Evaluating emissions reductions from zero waste strategies under dynamic conditions: A case study from Boston.

In 2018 and 2019 the City of Boston (Massachusetts, USA) conducted zero waste and carbon neutral planning efforts. Here we present the results of an accompanying analysis of the impacts of zero waste strategies on greenhouse gases (GHG) emissions associated with waste treatment. Emissions analysis in the waste sector is complicated by the contribution of significant indirect impacts that can exhibit temporal and spatial heterogeneity. For example, lifecycle GHG analysis of waste-to-energy combustion grants credits for the emissions avoided due to electricity generated from organic waste (biogenic carbon) that displaces electricity generation that could be carbon-emitting. As electricity grids decarbonize, this credit approaches zero. Long-term emissions planning needs to account for such dynamics to realistically assess the GHG mitigation potential associated with alternative waste management strategies. Here, we seek to capture these dynamics in a forward-looking analysis of waste sector emissions under a zero-waste strategy for the City of Boston. Using publicly available data sets such as EPA's Waste Reduction Model (WARM), we show that the implementation of zero waste strategies reduces the combustion of plastics and biomass in waste-to-energy (WtE) combustion facilities and associated GHG emissions. While WtE has been considered less-carbon intensive than other forms of waste treatment and fossil-based electricity generation, our analysis shows that more renewables will eventually eliminate the perceived GHG benefits associated with waste-to-energy combustion. While our approach provides policymakers with an understanding of the impacts of decisions in a dynamic context, we also identify common knowledge gaps in conducting forward-looking waste-GHG assessments.

Natural variation in host-finding behaviour of gastropod parasitic nematodes (Phasmarhabditis spp.) exposed to host-associated cues.

The gastropod parasitic nematode Phasmarhabditis hermaphrodita has been formulated into a successful biological control agent (Nemaslug®, strain DMG0001) used to kill slugs on farms and gardens. When applied to soil, P. hermaphrodita uses slug mucus and faeces to find potential hosts. However, there is little information on what cues other species of Phasmarhabditis (P. neopapillosa and P. californica) use to find hosts and whether there is natural variation in their ability to chemotax to host cues. Therefore, using chemotaxis assays, we exposed nine wild isolates of P. hermaphrodita, five isolates of P. neopapillosa and three isolates of P. californica to mucus from the pestiferous slug host Deroceras invadens, as well as 1% and 5% hyaluronic acid - a component of slug mucus that is highly attractive to these nematodes. We found P. hermaphrodita (DMG0010) and P. californica (DMG0018) responded significantly more to D. invadens mucus and 1% hyaluronic acid than other strains. Also, P. hermaphrodita (DMG0007), P. neopapillosa (DMG0015) and P. californica (DMG0017) were superior at locating 5% hyaluronic acid compared to other isolates of the same genera. Ultimately, there is natural variation in chemoattraction in Phasmarhabditis nematodes, with some strains responding significantly better to host cues than others.

The effect of sertraline, haloperidol and apomorphine on the behavioural manipulation of slugs (Deroceras invadens) by the nematode Phasmarhabditis hermaphrodita.

The nematode Phasmarhabditis hermaphrodita can infect and kill many species of slugs and has been formulated into a biological control agent for farmers and gardeners. P. hermaphrodita can manipulate the behaviour of slugs, making those infected move to areas where the nematode is present. Research suggests P. hermaphrodita uses manipulation of biogenic amines to achieve this, however the exact role of serotonin and dopamine needs further elucidation. Here we fed slugs Deroceras invadens (uninfected and infected with P. hermaphrodita) apomorphine, sertraline and haloperidol and observed their behaviour when given a choice between a P. hermaphrodita infested habitat, or a parasite free area of soil. In contrast to their usual P. hermaphrodita avoidance behaviour, uninfected D. invadens fed sertraline were attracted to the nematodes and conversely those fed haloperidol avoided the nematodes. D. invadens fed apomorphine were recorded equally on the control and nematode side. D. invadens pre-infected with P. hermaphrodita fed sertraline and apomorphine were found significantly more on the side with the nematodes. However, suppressing dopaminergic signalling through feeding with haloperidol abrogated this attraction and slugs were found on both sides. These results demonstrate that serotonin and dopamine are potential regulators of behavioural manipulation by P. hermaphrodita.

Comparison of 3-day and 7-day recall periods for food consumption reference values in foodborne disease outbreak investigations.

Investigations into an outbreak of foodborne disease attempt to identify the source of illness as quickly as possible. Population-based reference values for food consumption can assist in investigation by providing comparison data for hypothesis generation and also strengthening the evidence associated with a food product through hypothesis testing. In 2014-2015 a national phone survey was conducted in Canada to collect data on food consumption patterns using a 3- or 7-day recall period. The resulting food consumption values over the two recall periods were compared. The majority of food products did not show a significant difference in the consumption over 3 days and 7 days. However, comparison of reference values from the 3-day recall period to data from an investigation into a Salmonella Infantis outbreak was shown to support the conclusion that chicken was the source of the outbreak whereas the reference values from a 7-day recall did not support this finding. Reference values from multiple recall periods can assist in the hypothesis generation and hypothesis testing phase of foodborne outbreak investigations.

Evaluation of How Integrative Oncology Services Are Valued between Hematology/Oncology Patients and Hematologists/Oncologists at a Tertiary Care Center.

Evidence regarding opinions on integrative modalities by patients and physicians is lacking. Methods. A survey study was conducted assessing how integrative modalities were valued among hematology/oncology patients and hematologists and oncologists at a major tertiary medical center. Results. 1008 patients and 55 physicians were surveyed. With the exception of support groups, patients valued nutrition services, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, and other complimentary medicine services significantly more than physicians (P ≤ 0.05). Conclusion. With the exception of support groups, patients value integrative modalities more than physicians. Perhaps with increasing education, awareness, and acceptance by providers and traditional institutions, integrative modalities could be equally valued between patients and providers. It is possible that increased availability and utilization of integrative oncology modalities at tertiary hospital sites could improve patient satisfaction, quality of life, and other clinical endpoints.

An observational analysis of discontinuation and non-publication of osteoarthritis trials.

OBJECTIVE: Discontinuation and nonpublication are causes for concern in highly funded research areas of prevalent medical conditions. The aim of our study is to evaluate the rate of discontinuation and nonpublication in osteoarthritis randomized controlled clinical trials. DESIGN: We used the ClinicalTrials.gov advanced search using the keyword "osteoarthritis" for phase 3 or phase 4 clinical trials in adults. Two investigators then independently screened the search results by registered title, condition, study design, and completion date. We then performed a systematic search to determine the publication status of the study. RESULTS: Our final analysis included 273 studies. Our analysis of these studies included 243 (89%) completed and 30 (11%) discontinued trials. A total of 121,307 (92%) and 10,368 (8%) patients participated in completed and discontinued trials, respectively. Following our searches of PubMed, Embase, and Google Scholar, we identified 67 of the 243 (27.6%) studies as completed but having not reached publication in manuscript form. CONCLUSIONS: If discontinuation and non-publication rates in osteoarthritis trials continue to be sub-optimal, already scarce research resources will continue to be wasted. One possible explanation for the witnessed nonpublication that warrants further investigation is the issue of publication bias or selective reporting bias, two known problems that decrease research productivity and ethics.

Producer estimates of prevalence and perceived importance of lameness in dairy herds with tiestalls, freestalls, and automated milking systems.

Lameness is one of the most important welfare and productivity concerns in the dairy industry. Our objectives were to obtain producers' estimates of its prevalence and their perceptions of lameness, and to investigate how producers monitor lameness in tiestall (TS), freestall with milking parlor (FS), and automated milking system (AMS) herds. Forty focal cows per farm in 237 Canadian dairy herds were scored for lameness by trained researchers. On the same day, the producers completed a questionnaire. Mean herd-level prevalence of lameness estimated by producers was 9.0% (±0.9%; ±SE), whereas the researchers observed a mean prevalence of 22.2% (±0.9%). Correlation between producer- and researcher-estimated lameness prevalence was low (r = 0.19) and mean researcher prevalence was 1.6, 1.8, and 4.1 times higher in AMS, FS, and TS farms, respectively. A total of 48% of producers thought lameness was a moderate or major problem in their herds (TS = 34%; AMS =53%; FS = 59%). One third of producers considered lameness the highest ranked health problem they were trying to control, whereas two-thirds of producers (TS = 43%; AMS = 63%; FS = 71%) stated that they had made management changes to deal with lameness in the past 2 yr. Almost all producers (98%) stated they routinely check cows to identify new cases of lameness; however, 40% of producers did not keep records of lameness (AMS = 24%; FS = 23%; TS = 60%). A majority (69%) of producers treated lame cows themselves immediately after detection, whereas 13% relied on hoof-trimmer or veterinarians to plan treatment. Producers are aware of lameness as an issue in dairy herds and almost all monitor lameness as part of their daily routine. However, producers underestimate lameness prevalence, which highlights that lameness detection continues to be difficult in in all housing systems, especially in TS herds. Training to improve detection, record keeping, identification of farm-specific risk factors, and treatment planning for lame cows is likely to help decrease lameness prevalence.

International outbreak of multiple Salmonella serotype infections linked to sprouted chia seed powder - USA and Canada, 2013-2014.

Salmonella is a leading cause of bacterial foodborne illness. We report the collaborative investigative efforts of US and Canadian public health officials during the 2013-2014 international outbreak of multiple Salmonella serotype infections linked to sprouted chia seed powder. The investigation included open-ended interviews of ill persons, traceback, product testing, facility inspections, and trace forward. Ninety-four persons infected with outbreak strains from 16 states and four provinces were identified; 21% were hospitalized and none died. Fifty-four (96%) of 56 persons who consumed chia seed powder, reported 13 different brands that traced back to a single Canadian firm, distributed by four US and eight Canadian companies. Laboratory testing yielded outbreak strains from leftover and intact product. Contaminated product was recalled. Although chia seed powder is a novel outbreak vehicle, sprouted seeds are recognized as an important cause of foodborne illness; firms should follow available guidance to reduce the risk of bacterial contamination during sprouting.

Differential signaling through p190 and p210 BCR-ABL fusion proteins revealed by interactome and phosphoproteome analysis.

Two major types of leukemogenic BCR-ABL fusion proteins are p190BCR-ABLand p210BCR-ABL. Although the two fusion proteins are closely related, they can lead to different clinical outcomes. A thorough understanding of the signaling programs employed by these two fusion proteins is necessary to explain these clinical differences. We took an integrated approach by coupling protein-protein interaction analysis using biotinylation identification with global phosphorylation analysis to investigate the differences in signaling between these two fusion proteins. Our findings suggest that p190BCR-ABL and p210BCR-ABL differentially activate important signaling pathways, such as JAK-STAT, and engage with molecules that indicate interaction with different subcellular compartments. In the case of p210BCR-ABL, we observed an increased engagement of molecules active proximal to the membrane and in the case of p190BCR-ABL, an engagement of molecules of the cytoskeleton. These differences in signaling could underlie the distinct leukemogenic process induced by these two protein variants.

Elevated homocysteine with pseudo-homozygosity for MTHFR677T as predisposing factors for transient ischemic attacks: a case report.

A 21 year old male presented with a history of intermittent, transient neurological events. A brain MRI showed an area of restricted diffusion in keeping with an infarct, and an angiogram demonstrated an intracranial stenosis in the internal carotid artery, consistent with atherosclerosis. Laboratory investigations revealed a highly elevated plasma homocysteine, with low plasma folate and 5-methyltetrahydrofolate and methionine at the lower end of the normal ranges. The homocysteine normalized following treatment with folic acid. Molecular analysis found heterozygosity for the common MTHFR c.665C > T (aka 677C > T) variant and heterozygosity for a c.3G > C nucleotide substitution, which result in the lack of translation from this allele. It is proposed that the loss of p. Met1, coupled with folate deficiency, may be significant for the remethylation process, and may have contributed to the neurological events in this patient. If the two genetic variants are on alternate alleles, the patient would present with pseudo-homozygosity for MTHFR677T. It is probable that the combination of pronounced dietary folate deficiency, an MTHFR 'null allele' and the 677 T variant is sufficient to explain both the moderate hyperhomocysteinaemia and the clinical presentation in this patient. This case highlights the need to investigate other possible mutations in MTHFR, particularly in the absence of homozygous MTHFR 677C > T status in premature cardiovascular events.

Measles surveillance in Canada: 2015.

BACKGROUND: Measles has been eliminated in Canada since 1998. Every year, the Public Health Agency of Canada presents epidemiologic evidence to the Pan American Health Organization (PAHO) to verify that measles elimination continues in Canada. OBJECTIVE: To describe measles activity in Canada for 2015 as updated evidence for continued measles elimination status. METHODS: Measles surveillance data were captured by the Canadian Measles and Rubella Surveillance System (CMRSS) and the Measles and Rubella Surveillance (MARS) pilot project and assessed for distribution by demographics and risk factors. Outbreak characteristics were summarized and genotypic and phylogenetic analyses were conducted and described. Surveillance data for 2015 were evaluated against PAHO's essential criteria for measles elimination status. RESULTS: In 2015, the incidence of measles in Canada was 5.5 cases per 1,000,000 population, with 196 cases across four provinces. The majority of cases (87.2%, n=171) were not immunized and both age-specific incidence rates and case counts were highest among those aged 10 to 14 years (29.5 cases per 1,000,000 population, n=55). This was due in large part to a sizeable outbreak in a non-immunizing religious community. Overall, 10.7% (n=21) of cases were hospitalized. Genotype information was available for 100% of measles events (4/4 outbreaks and 6/6 sporadic cases). Canada met or partially met most of PAHO's criteria for verification of measles elimination. CONCLUSION: Although importations and areas of low immunization coverage continue to challenge Canada's elimination status, surveillance data for 2015 provides strong evidence that measles elimination has been maintained.

Social network investigation of a syphilis outbreak in Ottawa, Ontario.

BACKGROUND: The incidence of syphilis in Ottawa, Ontario, has risen substantially since 2000 to six cases per 100,000 in 2003, again to nine cases per 100,000 in 2007, and recently rose to 11 cases per 100,000 in 2010. The number of cases reported in the first quarter of 2010 was more than double that in the first quarter of 2009. OBJECTIVE: In May 2010, the Ontario Ministry of Health and Long Term Care requested the assistance of the Field Epidemiology Program to describe the increase in infectious syphilis rates and to identify social network sources and prevention messages. METHODS: Syphilis surveillance data were routinely collected from January 1, 2009 to July 15, 2010, and social networks were constructed from an enhanced social network questionnaire. Univariate comparisons between the enhanced surveillance group and the remaining cases from 2009 on non-normally distributed data were conducted using Kruskal-Wallis tests and χ(2) tests. RESULTS: The outbreak cases were comprised of 89% men. Seventeen of the 19 most recent cases consented to answer the questionnaire, which revealed infrequent use of condoms, multiple sex partners and sex with a same-sex partner. Information regarding social venues where sex partners were met was plotted together with sexual partnerships, linking 18 cases and 40 contacts, representing 37% of the outbreak population and connecting many of the single individuals and dyads. CONCLUSION: Uncovering the places sex partners met was an effective proxy measure of high-risk activities shared with infected individuals and demonstrates the potential for focusing on interventions at one named bar and one Internet site to reach a high proportion of the population at risk.

HISTORIQUE: L'incidence de syphilis à Ottawa, en Ontario, a beaucoup augmenté depuis 2000, passant de six cas sur 100 000 habitants en 2003 à neuf cas sur 100 000 habitants en 2007, puis à 11 cas sur 100 000 habitants en 2010. Le nombre de cas signalés pendant le premier trimestre de 2010 a plus que doublé par rapport à celui du premier trimestre de 2009. OBJECTIF: En mai 2010, le ministère de la Santé et des Soins de longue durée de l'Ontario a demandé l'aide du Programme canadien d'épidémiologie de terrain pour décrire l'augmentation du taux de syphilis infectieuses, en déterminer l'origine dans les réseaux sociaux et établir les messages de prévention. MÉTHODOLOGIE: Les chercheurs ont colligé systématiquement les données de surveillance sur la syphilis entre le 1er janvier 2009 et le 15 juillet 2010 et en ont établi les réseaux sociaux à partir d'un questionnaire amélioré sur les réseaux sociaux. Au moyen du test de Kruskal-Wallis et des tests du chi carré, ils ont effectué des comparaisons univariées des données non distribuées normalement entre le groupe de surveillance améliorée et les autres cas de 2009. RÉSULTATS: Les cas d'éclosion se composaient de 89 % d'hommes. Dix-sept des 19 cas les plus récents ont consenti à répondre au questionnaire, qui a révélé un usage peu fréquent du condom, de multiples partenaires sexuels et des relations sexuelles avec des partenaires de même sexe. Les chercheurs ont transcrit sur un graphique l'information relative aux lieux où les partenaires sexuels se sont rencontrés, ce qui a permis de relier 18 cas et 40 contacts, soit 37 % de la population de l'éclosion, et d'associer de nombreux individus uniques et de dyades. CONCLUSION: La découverte des lieux où les partenaires sexuels se sont rencontrés s'est révélée une mesure indirecte efficace des activités à haut risque partagées avec des personnes infectées et a démontré le potentiel d'intervenir seulement dans un bar précis et un site Internet donné pour joindre une forte proportion de la population à risque.

Outbreak of E. coli O157:H7 associated with lettuce served at fast food chains in the Maritimes and Ontario, Canada, Dec 2012.

BACKGROUND: Identification and control of multi-jurisdictional foodborne illness outbreaks can be complex because of their multidisciplinary nature and the number of investigative partners involved. OBJECTIVE: To describe the multi-jurisdictional outbreak response to an E. coli O157:H7 outbreak in Canada that highlights the importance of early notification and collaboration and the value of centralized interviewing. METHODS: Investigators from local, provincial and federal jurisdictions, using a national outbreak response protocol to clarify roles and responsibilities and facilitate collaboration, conducted a rapid investigation that included centralized re-interview of cases, descriptive methods, binomial probability, and traceback findings to identify the source of the outbreak. RESULTS: There were 31 laboratory confirmed cases identified in New Brunswick, Nova Scotia, and Ontario. Thirteen cases (42%) were hospitalized and one case (3%) developed hemolytic uremic syndrome; there were no deaths. Due to early notification a coordinated investigation was initiated before laboratory subtyping was available. Re-interview of cases identified 10 cases who had not initially reported exposure to the source of the outbreak. Less than one week after the Outbreak Investigation Coordinating Committee was formed, consumption of shredded lettuce from a fast food chain was identified as the likely source of the illnesses and the implicated importer/processor initiated a precautionary recall the same day. CONCLUSION: This outbreak investigation highlights the importance of early notification, prompt re-interviewing and collaboration to rapidly identify the source of an outbreak.

Randomized clinical trial of tetracycline hydrochloride bandage and paste treatments for resolution of lesions and pain associated with digital dermatitis in dairy cattle.

Digital dermatitis is an infectious disease that causes lameness in dairy cattle, a primary welfare concern of the dairy industry. One of the common treatments for this painful hoof disease is through the application of an antibiotic bandage that must be removed following treatment. The objectives of this randomized clinical trial were to determine if topical application of tetracycline hydrochloride in a paste would be as therapeutically effective for the treatment of digital dermatitis as a powdered form of tetracycline hydrochloride held in place by a bandage, and to quantify pain associated with digital dermatitis lesions. Two hundred and fourteen Holstein cow hooves with digital dermatitis lesions were randomly assigned to 1 of 3 treatments: a tetracycline hydrochloride paste, tetracycline hydrochloride powder held in place with a bandage for 2 d, or a negative (untreated) control. Lesions were examined at 2 time periods: 3 to 7 d posttreatment and 8 to 12 d posttreatment to determine healing rates. Nociceptive thresholds were measured using a pressure algometer to quantify the pain at the lesion site. The tetracycline hydrochloride paste was as effective as the powdered bandage treatment in terms of healing rates, with 47.4 and 57.1% hooves healed at 8 to 12 d posttreatment, respectively. Both treatments were more effective than the control, in which no lesions healed 8 to 12 d following initial examination. Mean (±SE) nociceptive thresholds for active, healing, and healed lesions differed, with limb-withdrawal response occurring at 7.45 (±0.67) kg, 12.84 (±1.85) kg, and censored to 25 kg (maximum value of algometer) of force applied, respectively. However, active lesions were not consistently associated with pain, as maximum force was tolerated when applied to 19% of active lesions, perhaps due to variability in stoicism between individual cattle or due to changes in pain during the progression of infection. In conclusion, tetracycline hydrochloride paste was as effective as tetracycline hydrochloride bandage, eliminating the need for bandage removal following treatment application. Digital lesions can be painful during both active and healing stages, suggesting the need for treatment and husbandry interventions for pain mitigation.

Third trimester amniocentesis for diagnosis of inherited bleeding disorders prior to delivery.

X-linked and autosomally inherited bleeding disorders confer a risk of foetal intracranial haemorrhage during delivery. Conventional prenatal diagnosis involving chorionic villus sampling or early amniocentesis is primarily aimed at offering the choice of pregnancy termination. Currently, non-invasive procedures, involving analysis of free foetal DNA in the maternal circulation, are restricted to gender determination, and are of limited value in women at risk of carrying a foetus with a bleeding disorder. These limitations, together with the rising proportion of women shown to be carrying an affected foetus, who decide to continue the pregnancy, have led to the development of prenatal mutation identification via late amniocentesis after 34 weeks of gestation, with the sole aim of directing delivery management. Although this approach has been documented in some cases of potential foetal anomaly, there are no previous reports of its use in women with heritable bleeding disorders. We report a single-centre experience of this technique in managing nine such deliveries. Of these, three showed an affected foetus, five showed an unaffected foetus and in one case no result could be obtained. In the three affected cases and the one with the inconclusive result restrictive birth plans were implemented, whereas the five unaffected cases underwent routine obstetric management; with one delivery necessitating interventions which would have been contraindicated if foetal status had not been determined. Late amniocentesis is a safe technique for guiding delivery management in women with bleeding disorders where the mutation is known.

Call to develop a standard acquisition charge model for kidney paired donation.

We propose a Medicare Demonstration Project to develop a standard acquisition charge for kidney paired donation. A new payment strategy is required because Medicare and commercial insurance companies may not directly pay living donor costs intended to lead to transplantation of a beneficiary of a different insurance provider. Until the 1970s, when organ procurement organizations were empowered to serve as financial intermediaries to pay the upfront recovery expenses for deceased donor kidneys before knowing the identity of the recipient, there existed similar limitations in the recovery and placement of deceased donor organs. Analogous to the recovery of deceased donor kidneys, kidney paired donation requires the evaluation of living donors before identifying their recipient. Tissue typing, crossmatching and transportation of living donors or their kidneys represent additional financial barriers. Finally, the administrative expenses of the organizations that identify and coordinate kidney paired donation transplantation require reimbursement akin to that necessary for organ procurement organizations. To expand access to kidney paired donation for more patients, we propose a model to reimburse paired donation expenses analogous to the proven strategy used for over 30 years to pay for deceased donor solid organ transplantation in America.

Characterisation of von Willebrand factor A1 domain mutants I1416N and I1416T: correlation of clinical phenotype with flow-based platelet adhesion.

BACKGROUND: Type 2M von Willebrand disease (VWD) results from mutations in the A1 domain of von Willebrand factor (VWF) that reduce its platelet-binding function. However, currently employed VWF functional static assays may not distinguish between clinical phenotype. METHODS: Fifteen individuals from five kindreds with VWF-A1 domain mutations I1416T or I1416N, correlated with mild and moderate clinical phenotypes, respectively, were investigated. The mutations were reproduced by site-directed mutagenesis and expressed in HEK293T cells; functional studies of the recombinant mutants, including GPIbα binding using a flow-based assay, were performed. RESULTS: Plasma from all individuals demonstrated discordant reductions in VWF antigen and platelet-binding function in the presence of high-molecular-weight VWF multimers consistent with VWD type 2M. There was lowered expression and secretion of both mutants compared with wild type (WT) recombinant (r)VWF as well as a significant reduction in GPIbα binding. Binding to collagen was normal and electrophoretic analysis demonstrated a similar multimer distribution between the mutant proteins and wt-rVWF. GPIbα binding under flow was also significantly reduced for I1416N and I1416T rVWF. Impairment of GPIbα binding was more marked for I1416N rVWF than I1416T under both static and flow conditions: this was in spite of similar VWF:Ristocetin cofactor (RCo) activities in patient plasma and is consistent with a respective clinical phenotype. CONCLUSIONS: Our findings have established for the first time that I1416N and I1416T are responsible for a type 2M VWD phenotype and demonstrate that quantification of VWF function under shear stress may provide a more accurate measure of clinical severity than the static functional measurements in current diagnostic use.

Standardization of flow cytometry in myelodysplastic syndromes: a report from an international consortium and the European LeukemiaNet Working Group.

Flow cytometry (FC) is increasingly recognized as an important tool in the diagnosis and prognosis of myelodysplastic syndromes (MDS). However, validation of current assays and agreement upon the techniques are prerequisites for its widespread acceptance and application in clinical practice. Therefore, a working group was initiated (Amsterdam, 2008) to discuss and propose standards for FC in MDS. In 2009 and 2010, representatives from 23, mainly European, institutes participated in the second and third European LeukemiaNet (ELN) MDS workshops. In the present report, minimal requirements to analyze dysplasia are refined. The proposed core markers should enable a categorization of FC results in cytopenic patients as 'normal', 'suggestive of', or 'diagnostic of' MDS. An FC report should include a description of validated FC abnormalities such as aberrant marker expression on myeloid progenitors and, furthermore, dysgranulopoiesis and/or dysmonocytopoiesis, if at least two abnormalities are evidenced. The working group is dedicated to initiate further studies to establish robust diagnostic and prognostic FC panels in MDS. An ultimate goal is to refine and improve diagnosis and prognostic scoring systems. Finally, the working group stresses that FC should be part of an integrated diagnosis rather than a separate technique.