Long-Term Safety Evaluation of Continuous Intraocular Delivery of Aflibercept by the Intravitreal Gene Therapy Candidate ADVM-022 in Nonhuman Primates.

Purpose: To evaluate the long-term safety of vascular endothelial growth factor (VEGF) suppression with sustained aflibercept expression after a single intravitreal injection (IVI) of ADVM-022, an anti-VEGF gene therapy, in non-human primates (NHPs). Methods: Non-human primates received bilateral IVI of ADVM-022, a gene therapy vector encoding aflibercept, a standard of care for the treatment of VEGF-based retinal disease. Aflibercept levels from ocular fluids and tissues were measured. Ocular inflammation was assessed by slit lamp biomicroscopy and fundoscopy. The integrity of the retinal structure was analyzed by optical coherence tomography and blue light fundus autofluorescence and electroretinography was performed to determine retinal function. Histologic evaluation of the retina was performed at the longest time point measured (2.5 years after injection). Results: Sustained expression of aflibercept was noted out to the last time point evaluated. Mild to moderate inflammatory responses were observed, which trended toward spontaneous resolution without anti-inflammatory treatment. No abnormalities in retinal structure or function were observed, as measured by optical coherence tomography and electroretinography, respectively. RPE integrity was maintained throughout the study; no histologic abnormalities were observed 2.5 years after ADVM-022 IVI. Conclusions: In non-human primates, long-term, sustained aflibercept expression and the resulting continuous VEGF suppression by a single IVI of ADVM-022, appears to be safe, with no measurable adverse effects on normal retinal structure and function evaluated out to 2.5 years. Translational Relevance: Together with the results from previous ADVM-022 preclinical studies, these data support the evaluation of this gene therapy candidate in clinical trials as a potential durable treatment for various VEGF-mediated ophthalmic disorders.

The popularity of neurology in Spain: An analysis of specialty selection. / Popularidad de Neurología en España: análisis de la elección de la especialidad.

INTRODUCTION: Neurology is one of the medical specialties offered each year to residency training candidates. This project analyses the data associated with candidates choosing neurology residency programmes in recent years. METHODS: Data related to specialty selection were obtained from official reports by the Spanish Ministry of Health, Social Services, and Equality. Information was collected on several characteristics of teaching centres: availability of stroke units, endovascular intervention, national reference clinics for neurology, specific on-call shifts for neurology residents, and links with medical schools or national research networks. RESULTS: The median selection list position of candidates selecting neurology training has been higher year on year; neurology was among the 4 most popular residency programmes in 2016. Potential residents were mainly female, Spanish, and had good academic results. The median number of hospitals with higher numbers of beds, endovascular intervention, stroke units, and national reference clinics for neurology is significantly lower. This is also true when centers are analysed by presence of specific on-call shifts for neurology residents and association with medical schools or national research networks. The centres selected by candidates with the highest median selection list position in 2012-2016 were the Clínico San Carlos, 12 de Octubre, and Vall d'Hebron university hospitals. CONCLUSIONS: Neurology has gradually improved in residency selection choices and is now one of the 4 most popular options. Potential residents prefer larger centres which are more demanding in terms of patient care and which perform more research activity.

Catalytic Biosensors from Complex Coacervate Core Micelle (C3M) Thin Films.

Enzymes have been applied to a variety of industrially and medically relevant chemistries as both catalysts and sensors. Incorporation of proteins and enzymes into complex coacervates has been demonstrated to improve the thermal, chemical, and temporal stability of enzymes in solution. In this work, a neutral-cationic block copolymer and an enzyme, alkaline phosphatase, are incorporated into complex coacervate core micelles (C3Ms) and coated onto a solid substrate to create a biocatalytic film from aqueous solution. The incorporation of photo-cross-linkable groups into the neutral block of the polymer allows the film to be cross-linked under ultraviolet light, rendering it insoluble. The morphology of the film is shown to depend most strongly on the protein loading within the film, while solvent annealing is shown to have a minimal effect. These films are then demonstrated as specific sensors for Zn2+ in solution in the presence of other metals, a model reaction for ion-selective heavy metal biosensing useful in environmental monitoring. They are shown to have low leaching and maintain sufficient activity and response for sensing for 1 month after aging under ambient conditions and at 40 °C and 50% relative humidity. The C3M immobilization method demonstrated can be applied to a wide variety of proteins with minimal chemical or genetic modification and could be used for immobilization of charged macromolecules in general to produce a wide variety of thin-film devices.

Complex coacervation of supercharged proteins with polyelectrolytes.

Complexation of proteins with polyelectrolytes or block copolymers can lead to phase separation to generate a coacervate phase or self-assembly of coacervate core micelles. However, many proteins do not coacervate at conditions near neutral pH and physiological ionic strength. Here, protein supercharging is used to systematically explore the effect of protein charge on the complex coacervation with polycations. Four model proteins were anionically supercharged to varying degrees as quantified by mass spectrometry. Proteins phase separated with strong polycations when the ratio of negatively charged residues to positively charged residues on the protein (α) was greater than 1.1-1.2. Efficient partitioning of the protein into the coacervate phase required larger α (1.5-2.0). The preferred charge ratio for coacervation was shifted away from charge symmetry for three of the four model proteins and indicated an excess of positive charge in the coacervate phase. The composition of protein and polymer in the coacervate phase was determined using fluorescently labeled components, revealing that several of the coacervates likely have both induced charging and a macromolecular charge imbalance. The model proteins were also encapsulated in complex coacervate core micelles and micelles formed when the protein charge ratio α was greater than 1.3-1.4. Small angle neutron scattering and transmission electron microscopy showed that the micelles were spherical. The stability of the coacervate phase in both the bulk and micelles improved to increased ionic strength as the net charge on the protein increased. The micelles were also stable to dehydration and elevated temperatures.

Expression of so-called adhesion proteins and DNA cytometric analysis in malignant parotid tumours as predictors of clinical outcome.

Tumours of the salivary glands are rare, and account for only 0.5-1% of all tumours. We have analysed the cytoarchitectural structure of such tumours by studying 3 binding proteins that act on different parts of the glandular epithelial architecture: e-cadherin, laminin, and CD44. We analysed the DNA using image cytometry to evaluate ploidy, S-phase, and 5c exceeding rate, and to compare the biological aggressiveness of the proteins. Our goal was to correlate the degree of structural integrity and the histological grade of the injury, and to try to find new biological factors that would help to predict the evolution of disease in the salivary glands. The immunoexpression pattern of the so-called adhesion proteins of the salivary glands, when combined, yields important data about the aggressiveness of malignant neoplasms, and provides useful tools with which to predict the biological evolution of malignant lesions.

Crop row detection in maize fields inspired on the human visual perception.

This paper proposes a new method, oriented to image real-time processing, for identifying crop rows in maize fields in the images. The vision system is designed to be installed onboard a mobile agricultural vehicle, that is, submitted to gyros, vibrations, and undesired movements. The images are captured under image perspective, being affected by the above undesired effects. The image processing consists of two main processes: image segmentation and crop row detection. The first one applies a threshold to separate green plants or pixels (crops and weeds) from the rest (soil, stones, and others). It is based on a fuzzy clustering process, which allows obtaining the threshold to be applied during the normal operation process. The crop row detection applies a method based on image perspective projection that searches for maximum accumulation of segmented green pixels along straight alignments. They determine the expected crop lines in the images. The method is robust enough to work under the above-mentioned undesired effects. It is favorably compared against the well-tested Hough transformation for line detection.

Angiotensin-converting enzyme gene single polymorphism as a genetic biomarker of diabetic peripheral neuropathy: longitudinal prospective study.

BACKGROUND: Identifying patients at risk of developing diabetic peripheral neuropathy (DPN) is of paramount importance in those with type 2 diabetes mellitus (T2DM) to provide and anticipate secondary prevention measures as well as intensify action on risk factors, particularly so in primary care. Noteworthy, the incidence of DPN remains unknown in our environment. AIMS: (i) To analyze a single angiotensin-converting enzyme (ACE) gene polymorphism (D/I) as a genetic marker of risk of developing DPN, and (ii) to determine the incidence of DPN in our environment. RESEARCH DESIGN AND METHODS: Longitudinal study with annual follow-up for 3years involving a group of T2DM (N=283) randomly selected. ACE gene polymorphism distribution (I=insertion; D=deletion) was determined. DPN was diagnosed using clinical and neurophysiology evaluation. RESULTS: Baseline DPN prevalence was 28.97% (95% CI, 23.65-34.20). ACE polymorphism heterozygous genotype D/I presence was 60.77% (95% CI, 55.05-66.5) and was independently associated with a decreased risk of DPN (RR, 0.51; 95% CI, 0.30-0.86). DPN correlated with age (P<0.001) but not with gender (P=0.466) or time of evolution of T2DM (P=0.555). Regarding end point, DPN prevalence was 36.4% (95% CI, 30.76-42.04), and accumulated incidence was 10.4% 3years thereafter. In the final Poisson regression analysis, the presence of heterozygous genotype remained independently associated with a decreased risk of DPN (RR, 0.71; (95% CI, 0.53-0.96). DPN presence remained correlated with age (P=0.002), but not with gender (P=0.490) or time of evolution (P=0.630). CONCLUSIONS: In our series, heterozygous ACE polymorphism (D/I) stands as a protective factor for DPN development. Accumulated incidence of DPN was relevant. Further prospective studies are warranted.

Associations of physical activity and fitness with adipocytokines in adolescents: the AFINOS Study.

BACKGROUND AND AIMS: Adipocytokines may have a key role in the development of atherosclerosis and type 2 diabetes. The purpose of this study was to examine the independent and joint associations of physical activity (PA), cardiorespiratory fitness (CRF) and muscular fitness (MF) with adiponectin and leptin in adolescents. METHODS AND RESULTS: A sample of 198 adolescents (96 girls), aged 13-17-year, was selected. Participants completed anthropometric measurements (height, weight, and waist circumference) and percentage of body fat (%BF) was estimated by bioelectrical impedance. PA was measured by accelerometer for 7-day. The 20-m shuttle-run test was used to assess CRF and two MF tests (handgrip strength and standing broad jump) were used to create an MF score. A cluster score of health status (0-3 risks) was created. Serum adiponectin and plasma leptin were also determined. Regression analyses controlling for age, sex, pubertal status and waist circumference showed that PA was not significantly associated with adiponectin and vigorous PA showed a significant inverse association with leptin. Both CRF and MF were significantly and inversely associated with adiponectin and leptin. Further analyses revealed that the 'healthy' group (0 risks) had significantly lower adiponectin and leptin than 'medium-healthy' (1 risk) and 'unhealthy' (2-3 risks) status groups. CONCLUSIONS: PA, CRF and MF are inversely and jointly associated with adiponectin and leptin concentrations in adolescents.

Daily consumption of milk enriched with fish oil, oleic acid, minerals and vitamins reduces cell adhesion molecules in healthy children.

BACKGROUND AND AIMS: Several studies have suggested that polyunsaturated fatty acids, vitamins and minerals have beneficial effects on lipid profile and systemic inflammation in adults. METHODS AND RESULTS: We examined the effects of a daily intake of milk enriched with longchain polyunsaturated fatty acids, oleic acid, carbohydrates, vitamins, minerals and low in saturated fatty acids (SFAs) for 5 months, on several cardiovascular (CVD) risk biomarkers in healthy children aged 8-14 years. In a randomized double-blind placebo-controlled trial, a total of 107 children of both genders were assigned to two study groups: 1) a supplemented group (SG, n=53) who consumed 0.6 L/day of an enriched dairy product, and 2) a control group (CG, n=54) who consumed 0.6 L/day of standard whole milk. Both groups consumed the dairy drinks for 5 months, in addition to their usual diet. Serum levels of adhesion molecules as indices of vascular endothelial cell activation were assessed in both groups at 0 and 5 months as well as white blood cell counts, lipid profile, serum proteins, total serum calcium, 25-OH vitamin D, glucose, insulin and adiponectin. In the enriched dairy drink supplemented group, adhesion molecules E-selectin and ICAM-1 as well as lymphocyte levels decreased while plasma docosahexaenoic acid (DHA) and serum calcium concentrations increased. In the control group, serum total protein, transferrin, total cholesterol, HDL-cholesterol and adiponectin concentrations decreased. CONCLUSION: The consumption of a milk enriched with fish oil, oleic acid, minerals and vitamins reduced indices of endothelial cell activation in the studied group of healthy children.

Immunomodulatory effect of fibres, probiotics and synbiotics in different life-stages.

Chronic diseases associated to modern lifestyle habits are usually related to immune system malfunction. In this context, since diet is very well-known to modulate host resistance to infectious and inflammatory processes, the consumption of fibre and probiotics seems to be a promising nutritional tool for immune system modulation in different populations. Health effects of dietary fibres and probiotics have been extensively documented in numerous epidemiological and intervention studies, especially their beneficial effect on intestinal microbiota with important clinical implications in the prevention and/or treatment of infectious and inflammatory diseases. Mechanisms may include modulation of the functional properties of the microbiota, epithelial cells, dendritic cells and immune cell types. Prebiotics have been extensively reported to affect the composition of the gut microbiota, stimulating directly or indirectly putative beneficial gut commensals other than lactic acid bacteria, opening promising areas of research for the discovery of new probiotic strains and synbiotic combinations. Age-related changes in gut physiology, microbiota and mucosal immune response are well established. Moreover, exposure to different challenges during life such as early encounter of environmental insults in the newborn, infant formula feeding, antibiotic treatment, gastrointestinal diseases and stress, also interferes with the normal development and balance of the healthy gut microbiota. Therefore, the current short review gives an overview of today's main aspects of the effect of fibres, probiotics and synbiotics on the immune system in different life-stages.

Physical activity, immunity and infection.

During the last few decades, scientific evidence has confirmed a wide range of health benefits related to regular physical activity. How physical activity affects the immune function and infection risk is, however, still under debate. Commonly, intensive exercise suppresses the activity and levels of several immune cells, while other immune functions may be stimulated by moderate physical activity. With this knowledge, the understanding of the relationship between different levels of physical activity on the immune function has been raised as a potential tool to protect health not only in athletes but also in the general population; the mechanisms that translate a physically active lifestyle into good health continue to be investigated. Reviewing the literature, although several outcomes (i.e. the mechanisms by which different levels and duration of physical activity programmes affect numerous cell types and responses) remain unclear, given that the additional benefits encompass healthy habits including exercise, the use of physical activity programmes may result in improved health of elderly populations. Moderate physical activity or moderate-regulated training may enhance the immune function mainly in less fit subjects or sedentary population and the pre-event fitness status also seems to be an important individual factor regarding this relationship. Although adequate nutrition and regular physical activity habits may synergistically improve health, clinical trials in athletes using nutritional supplements to counteract the immune suppression have been inconclusive so far.Further research is necessary to find out to what extent physical activity training can exert an effect on the immune function.

Acute and chronic anti-inflammatory properties of the stem bark aqueous and methanol extracts of Sclerocarya birrea (Anacardiaceae).

Sclerocarya birrea is used in folk medicine for the treatment of inflammatory disorders. The effect of the stem bark aqueous and methanol extracts of S. birrea (150 or 300 mg/kg) was evaluated on carrageenan-, histamine- or serotonin-induced paw oedema in rats. The methanol extract of S. birrea (300 mg/kg) being the most active, exhibited a maximum inhibition of 75.45 and 55.31% on carrageenan- and histamine-induced inflammation, respectively. When administered at 300 mg/kg, the methanol extract of S. birrea also exhibited 80.68% inhibition on the 10th day and 54.43% inhibition on the 21st day in formalin- or complete Freund's adjuvant (CFA)-induced paw oedema in rats. GSH level was significantly increased (75.14%), while MAD level was significantly decreased (31.22%) in the liver of CFA rats treated with S. birrea (300 mg/kg). The results suggest that the anti-inflammatory activity of the aqueous and methanol extracts of S. birrea is due to the inhibition of histamine and prostaglandin pathways and to its antioxidant activity.

Clinical screening and diagnosis of diabetic polyneuropathy: the North Catalonia Diabetes Study.

BACKGROUND: To evaluate the prevalence of diabetic polyneuropathy (DPN) and develop a simple and accurate method for the evaluation of DPN risk in primary care settings. MATERIALS AND METHODS: Cross-sectional descriptive study in a random sample (N = 307) of type 2 diabetes mellitus participants. DPN was diagnosed by both clinical neurological examination and simplified DPN Selection Method in each patient. Correlation between the two methods was obtained. RESULTS: Prevalence of DPN was 23.13% (confidence interval,18.38-27.87) according to clinical neurological examination. Noteworthy, clinical neurological evaluation scores were related to nerve conduction studies (r = 0.882; P < 0.0005). DPN presence was positively related to age, metabolic control (HbA1c levels), known duration of diabetes, diabetic retinopathy, cardiovascular disease, peripheral ischemia and systolic and diastolic blood pressure, but was negatively related to current high-density lipoprotein cholesterol (HDL-C) levels (P < 0.0001). The sensitivity and specificity of our DPN Selection Method (using four clinical parameters: age, retinopathy, HbA1c and HDL-C plasma levels) for diagnosis of DPN was 74.20% and 74.90%, respectively. CONCLUSIONS: The expected prevalence of DPN was observed. The sensitivity of the DPN Selection Method correlated well with formal clinical neurological exam in detection of the condition. We therefore conclude the DPN Selection Method is a useful tool in primary care settings in the evaluation and diagnosis of DPN.

Is soft drink consumption associated with body composition? A cross-sectional study in Spanish adolescents.

OBJECTIVES: Published data about the association between the consumption of sweetened soft-drinks (SSD) and obesity in childhood are controversial and still inconsistent. In addition, data are lacking in the Spanish population. The purpose of this study was therefore, to explore the cross-sectional association between body composition-related parameters and SSD consumption in Spanish adolescents. SUBJECTS AND METHODS: A representative sample of 1,523 adolescents (768 boys and 755 girls), with complete dietary data as well as anthropometric measurements, were included in this study. Weight, height, waist circumferences, and 6 skinfolds were measured, and BMI and percentage body fat were calculated. From a 24h dietary recall the subjects were grouped in 3 groups according to their SSD consumption: 1) Non-consumers (0 g of SSD consumption); 2) Moderate consumption (< 336 g/day of SSD, equivalent to the average SSD portion size); and 3) High consumption (> 336 g/day of SSD). RESULTS: 67% males and 75% females did not consume any SSD the day before the dietary recall interview. Males consumed more SSD than females. Regarding the association between SSD consumption and measures of obesity, no difference was observed between the three groups of SSD consumption in any of the anthropometric measurement, BMI or body fat. CONCLUSION: As no association was present between SSD consumption and obesity in our cross-sectional study we suggest that dietary patterns and habits as well as lifestyle factors such as physical activity should be present when examining cross-sectional or longitudinal relationships with obesity. Multidisciplinary intervention studies are crucial when trying to develop solutions against the increasing obesity epidemic.

Immunological changes after a single bout of moderate-intensity exercise in a hot environment.

This study was aimed to evaluate the possible changes caused by a single bout of moderate-intensity exercise in a hot environmental temperature on the immune function and on inflammatory markers. A total of 22 young male adults (VO2(max), 55.4 +/- 3.6 ml x kg(-1) x min(-1)) volunteered to participate in an exercise session of 60 minutes on a treadmill ergometer at moderate speed (60% of the maximum aerobic speed) in hot environmental conditions (35 degrees C and humidity 60%). Total leukocyte numbers, lymphocyte subsets (CD8+, CD4+, CD3+, NK and CD19+), cytokine production capacity by peripheral blood mononuclear cells (PBMCs) (IL-2, IL-4, IL-5, IL-10, IFN-gamma and TNF-alpha) as well as the concentration of several inflammation related proteins (ceruloplasmin, C-reactive protein (CRP), complement factors C3 and C4) were evaluated before and after exercise. The results show that leukocyte and neutrophil absolute values increased (P < 0.001) after the exercise period. In contrast, eosinophil values decreased (P < 0.05) after the exercise. In addition, ceruloplasmin, C3 and C4 values (P < 0.05) increased after exercise. No changes in T lymphocyte subsets, cytokine production, or CRP were observed. These data confirm previous studies suggesting that a 60 min exercise in a hot environment is enough to cause a physiologic adaptation to these special conditions leading to an increase of non-specific immune cells and promoting inflammatory processes. On the other hand, PCR values, lymphocyte subsets and the capacity of cytokine production by PBMC were not changed in a relatively short bout of exercise under these conditions in contrast with previous studies.

Effects of moderate beer consumption on first-line immunity of healthy adults.

Moderate alcohol consumption has shown to induce benefits on host specific (cell-mediated and humoral) immune system, but there is scarce literature regarding first-line immune responses. The aim of this study was to investigate differences in non-specific immunity after alcohol abstention and moderate beer consumption in healthy adults. After a 30 day-alcohol abstemious period, 57 healthy volunteers were submitted to a daily moderate consumption of beer (330 mL for women and 660 mL for men, respectively) during the following 30 days. White blood cell counts and phagocytic and oxidative burst activity were evaluated at three points: a) basal, b) abstemious, c) after moderate consumption of beer. Absolute values of leukocytes, neutrophils, lymphocytes and basophiles (x10(9)/L) increased significantly in women from point b to point c (6.34 +/- 1.26 vs. 7.27 +/- 1.97, 3.43 +/- 0.88 vs. 4.13 +/- 1.53, 2.14 +/- 0.50 vs. 2.38 +/- 0.63, and 0.05 +/- 0.02 vs. 0.06 +/- 0.03, respectively; p < 0.05) as well as basophils in men (0.05 +/- 0.03 vs. 0.06 +/- 0.03). A significant increase of oxidative burst capacity was also observed after the moderate consumption of beer in both women (33.90 +/- 19.00 vs. 48.86 +/- 21.83) and men (27.39 +/- 18.13 vs. 39.25 +/- 24.53). In healthy adults, after 30 days of moderate beer consumption the parameter describing the non-specific immunity improved when compared to the basal situation. For several of these parameters, the response is more enhanced in women.

[Nasal T lymphoma]. / Linfoma T nasal.

Nasal T lymphoma constitute a type of lymphoproliferative very infrequent symdrome. One of the fondamental problems it presents to bring a high probability of survival obtain a precocious diagnose. It is due that it originates inespecific histologic lesions, and to its clinic. Only the close cooperation between the otorhinolaryngologist and the anatomopathologist can arrive to obtain a very speedy diagnose and in that way the possibility of a correct treatment, because newly treatments appear, to which this type of disease every day better respond. We present the cases of nasal T lymphomas diagnosticated in the ORL Service of the Toledo area during 15 years, their symptomotology, treatment, evolution and survival. Besides a up to date bibliographic revision on this controversial syndrome.

[Laryngeal leishmaniasis]. / Leishmaniasis laríngea.

Leishmaniasis consists in a zoonotic infection, that means affect animals. Due to the puncture of the female sand fly type Phlebotomus (Ancient World) or Lutzomya (New World) the human being can be also affected. The clinical manifestations are very varied, depending to factors related with host, vector and the proper parasit. In this present work, we expose the three unic cases of Leishmaniasis affecting the larynx, diagnosticated in the sanitary area of Toledo. Due to the specific characteristics that present each case different treatments for each one have been realised, and its results and treatment exposed.

[Does beer have an impact on weight gain? Effects of moderate beer consumption on body composition]. / Influye la cerveza en el aumento de peso? Efectos de un consumo moderado de cerveza sobre la composición corporal.

BACKGROUND: The effects of alcohol consumption on body weight have been evaluated in a large number of studies suggesting to be inversely as well as positively related to body weight and body fat. OBJECTIVE: This study examined the relationships between moderate beer consumption and anthropometrical parameters in Spanish healthy adults. METHOD: After a 30 day alcohol abstemious period, 58 healthy volunteers were submitted to a daily moderate consumption of beer during the following 30 days. Weight, height, skinfolds and circumferences were measured at three points: (a) basal; (b) abstemious and (c) after moderate consumption of beer. RESULTS: Biceps skinfold (mm) increased (p < 0.05) in men after moderate beer consumption in regard to abstinence period (5.74 +/- 1.70 vs. 6.23 +/- 1.74). No significant differences were observed in the rest of anthropometrical parameters studied in both women and men along the study intervention. CONCLUSION: Moderate beer consumption during one month did not mostly change weight and weight-related parameters in healthy adults.

Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis.

BACKGROUND AND STUDY AIMS: An ideal treatment for choledocholithiasis in the laparoscopic era has not been established. The objective of this study was to elucidate whether a treatment strategy of performing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparascopic cholecystectomy (when choledocholithiasis is confirmed by intraoperative cholangiography) is better for patients with suspected common bile duct stones than the current strategy (preoperative ERCP followed by laparoscopic cholecystectomy). PATIENTS AND METHODS: This was a prospective randomized study to evaluate which of these two approaches was most benefit- and cost-effective for patients with intermediate risk of choledocholithiasis. Patients underwent either preoperative ERCP followed by a laparoscopic cholecystectomy a few weeks later (the "preoperative ERCP" group) or intraoperative ERCP (the "intraoperative ERCP" group). Intraoperative ERCP was performed using the rendezvous technique. RESULTS: There were 64 patients in the preoperative ERCP group and 59 patients in the intraoperative ERCP group. The demographic and clinical characteristics of the two groups were similar, except that the bilirubin and gamma-glutamyl transferase (GGT) levels and the number of patients treated on an inpatient basis were higher in the preoperative ERCP group. Success rates were similar (96.6 % in the preoperative ERCP group vs. 90.2 % in the intraoperative ERCP group in the per-protocol study). Total morbidity, post-ERCP morbidity, and post-ERCP acute pancreatitis rates were higher in the preoperative ERCP group, but there were no differences between the two groups in the frequency of residual common bile duct stones, the conversion rate to open cholecystectomy, or surgical morbidity. The length of hospital stay and costs were lower in the intraoperative ERCP group despite the longer surgical times in this group. Univariate analysis did not find any relationship between morbidity and total bilirubin or GGT. Logistic regression analysis confirmed that morbidity was related only to the treatment group and the time spent in the operating room: the relative risk (RR) was 4.37 for morbidity and 1.015 for the time spent in the operating room); the RR for papillotomy was 5.49. CONCLUSIONS: Both treatment approaches were equally effective but the intraoperative ERCP group had less morbidity, a shorter hospital stay, and reduced costs. The lower morbidity in the intraoperative ERCP group resulted from the lower rate of papillotomy and lower rates of post-ERCP pancreatitis and cholecystitis. Total morbidity was principally related to the type of treatment approach used.