radicals that are formed under UV and premature skin aging. This study was designed to determine the penetration of phenolic acids and vanillin into the human skin  Ultravir esters –8. A conr esters . Strong r esters . Brazilir esters –12. Alsoin vitro. The current study was designed to evaluate the ability of propolis phenolic acids and phenolic aldehyde vanillin to penetrate human skin from different carriers that were designed and developed for topical application.Therefore, the objective of this study was to evaluate the release of propolis phenolic acids and vanillin from experimental semisolid formulations and their penetration into the human skin layers Raw propolis was obtained from UAB Medicata Filia , and soft propolis extract was obtained from UAB Valentis ; acetonitrile (Chromasolv) was gradient grade for HPLC, ≥99.9% and acetic acid , ≥99.8% pure quality . The standards of phenolic compounds for HPLC were purchased from Sigma-Aldrich Chemie GmbH : vanillic acid (≥98%), caffeic acid (≥98%), vanillin (≥99%), coumaric acid (≥98%), and ferulic acid (≥99%). Purified water for preparation of solvents was filtered through the Millipore HPLC grade water preparation cartridge . Vaseline (white), glycerol, span 80 (sorbitan oleate), poloxamer 407 (polyoxyethylene-polyoxypropilene-polyoxyethylene tri-block copolymer), and sodium carboxymethylcellulose (50–200 cP) were purchased from Sigma-Aldrich Chemie GmbH ; lanolin, anhydrous ; Pionier PLW  ; sodium chloride  and sodium azide .Propolis sample-to-solvent ratio was 1 : 10 (w/v) when preparing aqueous propolis extract. Phenolic compounds from raw propolis were extracted using purified water with stirring at 70°C for 1 hour using a hotplate magnetic stirrer IKAMAG C-MAG HS7  , 14. Proμm particle size) using the mobile phase composed of acetonitrile (solvent A) and 0.5% (v/v) acetic acid in water (solvent B). The linear elution gradient from 1 to 21% of solvent A in B 25 min was applied. The injection volume was 0.2 μL, the flow rate was 20 μL/min, and the column temperature was 25°C. The specificity and identification of phenolic acids were confirmed with a PDA detector and UV spectra of the appropriate standards in the wavelength range of 210–600 nm. The integration of phenolic acids peaks was performed at 290 nm [Four phenolic acids  and vanillin were identified in propolis extracts using Agilent 1260 Infinity capillary LC  with Agilent diode array detector (DAD) and applying validated HPLC method for quantification of the above-mentioned phenolic compounds. The separation of phenolic acids and vanillin was achieved with an ACE C18 column  for syringes  prior to performing HPLC analysis.All propolis samples were filtered through 0.20 Choice of excipients for ointment and w/o cream semisolid vehicles were developed with the reference to earlier published research data . The comThe experimental propolis ointment and water-in-oil (w/o) cream were prepared at room temperature using the Unguator 2100 mixing machine . Ointment base components were mixed until homogeneity. Later soft propolis extract was added and dispersed in the ointment base. The final mixing step in propolis ointment formulation was performed for 2 min using normal general mixing procedure. Formulation of propolis w/o cream was performed by addition of aqueous phase to homogeneous oily phase containing emulsifying agent to produce primary emulsion. Soft propolis extract was added for dispersion, and final mixing was performed at mixing under 750 rpm, oscillation 1500 rpm, and continued for 2.25 min. Experimental propolis hydrogel formulation was prepared by cold method .n = 3).Dynamic viscosity (Pa·s) of experimental semisolid propolis preparations  was asseIn vitro release experiments were performed (n = 3) using the modified Franz type diffusion cells and the dialysis membranes of natural cellulose Cuprophan  [2. The infinite dose of the donor phase was placed into the diffusion cell. The aqueous receptor medium was stirred using the hotplate magnetic stirrer IKAMAG C-MAG HS7  maintaining the temperature of 32 ± 0.1°C. The samples from the receptor solution were removed at 0.5, 1, 2, 4, 6, 8 hour and replaced with the same volume of fresh receptor solution. All samples were analyzed by HPLC. don, UK) , 18. A dIn vitro skin permeation experiments (n = 6) were performed using Bronaugh type flow-through diffusion cells with full-thickness human skin. Acceptor phase was circulated by Masterflex L/S peristaltic pump with multichannel pump head  [2. The diffusion cells with human skin samples were placed on the heating block maintaining 37°C by a Grant GD120 thermostated circulating water bath .Caucasian women (age range 25–40 years) abdominal skin was obtained from Department of Plastic and Reconstructive Surgery, Hospital of Lithuanian University of Health Sciences, after cosmetic surgery, and was stored at −20°C not longer than 6 months before use. Kaunas Region Bioethical Committee has approved the use of human skin for transdermal penetration studies. IL, USA) , 20. The3 was maintained underneath the skin samples. After the equilibration period, the infinite dose of the donor phase was applied on the outer human skin side (stratum corneum side) surface, and the diffusion cells were covered with aluminum foil. Circulation rate of the acceptor medium underneath the skin samples (0.9% NaCl solution with 0.005% NaN3) was 0.6 mL/min.The equilibration of the diffusion testing system was performed for 12 hours, during which the circulation of 0.9% NaCl solution containing 0.005% NaNstratum corneum side was rinsed 2 times with 96.3% ethanol and 3 times with 0.9% NaCl. The skin samples (0.64 cm2) were trimmed off removing the outer residuals. Epidermis was separated from dermis applying dry heat separation method. The skin sample (epidermis side) was placed on the hot (approx. 60°C) metal surface for short time (1-2 s), and epidermis was peeled off. Then, epidermis and dermis were separately extracted with 1 mL of a mixture of methanol and deionized water (1 : 1) for 30 min under sonication in a Bandelin Sonorex Digitec bath .The donor phase was removed from the human skin surface after 24 hours, and U test and one-way ANOVA (Tukey's Honestly Significant Difference criterion) were used for data analysis. Correlation analysis was performed applying Spearman's rank coefficient.Experimental optimization was performed applying surface response central composite design in Design-Expert 6.0.8 software. Statistical analysis of experimental data was performed using SPSS software (version 19.0). Mann-Whitney Phenolic acids and phenolic aldehide vanillin were identified and quantitatively assessed in the aqueous and soft propolis extracts during experimental studies . The chaP value (ALOGPS 2.1) is 1.18 for vanillin, 1.24 for vanillic acid, 1.25 for caffeic acid, 1.42 for ferulic acid, and 1.53 for coumaric acid. Appealing to calculated logP values, it could be concluded that vanillin and vanillic acid are less lipophilic if compared to ferulic and coumaric acids. Referring to the experimental data it could be concluded that active compounds less affined to semisolid vehicle should be released first. Vehicles with lower content of lipophilic substances  released phenolic compounds more intensively, especially the more hydrophilic compounds, and this conforms to the published data [The results of the phenolic compounds release studies were in line with the published data, demonstrating that the release of drug substances from semisolid vehicles is influenced not only by the properties of drug molecule but also by the properties of the vehicle and concentration of the drug in the preparation . Releasehed data . Meanwhiin vitro to evaluate the ability of vanillin, and vanillic, caffeic, coumaric, and ferulic acids to penetrate into/through epidermis and dermis. Evaluation of penetrated fraction of phenolic acids demonstrated that after 24 hours epidermis contained approx. 5% of coumaric and ferulic acids, and in dermis 4% of coumaric acid and 6% of ferulic acid were determined (P < 0.01) direct correlation (R2 = 0.904) between lipophilicity of compounds  and their ability to penetrate into epidermis, whereas indirect correlation (R2 = −0.965) was statistically significant (P < 0.01) when lipophilicity of compounds was related to their ability to penetrate into dermis. It could be concluded that more lipophilic coumaric, ferulic, and caffeic acids were predominantly concentrated in epidermis, and only limited quantities of coumaric and ferulic acids penetrated into dermis. Meanwhile less lipophilic vanillin and vanillic acid were permeating epidermis and penetrating into dermis. These results indicate the dependence of phenolic compounds distribution profile on their lipophilicity and properties of skin layers.Aqueous propolis extract was applied to the human skin termined . VanilliP < 0.05) both in epidermis and dermis when hydrophilic gel was used as a vehicle for propolis phenolic compounds if compared to application of aqueous propolis extract  when compared to results after application of ointment. Vanillin and vanillic acid penetrated into dermis, but only in the case of vanilic acid significant difference (P < 0.05) between penetration results from cream and ointment into skin was confirmed. Both in the case of vanillin and vanillic acid epidermis did not present a barrier for penetration. Caffeic acid had no opportunity to enter epidermis as it was not released from the utilized ointment vehicle as was confirmed by release studies. When w/o cream vehicle was utilized, presence of caffeic acid was identified in epidermis, but it was not determined in dermis.Comparative evaluation of hydrophobic and emulsion type vehicles regarding their effect on skin penetration behavior of propolis active phenolic constituents revealed higher penetration values when emulsion system was applied . Penetrain vitro data confirmed the statistically significant (P < 0.05) difference of quantities of phenolic compounds in human skin after application of w/o cream compared to ointment or gel, thus confirming suitability of this w/o emulsion system for delivery of propolis phenolic compounds.The observed differences of penetration of phenolic acids and vanillin after application of cream and ointment could be partially explained by respective differences in released amounts of phenolic acids and vanillin from cream and ointment. Statistical analysis (ANOVA) of penetration stratum corneum from the vehicle. Surface active agents employed as emulsifying, wetting, and solubility modifying excipients can negatively affect barrier function of the skin thus impacting on the penetration of external chemical substances into skin. It could be supposed that surface active agents present in emulsion type and hydrophobic systems have influenced the penetration of phenolic compounds into the skin through modification of skin barrier function. The data from this study showed that the highest permeation values of phenolic compounds have been inherent for w/o emulsion system, so emulsion's aqueous phase may have affected the penetration process. The results of the study demonstrated that the composition of the vehicles affects both the release of propolis active components and their distribution in the skin.Published scientific data demonstrate that penetration into the skin increases with the increasing hydration of skin tissue . Pharmacin vitro were confirmed. Direct correlation between lipophilicity of compounds and their ability to penetrate into epidermis was demonstrated, whereas indirect correlation was established when lipophilicity of compounds was related to their ability to penetrate into dermis. The observed differences of penetration of phenolic compounds could be attributed to specific characteristics of semisolid vehicle. Gelification of propolis aqueous extract resulted in significant modification of qualitative and quantitative profile of phenolic acids and vanillin in epidermis and derma, thus suggesting the active role of the hydrophilic vehicle in penetration/permeation process. Most efficient process of phenolic acids and vanillin penetration was determined when emulsion type disperse system was applied, and the quantities of individual compounds were a few fold higher if compared to ointment though penetration profile was similar. Further research and development of efficient semisolid topical formulations for achieving higher penetration of most efficient antioxidant components from propolis extracts are deemed relevant and require further studies.Study results indicate the suitability of developed vehicle systems for incorporation of propolis extracts. The release profiles of vanillic acid, caffeic acid, ferulic acid, coumaric acid, and vanillin were reproducible when optimized formulations were applied. Penetration and permeation of phenolic acids and vanillin into human skin layers


Anacardium humile. Although the treatment of diabetic animals with A. humile did not alter body weight significantly, a reduction of the other evaluated parameters was observed. Animals treated with A. humile did not show variation of insulin levels, possibly triggered by a mechanism of blood glucose reduction. Levels of ALT  decreased in treated animals, suggesting a protective effect on liver. Levels of cholesterol were also reduced, indicating the efficacy of the extract in reestablishing the balance of nutrients. Moreover, a kidney protection may have been achieved due to the partial reestablishment of blood glucose homeostasis, while no nephrotoxicity could be detected for A. humile. The obtained results demonstrate the effectiveness of A. humile extracts in the treatment of alloxan-induced diabetic rats. Therefore, A. humile aqueous extract, popularly known and used by diabetic patients, induced an improvement in the biochemical parameters evaluated during and following treatment of diabetic rats. Thus, a better characterization of the medicinal potential of this plant will be able to provide a better understanding of its mechanisms of action in these pathological processes.The antihyperglycemic effects of several plant extracts and herbal formulations which are used as antidiabetic formulations have been described and confirmed to date. The main objective of this work was to evaluate the hypoglycemic activity of the aqueous extract of  Plants have been used for years as a source of traditional medicine to treat various diseases. Many of these medicinal plants are also excellent sources for phytochemicals, many of which contain potent antioxidant activities . The stuDiabetes mellitus characterizes the most common endocrine disease worldwide, reaching about 173 million people, and it is estimated that this number will more than double over the next 25 years. According to Funke and Melzig [Although other researchers had already noticed the presence of sugar in the urine of diabetics, this was demonstrated by Dobson only in 1755 . DiabeteDiabetes is now the fourth or fifth leading cause of death in most developed countries, and with people suffering from the disease worldwide, its incidence is approaching epidemic proportions .Diabetes mellitus is an apprehensive disease due to its diffused characteristics that, progressively, induce various pathologies with severe consequences.Diabetes is significantly (30% to 50%) related to diseases as ischemic cardiopathy, heart failure, cerebral vascular accident and systemic arterial hypertension . The incDiabetes therapies are associated with the control of the signs and symptoms of the pathologies without, however, promoting the disease cure. The currently available treatment options for hyperglycemia, apart from lifestyle changes and weight reduction, are oral hypoglycemic agents (OHAs) with various modes of action, and different types of insulin . Many clAnacardium humile St.-Hil., a species from the Anacardiaceae family, native to the Brazilian cerrado, has been popularly acclaimed against diabetes. This plant is a shrub , with very long roots, small flowers, a greenish calyx, and red petals with stripes [Anacardium species are known for their anti-inflammatory and astringent effects, activity against cancer cells, and their beneficial effects on gastrointestinal ulcers [A. humile on alloxan-induced diabetic rats.Many plants have been reported to present hypoglycemic activity in the last years. In Brazil, the popular use of medicinal plants to control diabetes is very common.  stripes . Anacardl ulcers –14. The A. humile was collected in the Brazilian cerrado, region of Araxá, Minas Gerais, Brazil, 19o43′04,0′′, W 46o53′54,0′′ and 949 m of altitude WGS84 datum, coordinates measured by Garmin, model Legend global positioning system. Plant material was dried in a circulating air oven at 50°C for 24 h and then ground in a knife mill until total pulverization. The stems from A. humile were washed and dried to constant weight in a forced air circulating drier at 40 ± 5°C. Dried stems were ground and stored at ∼4°C until use. To make an aqueous extract, the ground dried stems (100 g) were placed in a beaker containing deionized water (1 : 5 w/v) and held in a water bath at 60°C for 60 min and then hot-filtered through a gauze funnel. After cooling, the solution was frozen, lyophilized, and stored at −20°C, thereby enabling the weighing and dilution in deionized water. Before use, the freeze-dried aqueous extracts were weighed, dissolved in saline, and centrifuged at 10,000 ×g for 10 min, and the supernatants (stock solutions at 250 μg/μL) were stored at −20°C.Phloem of Rattus norvegicus, 8 weeks old; 200 ± 20 g) were grown in the Animal Facilities of the University of Ribeirão Preto-UNAERP. The animals were housed in polypropylene cages at room temperature (20–25°C) under 12 h light-dark photoperiod. During the experiment, the rats received ad libitum water and standard pellet diet (Nuvilab) composed of (wet weight) 66% carbohydrates, 16% proteins, 8% fat, and 10% micronutrients-vitamins-mineral salts for six days. After diabetes induction, the animals were isolated in metabolic cages with daily replacement of food (45 g) and water (200 mL) at 8:00 AM. The experiments described were approved by Institutional Committee for Ethics in Animal Experimentation and were done in accordance with the guidelines of the Brazilian College for Animal Experimentation (COBEA).Male Wistar rats  and animals that showed glucose concentration higher than 250 mg/dL were selected. Prior to diabetes induction, the animals were kept fasting for 12 hours. The inducing agent used was alloxan, dissolved in saline solution and injected intraperitoneally (100 mg/kg) within five minutes after dissolution , 16. ConN = 18) were distributed in three groups of 6 rats each: Group (1) non-diabetic control rats (C) and group (2) untreated diabetic rats (D) and Group (3) diabetic rats treated with the aqueous extract of A. humile (T). Clinical parameters as the ingestion of water and food, excretion of urine, body weight and the biochemical parameters as glucose, urea, creatinine and urinary proteins were evaluated on day 2. The glycemic parameter was checked weekly using a manual glucometer (Advantage II). Total cholesterol, alanine aminotransferase (ALT) and insulin were measured on the 28th day.After the isolation period, the animals . At the end of the experiment (28 days), the animals were anesthetized  with sodium thiopental . When rats were under deep anesthesia, a ventral midline incision was made, and 3 mL of blood was collected from the abdominal aorta and gently placed in Vacutainer tubes, containing a coagulation activator to avoid hemolysis. After coagulation, the material was centrifuged at 1,550 ×g for 5 minutes to separate the serum from the fibrin mesh. Biochemical analyses were performed within one hour after sampling.The laboratorial analyses were carried out at the Laboratory of Clinical Analysis of the University of Ribeirão Preto (UNAERP). Glucose levels in serum and urine were measured using the hexokinase method; urea in urine and total cholesterol were determined by the enzymatic method; urinary proteins were evaluated by a colorimetric method. All analyses were performed using Labtest kit (Bayer). The quantitative determination of ALT was performed employing the method optimized by the International Federation of Clinical Chemistry (IFCC) using the Biosystems test kit. Insulin was determined by the chemiluminescence method using the Kit Ultrasensitive insulin 33410-Beckman.P < 0.05.All collected data represent the average ± standard deviations (S.D.). Comparisons between the different groups were carried out by analysis of variance followed by the Tukey test. Differences were considered statistically significant when Alloxan was able to produce diabetes in rats, with the development of clinical and laboratory definition, including elevation of water intake , and uriA. humile aqueous extract (175 mg/kg) by gavage twice a day during 28 days , considered a hypoglycemiant plant. Dosing urine proteins is of great help for evaluating diabetes treatment, since it may indicate diabetic nephropathy, which may be preceded by a period of increased urinary albumin excretion UAE; 20–300 mg/24 h), defined as microalbuminuria . Urine p0 mg/24 hA. humile. According to these authors, the phenolic compounds participate in increasing the antioxidant function, and due to their action as metal chelators and enzyme modulators, they may attenuate renal damage caused by oxidative changes. In some cases this possible protection of renal function is consistent with the increase in urine creatinine levels; however, it was not observed in the present study  the excretion of urine urea along the treatment  in the diabetic rats, when compared to control animals at the end of the treatment, suggesting a hepatic protection of A. humile against the damaging effects of diabetes (A. humile extract did not change the pancreatic insulin levels during the experimental period (The administration of the diabetes . Also, rl period , suggestA. humile, the decrease in insulin degradation by the inhibition of the enzyme insulinase [β-cell [α-amylase secretion responsible for the increase of both glucose and triglycerides in the metabolism [Indeed, among the factors related to the effects of administration of sulinase  or the i [β-cell  or even  [β-cell  may be ctabolism . Finallytabolism .Anacardium humile aqueous extract to alloxan-induced diabetic rats is effective in regulating the levels of blood glucose and other related parameters. However, it does not seem to alter insulin secretion into the blood stream and shows no hepatic or renal toxicity. Analysis of the different bioactive compounds of A. humile aqueous extract, as well as the preclinical and clinical toxicity evaluation followed by the determination of therapeutic intervals, should insure the efficacy and safety of A. humile in the treatment of diabetes in humans. The potential use of this extract or its isolated compounds as alternative treatment and/or as molecular models for the development of new therapeutic agents in the treatment of diabetes or other diseases needs to be evaluated in future studies.In conclusion, the use of aqueous extracts and isolated natural products, exclusively derived from plants, in alternative therapies for antidiabetes drugs has been increasing. Obtained results demonstrate that the administration of


The present study was undertaken to identify patient populations at high risk for bone metastases (BM) at any time after diagnosis of operable breast cancer.A total number of 59 cases with breast cancer after mastectomy was subdivided into two main groups that included 30 patients with radiologically confirmed BM and 29 patients with no bone metastasis (NBM). Patients with NBM were formerly observed for a one-year follow-up interval to monitor the development of bone metastasis (new BM). Parameters included a full blood picture, tumour markers (carcinoembryonic antigen and CA 15.3) and some biochemical markers . A significant elevation was recorded in carcinoembryonic antigen level and alkaline phosphatase activity, as well as inflammation and vascularisation markers at the time of primary diagnosis in patients with BM, compared with those without BM. CA 15.3 was significantly higher in the new BM group as compared with the other two groups (patients free of bone metastasis [free BM] and BM). According to the likelihood ratio, a panel of single, calculated as well as combined markers was proposed to predict BM within one year in breast cancer patients. Vascularisation and inflammation markers, as well as CA 15.3 are predictive of bone recurrence within one year in breast carcinoma patients. We suggest that in cancer validation studies it is imperative to search for markers that link to the premetastatic process and to determine what type of mechanism is active in each stage.  Breast cancer in women is the most common type of cancer-related mortality among Egyptian women worldwide . AccordiThe process of breast cancer metastasis, including tumour cell seeding, tumour dormancy, and metastatic growth, is only partly understood . Bone isComplex biological pathways, including inflammation , 8, angiA flurry of surrogate biomarkers to detect micrometastasis has been developed in the last decade. These biomarkers open avenues for understanding cancer dormancy and metastasis, and may help predict outcome and therapeutic decisions at diagnosis and during follow-up of cancer patients . The aim of the present study is to investigate prospectively whether simple markers and their combination could be used as a tool to detect and predict bone metastasis in breast carcinoma patients. Egyptian women aged 30–69 years were recruited for this study (2007–2011) and selected from the outpatient clinic at the Clinical Pathology Department of the National Cancer Institute (NCI), Cairo University, Egypt. Physical examinations were processed by physicians in the Medical Oncology Unit, and routine clinical and pathological examinations were done. Once they were fully diagnosed and clinical staging of the disease was done according to the TNM classification of the American Joint Committee on Cancer (AJCC) TNM system, 59 patients were mastectomised and then scheduled for the appropriate treatment protocol of chemotherapy and radiotherapy. Of these patients, 29 had NBM and 30 had radiologically confirmed BM. Chemotherapy regimens included either FAC (5-fluorouracil + adriamycin + cyclophosphamide) or FEC (5-fluorouracil + epirubicin + cyclophosphamide) intravenously every 3 weeks for six cycles, and calcium supplements. Patients with BM received bisphosphonates, vitamin D, and calcium. Other therapeutic modalities included tamoxifen for hormone responsive patients, and Herceptin for human epidermal growth factor receptor-2 (HER2)-positive patients. Patients with NBM were observed for a one-year follow-up interval by bone scan to monitor the development of BM. All subjects gave written informed consent to participate in the study, which was carried out in accordance with the Helsinki Declaration. Serum alkaline phosphatase (ALP) was determined by a kinetic method using an assay kit provided by Globe Diagnostic , plasma tartrate-resistant acid phosphatase (TRAP5b) activity by an immunoassay method using an ELISA kit  and plasma carcinoembryonic antigen (CEA) level by an electrochemiluminescence immunoassay ‘ECLIA’ method using an assay kit provided from Roche Diagnostics, USA. Serum vascular endothelial growth factor (VEGF) and CA 15.3 levels were determined by the double-antibody enzyme immunoassay methods using ELISA kits . Serum zinc concentration was evaluated by atomic absorption spectrophotometry using a 3100 Perkin Elmer Atomic Absorption Spectrometer (USA) in the Central Laboratory, Faculty of Science, Ain Shams University. 7/L]/WBC count [109/L]) × 100 [9/L])2/(monocyte fraction [%] × segmented neutrophil fraction [%])] [A combination of previously reported markers was used in the present study that included monocytes% (monocyte count [10]) × 100  and P2mson [%])] . SimilarMann–Whitney U test was used for comparing results between two groups (NBM versus BM), and the Kruskal Wallis test was used for comparing the quantitative results among free BM, new BM and BM groups. Receiver operating characteristic (ROC) curves were constructed, and the area under the curve (AUC) was calculated to assess the diagnostic accuracy of the markers. Cross-tabulation analysis was carried out and the significance (χ2) and likelihood ratio (LR) were calculated from the chosen cutoff values. The ROC analysis was first conducted on individual markers and then in combination to explore the potential that a panel of markers can provide improved performance [The results were computed and statistics analysed using SPSS statistical software version 17.0 . The quantitative results were expressed as median with minimum–maximum values. The non-parametric formance . Characteristics of patients are depicted in 2<0.001) , and vascularisation (VEGF/mono%) markers, and in contrast a significant decrease in monocytes% at the time of primary diagnosis in patients with BM, compared with those with NBM .The CA 12<0.001) . No sign2<0.05) (2<0.002) , from 50% of patients who newly developed BM (≥100 pg/ml) (χ2<0.05) . Consequ2<0.002) . 2 <0.001) at the initial diagnosis. Accordingly, by calculating the ratio between ALP and monocytes%, and using a cutoff value of 4.9 for such ratio, we were able to differentiate between 72.7% of patients who were initially diagnosed with NBM (<4.9) and 90% of patients who had BM (≥4.9) (χ2<0.001). However, such differences did not reach significance when we compared free BM with new BM groups, probably due to the small number of patients in the latter group. Interestingly, by using the cutoff values of ALP + P2ms, we found that all patients without bone metastasis (free BM) had one or both markers below cutoff levels, whereas 66.7% of patients with new BM or 41.7% of all patients with bone metastasis  had both markers above the specified cutoff values. On the other hand, all patients with BM had both VEGF + ALP/mono% above cutoff levels, while 78.6% of free BM patients had one or both of the aforementioned parameters below the specified cutoff levels (χ2 <0.001). In addition, cross-tabulation revealed that 95.8% of all BM patients had one or both of VEGF+ALP above cutoff levels, and in contrast 72% of free BM patients had both indices below cutoff levels (χ2 < 0.01)   and 5. The result of the current study revealed that the strength of markers (according to the likelihood ratio) in predicting bone metastasis within one year is in the following descending order: VEGF + ALP; VEGF + ALP/mono%; VEGF/mono%; monocytes%; CA 15.3; ALP + P2ms; P2ms and VEGF . Metastasis is the leading cause of cancer death, and the metastatic cascade is a complex, yet inefficient process that we have only begun to understand recently . Recent Many prognostic biomarkers discovered to date are usually evaluated as single markers, which lack sufficient specificity. We concur with Chechlinska’s argument that most cancer prognostic biomarker studies using modern technologies are methodologically flawed as they compare samples from cancer patients with those of healthy, inflammation-free people  or at bep < 0.05) increase in BM group; however, after redistributing the patients into three groups, we found that CA15.3 was significantly higher (p < 0.01) in the new BM group as compared with free BM and BM groups. This change in pattern was not observed for the CEA marker. Comparable outcomes were reported by Duffy [et al [Comparing CA 15.3 and CEA tumour markers in NBM versus BM patients revealed that only CEA showed a significant  is an antioxidant, or free radical scavenger. Changes in zinc level in the blood of cancerous patients may be the cause of malignant tumour occurrence . Anotheret al [The contribution of platelets to the progression of cancer is an emerging area of research interest. Complex interactions between tumour cells and circulating platelets play an important role in cancer growth and dissemination, and a growing body of evidence supports a role for physiologic platelet receptors and platelet agonists in cancer metastases and angiogenesis , 39–41. et al  characteThe inverted correlation between platelets and monocytes% and segmented neutrophils% (known as P2ms) was recently used as a non-invasive test for hepatic fibrosis , 43, 44.According to the data emerging from several studies, markers of bone metabolism may be an additional, useful, noninvasive diagnostic and prognostic tool to improve cancer disease management , 46. TwoTartrate-resistant acid phosphatase isoform 5b (TRAP5b) is a biochemical marker of osteoclast number and activity. Mounting evidence has demonstrated serum TRAP5b as a useful marker of bone resorption and is among one of the many markers that have been studied to be a surrogate marker of BM in cancer patients , 47, 48.et al [It was not possible to demonstrate a statistically significant difference in TRAP5b activity among all groups in the present study. Hung and Oremek  reportedet al , who antTotal alkaline phosphatase (ALP) is a bone formation marker, used as a routine marker for skeletal involvement; however, different publications have pointed to the fact that bone-specific ALP is a better choice as an index of bone formation due to its higher specificity for bone . Total AOur relatively small study population limits the predictive power of the panels presented here, but the benefits of a serum biomarker and multimarker approach are clearly illustrated, and further studies utilising larger clinical cohorts are well warranted. This study demonstrates that a simple blood sample harbours information of tumour relapse in breast cancer patients and brings benefit to existing clinical predictors. We prove the importance of determining whether the patient has dormant disease, together with her systemic inflammatory response in order to improve the predictive marker validation. The authors would like to thank Dr. Ola Mohamed Reda Khorshid, Assistant Professor of Medical Oncology, National Cancer Institute, Cairo University, for her cooperation and kind help in samples’ collection.


Background: A reduction in the use of polybrominated diphenyl ethers (PBDEs) because of human health concerns may result in an increased use of and human exposure to organophosphate flame retardants (OPFRs). Human exposure and health studies of OPFRs are lacking.Objectives: We sought to define the degree of temporal variability in urinary OPFR metabolites in order to inform epidemiologic study design, and to explore a potential primary source of exposure by examining the relationship between OPFRs in house dust and their metabolites in urine.Methods: Nine repeated urine samples were collected from 7 men over the course of 3 months and analyzed for bis phosphate (BDCPP) and diphenyl phosphate (DPP), metabolites of the OPFRs tris phosphate (TDCPP) and triphenyl phosphate (TPP), respectively. Intraclass correlation coefficients (ICCs) were calculated to characterize temporal reliability. Paired house dust and urine samples were collected from 45 men.r (rS) = 0.31] but significant (p = 0.03) correlation between urinary BDCPP and TDCPP concentrations in house dust that strengthened when nondetects (rS = 0.47) were excluded. There was no correlation between uncorrected DPP and TPP measured in house dust (rS < 0.1).Results: BDCPP was detected in 91% of urine samples, and DPP in 96%. Urinary BDCPP showed moderate-to-strong temporal reliability . ICCs for DPP were lower, but moderately reliable . There was a weak [Spearman Conclusions: Household dust may be an important source of exposure to TDCPP but not TPP. Urinary concentrations of BDCPP and DPP were moderately to highly reliable within individuals over 3 months. Flame retardant chemicals are commonly added to consumer products and raw materials to delay combustion and meet fire safety standards. Because many flame retardants are additive rather than chemically bonded with the material, over time they can leach out of the treated materials, which may result in human exposure through various pathways and routes. This includes ingestion, inhalation, and dermal contact with household dust, among other sources . Flame rOf a number of available alternatives to PBDEs, the use of organophosphate flame retardants (OPFRs), such as the triesters tris phosphate (TDCPP) and triphenyl phosphate (TPP), are currently widespread and expected to increase . TDCPP and TPP are used as additive flame retardants in polymers, resins, latexes, and foams; TPP is also used as a plasticizer and lubricant and in hydraulic fluids . The UniLimited animal studies suggest that certain OPFRs may be carcinogenic, neurotoxic, and/or reproductive toxicants . As far in vitro metabolism of these same two OPFRs in human liver microsomes demonstrated that the primary metabolites in humans were also likely BDCPP and DPP  phosphate (BDCPP), and diphenyl phosphate (DPP), respectively . Further and DPP . We rece and DPP . In thata) characterize the distribution of urinary BDCPP and DPP in a population of U.S. men from an ongoing study; b) define the degree of temporal variability in these OPFR metabolites in order to inform exposure assessment efforts in epidemiologic studies; and c) determine the relationship between OPFRs in house dust and their metabolites in urine as a first step in identifying possible sources, pathways, and routes important for human exposure. Identification of how exposure takes place is a critical step for risk management through effective exposure reduction strategies.The goals of the present study were to Study participants. The present study was conducted on a subset of men participating in an ongoing study of environmental factors in reproductive health. Details of subject recruitment into the parent study have been previously described  in order to determine temporal variability of various exposure biomarkers. A urine sample was collected on each of 3 repeated days in three separate cycles that were 1 or 2 months apart; upon enrollment into the variability study, men provided urine samples from days 1, 2, 3, 30, 31, 32, 91, 92, and 93. Seven of these men from the variability substudy were included in the present analysis. One of the seven men had 1 missing repeat urine sample, and 1 sample from a second man had insufficient volume for extraction. Thus, a total of 61 urine samples were analyzed from the variability substudy.Urine analysis. Urine samples, which were collected in glass vials [either a 30 mL Qorpak vial  or a 25 mL Wheaton vial ] and stored at –80°C, were analyzed for BDCPP and DPP as previously described (n = 6) and ran 12 samples in duplicate. Recoveries of the internal quantification standards, d10-BDCPP and d10-DPP, averaged 88 ± 16% and 89 ± 15%, respectively. BDCPP and DPP were present at very low levels in laboratory blanks and averaged 0.06 ± 0.05 ng and 0.14 ± 0.09 ng, respectively. The method detection limit was calculated using three times the SD of the blanks normalized to the urine volume extracted, which was 32.7 pg/mL and 55.3 pg/mL, for BDCPP and DPP respectively. Specific gravity (SG) was measured in each urine sample before analysis using a digital handheld refractometer.escribed . BrieflyDust analysis. Dust from participants’ household vacuum bags was sieved (150 μm screen) and analyzed for TDCPP and TPP as described in our previous report , replicate samples (n = 3), and in matrix spikes (n = 3). Sample measurements were blank corrected by subtracting the average level measured in the laboratory blanks. Blank levels for TDCPP and TPP were 11.7 ± 6.6 and 15.7 ± 11.9 ng, respectively. Method detection limits were calculated as three times the SD of the blank levels. Matrix spikes were prepared by adding between 25 and 100 ng of TDCPP and TPP to the ASE cells [stainless steel cells used on the ASE 300 (Dionex Inc.)] filled with sodium sulfate powder. Matrix spikes were extracted using the same method used for dust and examined for percent recovery using 50 ng of 13C chlorinated diphenyl ether 141 as an internal standard. Recoveries averaged 86 ± 7% and 89 ± 2% for TDCPP and TPP, respectively.As part of our quality assurance criteria, we examined levels of these specific analytes in laboratory blanks . Distributions of urinary BDCPP and DPP concentrations, along with dust concentrations of TDCPP and TPP, were tabulated. Graphs were constructed to visually and qualitatively compare urinary metabolite concentrations over time within and between subjects. To quantitatively assess between- and within-person variability in urinary BDCPP and DPP concentrations, intraclass correlation coefficients (ICCs) and their 95% confidence intervals (CIs) were calculated using mixed random effects models in SAS PROC MIXED (OC MIXED . ICC is OC MIXED .a) men with the four highest 3-month exposure levels (> 43rd percentile), b) men with the three highest 3-month exposure levels (> 57th percentile), or c) men with the two highest 3-month exposure levels (> 71st percentile). Men were then ranked by exposure for each individual time point  based on the concentrations measured in that individual sample. A contingency table was then constructed for each time point comparing predicted and observed categories. Contingency tables from all 9 time points were then combined into a single table, where sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each metabolite and for each of the three category cutoff schemes.In addition to calculating ICCs, we also conducted a sensitivity analysis to evaluate how well OPFR metabolite concentrations from a single urine sample  could correctly classify men into the highest exposure category based on their 3-month geometric mean (GM) concentration  calculated from the nine repeated samples . In thisrS) were then calculated to evaluate the relationships between concentrations of TDCPP and TPP in house dust and concentrations of their metabolites in urine from the same men from their clinic visit at study entry. For urinary metabolites, all analyses were conducted for both uncorrected concentrations and concentrations corrected for specific gravity using the following formula:Finally, scatter plots were constructed to assess the relationship between dust and urine metabolite concentrations. Spearman rank correlations (cP = P × [(1.024–1)/(SG–1)], [1]cP is the SG-corrected metabolite concentration (in nanograms per milliliter), P is the observed metabolite concentration (in nanograms per milliliter), and SG is the specific gravity of the urine sample .Overall, of the 106 samples we analyzed for the two OPFR metabolites, BDCPP was detected in 96 samples (91%), and DPP was detected in 102 samples (96%). n = 61). For BDCPP  are shown in n = 45). Uncorrected urinary BDCPP was weakly (rS = 0.31) but significantly (p = 0.03) correlated with TDCPP concentrations in house dust . There was no correlation between uncorrected   DPP and TPP measured in house dust. When excluding seven nondetects (not shown), the correlation of TDCPP with BDCPP increased to 0.47 (p = 0.003). However, removing three nondetects did not improve the correlation between TPP and DPP (Sr = 0.05). Finally, we calculated correlations when stratifying by time between collection of urine and dust samples, but correlations did not improve when limiting the analysis to samples collected within 2 weeks (n = 22) or within 1 week (n = 10) of one another.use dust . This cop = 0.8)  or SG-coBDCPP and DPP were detected in nearly all urine samples analyzed from a study of exposure to environmental chemicals and reproductive health among men from the Boston, Massachusetts, area. This confirms the previous findings from our method development study that found detectable levels of both DBCPP and DPP in all nine samples randomly collected from adults in North America . In bothAlthough toxicokinetic information on TDCPP and TPP is limited, studies using rat and human liver microsomes suggest that TDCPP and TPP are metabolized rapidly to diesters  and other metabolites . Thus, tIn the ICC analysis, there was moderate reliability for DPP (ICC = 0.4–0.5), and moderate to strong reliability for BDCPP (ICC = 0.6–0.7). The ICCs for both metabolites were higher than other urinary biomarkers of nonpersistent chemicals that have been measured in overlapping groups of men from the same cohort , especiaBoth metabolites showed high sensitivities for a single urine sample to predict high exposure groups based on 3-month GM concentrations. For DPP, which did not perform as well in the ICC analysis compared with BDCPP, this may indicate that there may be significant within-person variability in concentrations over time, but that DPP concentrations among the most highly exposed individuals tend to remain among the highest relative to other individuals over the course of 3 months. However, it should be noted that the sensitivity analysis included samples from only seven men and that results may be unstable because of the relatively small sample size. Future studies should assess the temporal variability of these and other OPFR markers of exposure in a larger number of participants.Dust in the home and in other environments has been shown to be a major source of exposure for other flame retardants such as PBDEs, with hand-to-mouth contact representing one of the primary exposure pathways . HoweverWe found no correlation between TPP in house dust and DPP in urine. This suggests that TPP in house dust may not be a primary source of exposure among adult men. As opposed to halogenated OPFRs such as TDCPP, which tend to be primarily used as flame retardants, nonderivatized alkyl phosphates such as TPP may be predominantly used as plasticizers and lubricants or in other applications . These dExposure to TDCPP and TPP among adult men in the United States is likely common. In the present study a high degree of variability between persons for concentrations of TDCPP and TPP in house dust and their metabolites in urine was observed, and urinary concentrations of BDCPP and DPP were moderately to highly reliable within individuals over the course of 3 months. Our data suggest that household dust may be an important source of exposure to TDCPP but not TPP, although more detailed research on the exposure sources, pathways and routes of exposure to these chemicals is needed. If the indoor environment at home is the primary source of exposure to OPFRs, measuring concentrations in house dust may be a desirable approach to assessing long-term exposure to these chemicals that are likely metabolized and excreted rapidly once entering the body. However, concentrations in dust from other microenvironments where people spend the most time may also need to be considered, which would increase the time and costs required and may become infeasible in large epidemiologic studies. On the other hand, if sources of OPFR exposure are multiple and varied, exposure biomarkers such as urinary metabolites that account for all routes of exposure may be the best approach. However, knowledge of their utility through a better understanding of toxicokinetics, temporal variability, and other parameters is needed.


It is a widely accepted fact that severe fluid loss is the greatest problem faced following major burn injuries. Therefore, effective fluid resuscitation is one of the cornerstones of modern burn treatment. The aim of this article is to review the current approaches available for modern trends in fluid management for major burn patients. As these current approaches are based on various experiences all over the world, the knowledge is essential to improve the status of this patient group. Appropriate fluid management of major burns directly improves the survival rates of burn patients. Despite the vast array of experience, there are still controversies regarding the best type of fluid management in major burns in the first 24 hours after injury. Currently, fluid resuscitation formulas which were developed over 30 years ago, have been accepted as guidelines, but ongoing studies are focussed on the growing concerns that burn patients are being over-or under fluid-resuscitated, often with indistinct and inappropriate end-point targets. The aim Major burn injuries result in an area of necrotic zone, beneath this lies the zone of stasis and results in release of inflammatory mediators  that increase capillary permeability and lead to localised burn wound oedema.3 This oc27As mentioned above, during this early period in which various pathopysiological changes take place, appropriate fluid management plays a fundamental role.The goal of fluid management in major burn injuries is to maintain the tissue perfusion in the early phase of burn shock, in which hypovolemia finally occurs due to steady fluid extravasation from the intravascular compartment.Burn injuries of less than 20% are associated with minimal fluid shifts and can generally be resuscitated with oral hydration, except in cases of facial, hand and genital burns, as well as burns in children and the elderly. As the total body surface area (TBSA) involved in the burn approaches 15–20%, the systemic inflammatory response syndrome is initiated and massive fluid shifts, which result in burn oedema and burn shock, can be expected. The route for fluid management is of importance in these instances. Although enteral resuscitation has been attempted for even major burn injuries, vomiting has been a limiting problem for this route. Current 10Formal fluid resuscitation formulas which were introduced in the 1960s and 1970s have been used effectively all over the world. The “ParIn centres experienced with paediatric burns, formulas which are sufficient for paediatric fluid management have been developed, as the body surface area to mass ratio in children is higher than in adults and hepatic glycogen stores in young children are depleted after 12–14 hours of fasting.16Baxter found that patients with inhalation injury required additional fluid when compared to others. Pruitt r19The most commonly used formulas are the Parkland, modified Parkland, Brooke, modified Brooke, Evans and Monafo’s formulas. These formulas take into account the body weight and the burn surface area. Several 17Initial 24 hours: Ringer’s lactated (RL) solution 4 ml/kg/% burn for adults and 3 ml/kg/% burn for children. RL solution is added for maintenance for children:4 ml/kg/hour for children weighing 0–10 kg40 ml/hour +2 ml/hour for children weighing 10–20 kg60 ml/hour + 1 ml/kg/hour for children weighing 20 kg or higherThis formula recommends no colloid in the initial 24 hours.Next 24 hours: Colloids given as 20–60% of calculated plasma volume. No crystalloids. Glucose in water is added in amounts required to maintain a urinary output of 0.5–1 ml/hour in adults and 1 ml/hour in children.Initial 24 hours: RL 4 ml/kg/% burn (adults)Next 24 hours: Begin colloid infusion of 5% albumin 0.3–1 ml/kg/% burn/16 per hourInitial 24 hours: RL solution 1.5 ml/kg/% burn plus colloids 0.5 ml/kg/% burn plus 2000 ml glucose in waterNext 24 hours: RL 0.5 ml/kg/% burn, colloids 0.25 ml/kg/% burn and the same amount of glucose in water as in the first 24 hoursInitial 24 hours: No colloids. RL solution 2 ml/kg/% burn in adults and 3 ml/kg/% burn in childrenNext 24 hours: Colloids at 0.3–0.5 ml/kg/% burn and no crystalloids are given. Glucose in water is added in the amounts required to maintain good urinary output.First 24 hours: Crystalloids 1 ml/kg/% burn plus colloids at 1 ml/kg/% burn plus 2000 ml glucose in waterNext 24 hours: Crystalloids at 0.5 ml/kg/% burn, colloids at 0.5 ml/kg/% burn and the same amount of glucose in water as in the first 24 hoursMonafo recommends using a solution containing 250 mEq Na, 150 mEq lactate and 100 mEq Cl. The amount is adjusted according to the urine output. In the following 24 hours, the solution is titrated with 1/3 normal saline according to urinary output.The formulas developed for children are as fInitial 24 hours:For older children:2 total Lactated Ringer’s (RL) solution 4 ml/kg/% burn +1500 ml/mFor younger children:2 total, in the first 8 hours4 ml/kg/% burn +1500 ml/m3RL solution + 50 mEq NaHCORL solution in the second 8 hours5% albumin in LR solution in the third 8 hours2 burn + 2000 ml/m2 total Initial 24 hours: RL 5000 ml/mThe ideal burn resuscitation is the one that effectively restores plasma volume, with no adverse effects. Isotonic crystalloids, hypertonic solutions and colloids have been used for this purpose, but every solution has its advantages and disadvantages. None of them is ideal, and none is superior to any of the others.D-lactate in RL solution containing a racemic mixture of the D-lactate and L-lactate isomers has been found to be responsible for increased production of ROS.[in vivo dilution with crystalloids  resulted in a hypercoagulable state.[Crystalloids are readily available and cheaper than some of the other alternatives. RL solution, Hartmann solution (a solution similar to RL solution) and normal saline are commonly used. There are some adverse effects of the crystalloids: high volume administration of normal saline produces hyperchloremic acidosis, RL incren of ROS. RL used le state.–41Despite these adverse effects, the most commonly used fluid for burn resuscitation in the UK and Ireland is Hartmann’s solution . Another et al. were able to achieve effective physiological resuscitation with a lower total volume when compared to isotonic solutions in the initial 24 hours.[et al. found that after 48 hours cumulative fluid loads of the patient groups who were treated with hypertonic solutions or RL were similar. They also demonstrated that hypertonic sodium solution resuscitation was associated with an increased incidence of renal failure and death.[The importance of sodium ions in the pathophysiology of burn shock has been emphasised in some previous studies. The sodium shift into the cell results in cellular oedema and hypo-osmolar intravascular fluid volume. Rapid infusion of hypertonic sodium solutions has proven to increase the plasma osmolality and limit cellular oedema. Using solutions with a concentration of 250 mEq/l, Moyer 24 hours.29 But Hund death. Currentlet al., found that albumin extravasation stops 8 hours after injury. According to Demling, capillary leakage of protein ceases significantly about 12 hours following the burn.[et al. recently showed that endothelial dysfunction and capillary leakage are present within 2 hours after burn injury and last for a median of 5 hours, much shorter than that previously described.[et al. have recently demonstrated decreased mortality in patients who received albumin. Additionally, some burn clinicians reported successful resuscitation including albumin in the early post burn period with decreased volume requirements and low weight gain compared with pure crystalloid resuscitation.[et al. demonstrated decreased fluid requirements and lower intraabdominal pressures with use of fresh frozen plasma in the first 48 hours following large burns (>50%).[et al. have found that the addition of colloid to Parkland formula rapidly reduced hourly fluid requirements, restored normal resuscitation ratios, and ameliorated fluid creep.[Leakage and accumulation of plasma proteins outside the vascular compartment contributes substantially to oedema formation. The time at which the protein leakage stops has been found to differ by various authors. Baxter’s early work showed that capillary leak may persist for 24 hours post burn. Carvajalthe burn. Vlachou escribed. Colloidsescribed.48 The cocitation.50 O’Maras (>50%). Most recid creep.In our burn centres located in two different regions of Turkey , we avoid using human albumin solution unless blood albumin levels are under 2 g/dl. If necessary, albumin administration is started at least 5 hours after the injury. The preferred dose of albumin after the first 24 hours is 0.5–1 g/kg/% burn. In the following days, the albumin support is continued until the blood level of albumin is 3 g/dl. But decisions for each individual patient are made according to current data from monitoring parameters such as existence of oedema, urine output, central venous pressure, pulse rate, pulse oximetry, and so on.53in vitro study, we found that the addition of the membrane-stabilising vitamin E, zinc and selenium prevented the increase of acid phosphatase  significantly (P < 0.01).[The membrane lipid peroxidation and ROS are the main components of burn shock. In addition, it is well known that the changed permeability of leukocyte membranes due to thermal injury causes an increase in serum enzyme levels. As such, it has been assumed that membrane-stabilising agents such as zinc, selenium and vitamin E could help in the recovery of burned patients. Antioxid54 < 0.01). In a pro < 0.01). Recently < 0.01).et al. compared burn patient groups treated in 1975–1979 with similar patients treated in 2000.[Opioids have been the mainstay of pain control in burn patients. These drugs have a significant effect on the cardiovascular system. Use of these drugs is associated with decreased blood pressure. In a recent study, Sullivan et al. suggested that measuring the hourly ratio of fluid infusion (ml/kg/% TBSA/kg) and urine output (ml/kg/hour) was an effective means of expressing and tracking fluid requirements.[All resuscitation formulas are meant to serve as guides only. Consequently, fluid management in major burns should be monitored using clinical and laboratory parameters. In severe burns, if peripheral intravenous access cannot be achieved, central venous catheterisation or surgical vascular access must be considered. After the venous line is in place, a urinary catheter and a nasogastric tube should be inserted to control and monitor the patient’s fluid balance. Hypotensirements.The treatment of all patients begins at the time of hospitalisation. Following a routine examination, IV fluid  is administered, and following the results of the electrolyte measurements, provided potassium levels are normal, the solution is changed to Ringer’s lactate. The rate of administration is adjusted according to urine output of at least 50 ml/hour. If the patient is oliguric and acidotic, sodium bicarbonate, 20–40 g of mannitol and 40–100 mg furosemide are given. If the patient still remains oliguric and potassium, blood urea nitrogen, and creatinine levels are rising, peritoneal or haemodialysis using a double lumen subclavian catheter is resorted. We think that this system is very easy to use for both haemodialysis and parenteral nutrition. A urinary catheter and a central venous pressure line are used only in severe cases or if clinical evaluation so indicated.Following initial stabilisation, the patients are taken to the dressing room for re-evaluation, and if necessary, debridement, escharotomy, and fasciotomy are preformed.61 EscharPruitt reported that patients with electrical burns required additional fluid. In our pet al. have also advocated that CVVH is an appropriate tool for treating ARF, with a lower incidence of vascular complications than continuous arteriovenous haemodialysis.[ARF is a severe complication of burns, which occurs in 0.5–30% of burn patients. ARF has 6264dialysis.et al. reviewed recent data in the literature to support an appropriate fluid management in burn patients, but they found that there are insufficient data in the literature for this purpose. So, they recommended a rational approach for the initial treatment of burn patients in the light of their investigations. The following are the practice guidelines for burn shock resuscitation, recommended by the American Burn Association.[Pham ociation.Adults and children with burns greater than 20% TBSA should undergo formal fluid resuscitation using estimates based on body size and surface area burned.Common formulas used to initiate resuscitation estimate a crystalloid need for 2–4 ml/kg body weight/% TBSA during the first 24 hours.Fluid resuscitation, regardless of solution type or estimated need, should be titrated to maintain a urine output of approximately 0.5–1.0 ml/kg/hour in adults and 1.0–1.5 ml/kg/hour in children.Maintenance fluids should be administered to children in addition to their calculated fluid requirements caused by injury.Increased volume requirements can be anticipated in patients with full-thickness injuries, inhalation injury and a delay in resuscitation.The addition of colloid-containing fluid following burn injury, especially after the first 12–24 hours postburn, may decrease the overall fluid requirements.Oral resuscitation should be considered in awake and alert patients with moderately sized burns and is worthy of further study.Hypertonic saline should be reserved for providers experienced in this approach. Plasma sodium concentrations should be closely monitored to avoid excessive hypernatraemia.Administration of high-dose ascorbic acid may decrease the overall fluid requirements, and is worthy of further study.et al. emphasised that the guidelines they had designed could aid especially the physicians who were responsible for the triage and initial treatment of burn patients.[In the above-mentioned study, Pham patients.Several studies have supported that patients who receive larger volumes of resuscitation fluid are at higher risk for injury complications and death. In the light of this prediction, the chosen types and rates of the fluid administration in major burns are at the focus of controversy. It must be kept on minds that these debates look for a rational approach for an adequate fluid resuscitation. Currently used guidelines are based on the various experiences all over the world, and the developing experiences will bring a new approach. So, clinicians must be aware of this vast experience and ongoing literature debates in order to improve the status of this patient group.


To assess the potential of an online platform, PatientsLikeMe.com (PLM), for research in multiple sclerosis (MS). An investigation of the role of body mass index (BMI) on MS disease course was conducted to illustrate the utility of the platform.First, we compared the demographic characteristics of subjects from PLM and from a regional MS center. Second, we validated PLM’s patient-reported outcome measure  against standard physician-rated tools. Finally, we analyzed the relation of BMI to the MSRS measure.Compared with 4,039 MS Center patients, the 10,255 PLM members were younger, more educated, and less often male and white. Disease course was more often relapsing remitting, with younger symptom onset and shorter disease duration. Differences were significant because of large sample sizes but small in absolute terms. MSRS scores for 121 MS Center patients revealed acceptable agreement between patient-derived and physician-derived composite scores (weighted kappa = 0.46). The Walking domain showed the highest weighted kappa (0.73) and correlation (rs = 0.86) between patient and physician scores. Additionally, there were good correlations between the patient-reported MSRS composite and walking scores and physician-derived measures: Expanded Disability Status Scale , Timed 25 Foot Walk , and Ambulation Index . Finally, using PLM data, we found a modest correlation between BMI and cross-sectional MSRS (rho = 0.17) and no association between BMI and disease course.The PLM population is comparable to a clinic population, and its patient-reported MSRS is correlated with existing clinical instruments. Thus, this online platform may provide a venue for MS investigations with unique strengths . To illustrate its applicability, we assessed the role of BMI in MS disease course but did not find a clinically meaningful role for BMI in this setting. Investigations of factors associated with progressive disease in multiple sclerosis (MS) have been hampered by the variable and slow course of the disease, a lack of robust biomarkers and the costs of generating large datasets longitudinally. The emergence of online patient-centered research platforms holds great promise for certain forms of clinical research by providing rapid access to data from large numbers of patients at frequent intervals. However, the quality and validity of data collected online must be assessed critically.www.patientslikeme.com; PLM) is an online platform that includes 29,570 subscribers reporting having MS (as of October 2012). In addition to personal and disease characteristics, individuals also report their disease severity using an MS Rating Scale (MSRS) designed by PLM PatientsLikeMe , a risk factor for MS PLM is an online research platform based in Cambridge, Massachusetts, designed to allow patients to share data about their conditions, treatments, symptoms and comorbidities through structured data collection . We included all subjects aged 18 or older, with an MS diagnosis by 2005 McDonald Criteria, who were evaluated clinically at least twice at the Partners MS Center since 1/1/2009 . IRB approval was obtained for the analysis of the existing PLM and Partners data from the Partners Healthcare Human Research Committee, our Institutional Review Board. Given the consent documents governing the use of the Partners MS center data, we could not determine whether any MS Center patients were also members of PLM.The Partners MS Center  is a regional MS referral center in the Northeastern United States. Detailed electronic records of patient visits to the Center are captured using structured encounter forms and stored within an Oracle software-based relational database designed to follow the longitudinal histories of patients with demyelinating diseases. Data derived from this cohort have been extensively described T-tests were used for continuous outcomes and chi-squared analyses were used for categorical outcomes. Identical analyses were performed for subsets of patients treated with glatiramer acetate and interferons. Due to missing data for certain individuals, percentages for each variable were calculated based on a different sample sizes.Patient- and physician-derived MSRS scores were compared for a sample of MS patients seen at the Partners MS Center over 20 days in November 2011. All patients aged 18 or older, who carried a diagnosis of MS based on 2005 McDonald Criteria by an MS Center physician, were fluent in English, and who presented for routine neurological follow up at the Partners MS Center were approached. IRB approval was obtained from the Partners Healthcare Human Research Committee. Verbal informed consent was obtained from participants, in compliance with the IRB, because it was determined that the research presented no more than minimal risk of harm to subjects and involved no procedures for which written consent is normally required outside the research context. A study fact sheet describing the study was provided with the questionnaire to each patient approached, in compliance with the IRB. Thus only consenting individuals would complete the questionnaire, and blank questionnaires would be stored for those who did not consent. None of the 162 patients who were approached refused participation. Of these patients, 34 were unable to participate due to the constraints of the MS Center schedule for clinical encounters. In addition, 7 patients who filled out the questionnaire did not have a definite MS diagnosis. This resulted in 121 subjects and their physician completing an MSRS evaluation.Table S1).In this 7-item questionnaire, patients rate their disability on a 0–4 scale in 7 areas . Total scores range from 0–28  For comparisons of patient- and physician-derived MSRS scores, a weighted kappa statistic was calculated for each MSRS domain, as well as for the composite (sum) score to assess the agreement between the two raters. For the composite score, a Bland-Altman plot for the patient and physician score was also created. In addition, Spearman’s correlation coefficient was also calculated to assess the level of association between the two raters. Finally, the proportion of agreement between physician and patient was calculated for each MSRS domain, and reason for lack of concordance  was recorded. Nonparametric Spearman correlation coefficients were also calculated between EDSS, T25FW, and AI and both patient- and physician-derived MSRS composite and walking domain subscores. This allowed us to assess the criterion validity , but with profiles updated at least twice between 1/1/2009 and 1/1/2012 . IRB approval was obtained for analysis of these existing PLM data from the Partners Healthcare Human Research Committee.Self-reported height, weight, and calculated BMI (kg/m2) were included for all PLM subjects in the study. The following measurements were excluded: height <55 or >85 inches, weight <70 or >540 lbs, and BMI >190.2), normal weight (18.50–24.99 kg/m2), overweight (25.00–29.99 kg/m2), and obese (≥30.00 kg/m2). Then, a cross-sectional analysis was performed correlating continuous BMI at most recent data entry point with MSRS composite score, using nonparametric correlations and adjusting for age, sex, race, disease duration, and disease type. Third, to assess the impact of BMI on longitudinal accumulation of disability (MSRS), we used two mixed models with random slopes and intercepts and robust standard errors to estimate the interaction between BMI and follow-up time, controlling for age, sex, race, disease duration, and disease type, and the interaction between disease type and follow-up time. In the first model, the predictor of interest was the earliest BMI available for each subject after symptom onset. In the second model, the predictor of interest was BMI within the first three months of symptom onset, which was available for a subset of subjects.BMI was first classified according to WHO criteria to examine the distribution of this parameter in our sample: underweight (<18.50 kg/mwww.r-project.org) or SAS Software (Version 9.3).Only de-identified PLM data were transferred to the Brigham and Women’s Hospital research team for quality control and analysis. All statistical analyses were performed using either the R version 2.14.2 (Table S2).In comparing how an online patient population recruited at a national level (PLM members) relates to a patient population found at a large regional MS center (the Boston-based Partners MS Center patient population), we found small (in absolute terms) but statistically significant differences for all tested variables .To assess the validity of the patient reported MSRS instrument deployed in PLM’s online platform, we administered this instrument to 121 MS patients at the Partners MS Center, with comparable demographic and disease characteristics to the entire MS Center population described in ; Figure S1). The two scores were strongly correlated . When we examined individual domains, the walking score had the highest level of agreement (weighted kappa = 0.732) and the highest level of correlation (rs = 0.856). There was also good agreement and association for upper extremity weakness and swallowing . The other four domains had lower levels of agreement between physician and patient assessments but all were significantly correlated (p<0.0001). The relationships between the patient and physician scores for each domain are shown in Table S4a–g. There did not appear to be any systematic under- or over-reporting of symptoms by either patients or physicians, as evidenced by the percentages of patients vs. physicians providing a higher score , Timed 25 foot walk (T25FW) , and ambulation index (AI) . In terms of subdomains, the MSRS walking domain demonstrated a similar level of correlation with EDSS (rs = 0.807), T25FW (rs = 0.693), and AI (rs = 0.840) . We also compared patient-derived MSRS composite scores with physician-derived clinical scales; while the correlations were weaker, these remained highly significant (p<0.001): EDSS (rs = 0.609), T25FW (rs = 0.497), and AI (rs = 0.591). Correlations with the MSRS walking domain score were somewhat stronger: EDSS (rs = 0.738), T25FW (rs = 0.650), and AI (rs = 0.738).When we compared physician-derived MSRS scores with disease severity measures routinely captured at the Partners MS Center, there was good correlation between the composite MSRS and EDSS , with 25.7% subjects who were overweight (BMI>24.9) and 26.7% subjects who were obese (BMI>29.9)  Table 3.Cross-sectionally, we noted a very modest correlation  between greater BMI (continuous variable) and greater MSRS Table 4.In this study, we report good correlation of the patient-reported MSRS measure developed by PLM with standard clinical assessment measures used in MS, such as the EDSS. The availability of this online instrument and of the large PLM membership provides a useful, complementary platform for MS clinical research. It does not replace rigorous, prospective cohort studies or targeted clinical research projects performed in academic MS centers; instead, it offers a different option, that has an opportunity to leverage the frequent sampling of data from a large subject population.Table S5). Here, we found statistically significant but small absolute differences in demographic characteristics, further suggesting that the PLM members, offer a reasonable alternative platform for MS clinical research that could yield insights that are generalizable to other MS populations after appropriate control for confounders.While we found small demographic differences between PLM members with recent profile updates and patients at our MS center, they were modest in absolute terms. It should be noted that both sets of subjects represent somewhat biased subsets of the overall MS patient population; this limitation is somewhat mitigated by their large sample size but needs to be clearly stated. Interestingly, the differences that we describe between the patient populations we compared – including that PLM members had a younger age, higher education, larger proportion of women and lower proportion of self-reported white non-Hispanic origin - are slightly at odds with other demographic surveys of users of online tools, that have noted greater use and more frequent use by individuals who are white, female, older, with higher incomes, with good internet skills, and who are not employed In this study, we explored the use of PLM to answer a timely clinical question in which the current literature offers conflicting results: the relationship between excess body weight and MS disease course in the North American population that is becoming increasingly heavier. Obesity in an individual’s mother Our findings and those of others relating BMI and disease severity in adults There are challenges and limitations to online research platforms, including biases arising from the digital divide, issues of privacy, autonomy and data storage, variable and inconsistent data sampling schedules, and lack of objective validation of reported data such as height and weight In conclusion, online research remains in its infancy and continues to pose ethical and methodological challenges. Nonetheless, the opportunity of capturing an assessment of disability on a very frequent basis opens exciting new possibilities that are not possible using more episodic data collection strategies such as those collected by NARCOMS. Prospective tracking of symptoms in “real time” may eventually allow researchers to assess whether certain symptoms such as increases in fatigue or fluctuations in “brain fog” can serve as harbingers for clinical attacks or be useful in assessing a patient’s clinical trajectory or response to disease-modifying therapy. The PLM member population therefore offers an intriguing new platform for MS investigations. Its results, after appropriate consideration of potential demographic and other confounders, may be generalizable to and replicable in the larger patient population seen in large MS centers.Figure S1Bland-Altman plot for Patient and Physician Total MSRS scores.(DOCX)Click here for additional data file.Table S1Illustration: The Multiple Sclerosis Related Severity (MSRS) questionnaire.(DOCX)Click here for additional data file.Table S2Comparison of patient and disease characteristics for patients treated with glatiramer acetate and interferons.(DOCX)Click here for additional data file.Table S3Individual and Disease Characteristics of 121 MS Center patients completing MSRS questionnaire.(DOCX)Click here for additional data file.Tables S4a–gDistribution of patient and physician scores for individual patients.(DOCX)Click here for additional data file.Table S5Comparison of PLM members' individual and disease characteristics with those of patients followed in the NARCOMS Registry.(DOCX)Click here for additional data file.


Pentalogy of Cantrell is a rare malformation described in the literature. We report a case of pentalogy of Cantrell associated with left limb deficiency in a twin pregnancy. The fetus with multiple anomalies revealed kyphosis, ectopia cordis, and a large defect with protruding liver and bowel loops at 12 weeks and 3 days of gestational age on ultrasound scan. The other fetus was ultrasonographically normal. We diagnosed a case of pentalogy of Cantrell in a twin pregnancy after exclusion of limb body wall complex, body stalk anomaly, and amniotic band syndrome and after delivery of the fetuses. Macroscopic examinations were ectopia cordis, extrusion of the abdominal organs without membranes surrounding, and agenesis of the left limb. Many cases of pentalogy of Cantrell (PC) have been reported since the first case which was defined by Cantrell and colleagues in 1958 [We have reviewed the published literature on PC and reported a twin case with the diagnosis of PC and a normal fetus.A 20-year-old gravida 1, para 0, abortus 0 pregnant woman was admitted to our perinatology unit with the suspicion of ectopia cordis in a twin pregnancy at the 12th week of gestation.She was performed transvaginal ultrasound scan and the scan revealed a dichorionic-diamniotic twin pregnancy. Crown-rump lengths were 48 mm and 46 mm corresponding to 11 + 5 weeks and nuchal translucencies were 1.2 and 1.6 mm, respectively. Ultrasound scan of the first twin revealed ectopia cordis and a large defect with protruding liver and bowel loops . The secPentalogy of Cantrell is a rare syndrome with an estimated incidence of 5.5 per 1 million live births . The etiVarious intracardiac anomalies have been described in the PC including ventricular septal defects (VSD) 100%), atrial septal defects (ASD) 53%), tetralogy of Fallot (TOF) (20%), pulmonary stenosis (33%), and left ventricular diverticulum (20%), whereas Vazquez-Jimenez et al. have reported that VSD is not consistent in every case (72%) [00%, atri%, tetralPC is a syndrome characterized by a distinct phenotypic variability. Toyama suggested three classes of PC: class 1: complete form, all five defects are present; Class 2: probable diagnosis that four defects are present, including intracardiac and ventral wall abnormalities; and class 3: incomplete expression, always including sternal abnormality with various combinations of defects . Class 1Abdominal wall defects that are seen in PC are omphalocele, diastasis recti, epigastric hernia, umblical hernia, and combined defects. Sternal malformations that can be seen in PC include bifid sternum, absent xiphoid process, short sternum, and defective formation of lower third . DiffereWe have reviewed the published literature on PC and reported a twin case with the diagnosis of PC and a normal fetus. Uygur et al. and Chen et al. have reported two cases with pentalogy of Cantrell and limb defects , 10. ChePC is a syndrome with high mortality rate and the survival rate is lower than 40% . The optIn conclusion, early counseling should be made to make differential diagnosis. When the PC is diagnosed, a multidisciplinary team including an obstetrician, a neonatologist, a pediatric cardiologist, a pediatric surgeon, and a genetics specialist should agree on the best approach to PC.