dossier microdacyn

Transcription

dossier microdacyn

Microdacyn
Wound Care
www.sdomedical.com
Composición Microdacyn Wound Care® Solución
Compuestos
Fórmula química
Concentración (%)
Agua
H2O
99,9
Cloro libre disponible
Ácido hipocloroso
HOCl
Hipoclorito de sodio
NaOCl
Cloruro de sodio
NaCl
Carbonato sódico
Na2CO3
Hidróxido sódico
NaOH
Peróxido de hidrógeno
H2O2
Dióxido de cloro
Ozono
PH
ClO2
O3
6,2-7,8
Composición Microdacyn Hidrogel®
Sodium Magnesium Lithium Fluorsilicate
Polydimethylsiloxane, trimethylsiloxy
Sodium Phosfhate
Sodium Chloride
Hipochlorous Acid
Sodium Hypochlorite
Elecrolysed Water
Ph
Gelling
Film forming
NaH2PO4
NaCL
HOCL
NaOCL
Vehicle
6,2-7,8
TABLA DE ACCION ANTIMICROBIANA DE MICRODACYN
MICROORGANISMO
Estafilococos aureus Meticilino Resistente
(MRSA)
Enterococos faecium resistente a vancomicina(VRE-MDR)
Enterococos faecalis resistente a vancomicina
(VRE)
Estafilococos epidermis
Estafilococos haemolyticus
Estafilococos hominis
Estafilococos saprophyticus
Estreptococos pyogenes
Micrococo luteus
Bacteria Escherichia coli
GramAcinetobacter baummannii
Negativa Bacteroides fragilis
Enterobacter aerogenes
Haemophilius influenzae
Klebsiella oxytoca resistente a MDR
Klebsiella pneumonia
Proteus mirabilis
Pseudomonas aeruginosa
Serratia marcescens
Levadura Candida albicans
TrichophytuonMentagrophytes
Bacteria
GramPositiva
TIEMPO DE
% DE
ELIMINACIÓN DISMINUCIÓN
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
30 segundos
MDR: Fármaco multiresistente
MRSA: resistente a la meticilina Estafilococos aureus
VRE Enterococo resistente a la vancomicina.
99.999
99.999
99.999
99.999
99.999
99.996
99.998
99.999
99.996
99.999
99.999
99.999
99.997
99.999
99.999
99.999
99.993
99.999
99.999
99.999
99.998
99.999
99.999
99.999
Virus Testing Summary of all strains tested with Microcyn. All the virus listed below had complete inactivation by Microcyn
Name
Oculus Source
HIV-1
ATS- TR31061-02
Influenza A
Apptec - TR32003
Microcyn Viral
Inactivation
>3.75 log 10min
EPA carrier test
>5.09 log 1 min
Type
Enveloped
Capsid
Group IV +ssRNA
Yes
Yes
Yes
Helical
No
icosahedral
Yes
Helical
No
icosahedral
Retroviridae
Group V –ssRNA
Orthomyxoviridae
Parvovirus
Human Coronavirus
Rhinovirus type 37
ATS -TR31061-04
ATS – 31285-01
ATS- TR31286-01
>5 log 15 min
EPA carrier test
>3 log 15 sec, 30 sec
>3.25 log 1 min
1% soil
2.75 log 15 sec
3.25 log 30 sec
2.75 log 1 min
>4.75 log 5 min
1% soil
Group II ssDNA
Parvoviridae
Group IV +ssRNA
Coronaviridae
Group IV +ssRNA
Picornaviridae
Name
Oculus Source
FVC – ATCC 2280
Feline calcivirus –
surrogate for Norwalk
Virus.
Influenza A H1N1
Johannesburg/82/96
Flu A H3N1
Sydney/5/97
HSV1
MacIntyre-92
HSV2
clinical-87
Polio 1
lab standard
Rhino 1A
clinical-75
RSV Human respiratory
syncytial virus
clinical; no date available
WNV – West Nile Virus
NY-99
Hepatitis B
Taketa-Grahm, Gutierrez,
Thatcher.
Microcyn Viral Log
Reductions
/Inactivation
5 log 1 min
6 log 5 min
Thatcher.
Thatcher.
Thatcher.
Thatcher.
Thatcher.
Thatcher.
Thatcher.
7 log 1 min
7 log 5 min
7 log 1 min
7 log 5 min
6 log 1 min
6 log 5 min
6 log 1 min
6 log 5 min
4-6 log 1 min - TBD
Thatcher.
NA
7 log 1 min
8 log 5 min
Not Tested.
Type
Enveloped
Capsid
Group IV +ssRNA
No
Spherical
Yes
Helical
Yes
Helical
Yes
icosahedral
Yes
icosahedral
No
icosahedral
No
icosahedral
Yes
Yes
Yes
spherical
Yes
icosahedral
Caliciviridae
Group V –ssRNA
Orthomyxoviridae
Group V –ssRNA
Orthomyxoviridae
Group I dsDNA
Herpesviridae
Group I dsDNA
Herpesviridae
Group IV +ssRNA
Picornaviridae
8 log 1 min
8 log 5 min
4 log 1 min
4 log 5 min
Group IV +ssRNA
Picornaviridae
Group V –ssRNA
Paramyxoviridae
Group IV +ssRNA
Flaviviridae
Group VII dsDNA-RT
Hepadnaviridae
Filoviridae viral family of RNA viruse
Eficacia , seguridad
y compatibilidad de la
tecnología Microcyn ®
Introducción
Este documento proporciona una visión general del rendimiento, seguridad y compatibilidad de los resultados de un estudio
relacionado con la tecnología Microcyn™ y enumera las características generales de la tecnología Microcyn™. Esta tecnología es
la base de aplicaciones de productos individuales, como Dermacyn™ Wound Care, Desinfectante Oculus Microcyn 60 etc.
Descargo de responsabilidad: La siguiente información no debe interpretarse como una guía de aplicación para los distintos
productos. Las normativas son específicas para la aplicación de cada producto y y se requiere una aprobación normativa
individual (por ejemplo, la certificación CE según la Directiva de Dispositivos Médicos 93/42/CEE). Por favor, consulte las
instrucciones de uso del producto correspondientes para las aplicaciones específicas del producto.
Tecnología Patentada
Eficacia
Bactericida (ensayo en portador)
Las características bactericidas de Microcyn™ se ensayaron utilizando el método
de Dilución de Uso AOAC, un ensayo en portador, según los requisitos de las
directrices de Estados Unidos EPA DIS/TS5-01. Los organismos analizados
fueron Pseudomonas aeruginosa (ATCC nº 15442), Staphylococcus aureus
(ATCC nº 6538) y Salmonella choleraesuis (ATCC nº 10708). Se utilizaron 60
muestras por organismo para probar las propiedades bactericidas de Microcyn™.
Cada muestra consistió en un cilindro de acero inoxidable con una película de las
bacterias específicas secada sobre el mismo. Los cilindros fueron expuestos
durante 10 minutos a Microcyn™ y luego transferidos a recipientes con un
medio de subcultivo. Tras una incubación de 48 horas a 35 °C ± 2 °C, las
muestras fueron observadas en busca de bacterias supervivientes.
Conclusión: para cada organismo, el número de bacterias que sobrevivieron fue
1 sobre 60 muestras o menos, cumpliendo así con los requisitos EPA. [ATS
Labs., Estados Unidos]
Bactericida (Prueba en suspensión)
Las propiedades bactericidas de Microcyn™ se evaluaron de acuerdo con el
borrador de norma BS EN 13727:1999, un ensayo en suspensión. Para cada
organismo, se prepararon suspensiones bacterianas con una concentración entre
1,5 x 108 y 10 x 5,08 /ml para Pseudomonas aeruginosa (ATCC nº 15442),
Staphylococcus aureus (ATCC nº 6538) y Enterococcus hirae (ATCC nº 10541).
Se añadió 1 ml de cada una de las suspensiones bacterianas a 8 ml de
Microcyn™ junto con 1 ml de albúmina bovina (0,03 g/l) como sustancia
interferente. Las mezclas de ensayo se mantuvieron a 20 °C durante 15 minutos
y luego se cultivaron en placas de agar tripticasa-soja (TSA). Después de 48
horas de incubación a 36 °C ± 1 °C, se observó el crecimiento de las placas.
Conclusión: para los tres organismos ensayados se consiguió una reducción de
la carga bacteriana de más de 105, en de un tiempo de contacto de 15 minutos
con Microcyn™ en cinco réplicas realizadas en dúplex. [Micromed Laboratories
lnc., Estados Unidos]
Cepas resistentes a bactericidas (MRSA)
En este ensayo se probaron las características bactericidas de Microcyn™ contra
Staphylococcus aureus resistentes a la Meticilina (ATCC nº 33592; MRSA),
según las directrices DIS/TSS-05. Utilizando el método de dilución de uso
AOAC, 20 penicilindros con una película bacteriana secada sobre ellos se
sumergieron durante 10 minutos en Microcyn™. Tras la exposición, los cilindros
se transfirieron a un medio de cultivo neutro y se incubaron durante 48 horas a
35 - 37 °C. Después de la incubación, las muestras fueron observadas en busca
de bacterias supervivientes.
Conclusión: en las condiciones de esta investigación, ninguna de las 20
muestras mostró crecimiento, lo que demuestra el cumplimiento de los requisitos
EPA. [ATS Labs., Estados Unidos]
Cepas resistentes a bactericidas (VRE)
En esta ensayo se probaron las características bactericidas de Microcyn™ contra
Enterococcus faecalis resistentes a la vancomicina (ATCC nº 51299; VRE),
según las directrices DIS/TSS-05. Utilizando el método de dilución de uso
AOAC, 20 penicilindros con una película bacteriana secada sobre ellos se
sumergieron durante 15 minutos en Microcyn™. Tras la exposición, los cilindros
se transfirieron a un medio de cultivo neutro y se incubaron durante 48 horas a
35 - 37 °C. Después de la incubación, las muestras fueron observadas en busca
de bacterias supervivientes.
Conclusión: en las condiciones de esta investigación, ninguna de las 20
muestras mostró crecimiento, lo que demuestra el cumplimiento de los requisitos
EPA. [ATS Labs., Estados Unidos]
Tuberculicida (Mycobacterium)
En este ensayo se probaron las propiedades bactericidas de Microcyn™ contra
Mycobacterium bovis (O'T nº 105401) según las directrices EPA DIS/TSS-06
para pruebas de tuberculicidas. Se prepararon suspensiones bacterianas con una
carga de un 5% de materia orgánica (suero fetal bovino). Se inoculó un solo tubo
con la suspensión bacteriana, seguido de exposición a Microcyn™ 5 minutos.
Conclusión: durante la incubación durante 20 días a 35 °C ± 2 °C no se
observó crecimiento y se concluyó que Microcyn™ cumple con los requisitos
tuberculicidas de esta investigación. [ATS Labs., Estados Unidos]
Virucida
Microcyn™ fue ensayado para determinar sus características virucidas contra el
virus de inmunodeficiencia humana tipo I (HN-D, cepa HTLV-IIIB, según las
directrices EPA DIS/TS5-07 de EE.UU. El virus se aplicó como una película
seca sobre placas de Petri de vidrio estériles, seguido por exposición a
Microcyn™ durante 10 minutos. Posteriormente, el virus se separó de la
sustancia de ensayo por filtración en gel y se tituló mediante diluciones en serie
para el ensayo de inactivación.
Conclusión: por grupos de dilución (7 grupos: de 10-1 "a 10-7), se observaron 8
muestras y no se detectó ninguna actividad infecciosa. La reducción en el título
viral fue 3,75 log 10 para todas las muestras. En las condiciones de esta
investigación, Microcyn ™ demostró la inactivación completa del HIV-I tras un
tiempo de exposición de 10 minutos, de acuerdo con los requisitos para
virucidas definidos por la EPA. [ATS Labs., Estados Unidos]
Fungicida
Microcyn™ fue ensayado para determinar sus características fungicidas contra el
hongo Tichophyton mentagrophytes (ATCC nº 9533). El ensayo se realizó de
acuerdo con las directrices EPA DIS/TS5-06, utilizando el método de dilución de
uso AOAC. Las células fúngicas se aplicaron en forma de película seca en
soportes de acero inoxidable y se expusieron durante 10 minutos a Microcyn™,
con una carga orgánica de un 5% (suero fetal bovino). Después de la exposición
los portadores se transfirieron a un medio de subcultivo neutralizante y se
ensayaron en busca de supervivientes después de la incubación.
Conclusión: En las condiciones de este experimento, Microcyn™ resultó
fungicida frente a Tichophyton mentagrophytes tras una exposición de diez
minutos a 20 °C. [ATS Labs., Estados Unidos]
Esporicida
Microcyn™ fue ensayado para determinar sus características esporicidas contra
esporas Bacillus atrophaeus (ATCC nº 6633). El ensayo se realizó de
conformidad con el borrador de la norma BS EN 14347:2002. Se preparó una
solución de esporas con una concentración de esporas de 108-109 / ml a partir de
una suspensión de esporas comercial. Las muestras de ensayo contenían 1 ml de
la solución de esporas, 1 rnl de agua y 8 ml de Microcyn™. La solución de
esporas se expuso durante 15 minutos a Microcyn™, después de la exposición
las muestras se cultivaron y se incubaron durante cuatro días a 36 ± 1 ºC.
Conclusión: En las condiciones de este experimento Microcyn ™ resultó
esporicida contra esporas de Bacillus subtilis. La reducción media de las
esporas fue de log 6.5, cumpliendo de este modo los requisitos del método de
ensayo aplicado. [Micromed Laboratories lnc., Estados Unidos]
Pioneros en innovación en ciencias de la vida y tecnologías disruptivas que están revolucionando la industria
Seguridad / Biocompatibilidad
Genotoxicidad
Microcyn "fue evaluado en cuanto a su potencial genotóxico según la directiva
474 de la OCDE (Ensayo de micronúcleos en eritrocitos de mamíferos), según la
norma ISO 10993-3:2003. La sustancia ensayada se inyectó por vía
intraperitoneal en una población de ensayo de 5 machos y 5 hembras de ratón. La
dosis aplicada fue 12,5 ml de Microcyn™ / kg de peso corporal durante 2 días
consecutivos. Después de la inyección, los ratones fueron observados en cuanto a
su salud en general y reacciones adversas. Al tercer día, los ratones finalizaron el
tratamiento y se determinó la relación entre eritrocitos policromáticos y
normocromáticos. Además, se examinó la incidencia de micronucleación en los
eritrocitos policromáticos.
Conclusión: las observaciones clínicas no revelaron signos de toxicidad durante
el estudio. El examen microscópico de frotis de médula ósea de los animales
utilizados mostró ausencia de toxicidad en los animales tratados comparable a
la de los resultados encontrados en el ensayo negativo, en el que se utilizó un
0,9% de solución de NaCl. La misma comparación se hizo para la
micronucleación de los eritrocitos policromáticos. En los animales tratados y en
los animales del ensayo negativo, este número no aumentó, mostrando la
ausencia de efectos mutagénicos. En base a este estudio, se concluyó que
Microcyn™ no causa efectos genotóxicos. [Biomatech SAS, Francia]
Citotoxicidad
Esta prueba se ejecutó de acuerdo con la norma ISO 10993-5:1999 para
determinar el potencial de Microcyn™ de causar citotoxicidad. Se colocó un
disco de filtro con 0,1 ml de Microcyn™ sobre una superficie agarosa,
superponiendo directamente una monocapa de fibroblastos de ratón (L-929). Las
muestras preparadas se observaron en busca de daños citotóxicos al cabo de 24
horas de incubación a 37 ºC en presencia de un 5% de CO 2. Las observaciones se
compararon con muestras de control positivas y negativas.
Conclusión: las muestras que contenían Microcyn™ no presentaron ninguna
evidencia de lisis celular o toxicidad, mientras que los controles positivos y
negativos fueron según lo previsto. En base a este estudio se concluyó que
Microcyn™ no genera efectos citotóxicos. [Namsa, Estados Unidos]
Sensibilización de la piel
Se realizó un estudio de sensibilización de la piel en 15 machos y 15 hembras de
cobaya albino de pelo corto para determinar si Microcyn™ produce alguna
reacción de sensibilización. La prueba se realizó según las directrices de EE.UU.
EPA OPPTS 870.2600 y es necesaria para el cumplimiento de la norma ISO
10993-10:2002. En un grupo de control se incluyeron 5 animales de cada sexo.
Estos animales permanecieron sin tratar durante cinco semanas, y posteriormente
se les administró una dosis única de 0,4 ml de Microcyn™. Los animales
restantes fueron tratados una vez por semana durante tres semanas con 0,4 ml de
Microcyn™, descansaron durante 2 semanas y en la quinta semana del
experimento se les administró, una vez más, 0,4 ml de Microcyn™.
Conclusión: no se observó irritación de la piel en los animales del grupo de
control. Tampoco se observó ninguna irritación en el otro grupo. Debido a la
ausencia de respuesta cutánea, se llegó a la conclusión de que Microcyn no es
sensibilizante de la piel. [Stillmeadow, Inc., Estados Unidos]
Irritación cutánea
Se realizó un ensayo para cumplir con la norma ISO 10993-10:2002 a fin de
determinar el potencial de irritación de la piel de Microcyn™. En esta prueba, en
tres conejos blancos de Nueva Zelanda se aplicó una dosis de 0,5 ml de
Microcyn™ en los puntos de ensayo especificados en el animal. La sustancia de
ensayo se administró en una gasa y se fijó a los puntos de ensayo para producir 4
horas de contacto con la piel. La piel tratada se observó durante 72 horas a
intervalos de tiempo regulares y se comparó con puntos de piel no tratada en el
mismo animal. Los animales fueron observados en cuanto a formación de edema,
formación de eritema o escaras.
Conclusión: todos los animales fueron encontrados sanos durante todo el
estudio. No se detectó irritación de la piel durante todo el periodo de estudio. En
base a este estudio, se concluye que la irritación cutánea de Microcyn™ es
despreciable. [Northview Pacífic Laboratories Inc., Estados Unidos]
Irritación ocular
Se efectuó un ensayo de irritación ocular para cumplir con la norma ISO 1099310:2002 a fin de determinar el potencial de irritación ocular de Microcyn™. En
esta prueba, en tres conejos blancos de Nueva Zelanda se aplicó una dosis de 0,1
ml de Microcyn™ en el ojo derecho de cada animal. El ojo izquierdo se dejó sin
tratar y sirvió como control. Tras la aplicación de la sustancia de ensayo, los ojos
se examinaron a intervalos de tiempo regulares para ver si había irritación.
Conclusión: todos los animales fueron encontrados sanos durante todo el
estudio. No se detectó irritación ocular durante todo el período de estudio. En
base a este estudio, se concluye que Microcyn™ no causa irritación ocular.
[Northview Pacífic Laboratories Inc., Estados Unidos]
Toxicidad oral aguda
Se evaluó el potencial de toxicidad oral aguda de Microcyn™ cuando se
administra como una dosis por sonda a un nivel de 5000 mg / kg de peso
corporal para una población de ensayo consistente en 3 ratas albinas hembras. El
ensayo se realizó según el reglamento EPAOPPTS 870.1100 de EE.UU. a fin de
cumplir con la norma ISO 10993-11:1996. Los animales tratados recibieron 4,98
ml de Microcyn™/kg de peso corporal y se observaron durante 14 días.
Conclusión: no se detectó mortalidad ni signos de toxicidad clínicos o de
conducta. La necropsia realizada al final del estudio no reveló anomalías
observables. En base a este estudio, se concluye que Microcyn™ no causa
toxicidad oral. [Stillmeadow, Inc., Estados Unidos]
Toxicidad dérmica aguda
La prueba fue ejecutada de acuerdo con el reglamento EPAOPPTS 870.1200 de
EE.UU. para determinar la toxicidad dérmica aguda y la irritación cutánea
relativa de Microcyn™, según se requiere para el cumplimiento de la norma ISO
10993-11:1996. Microcyn™ se aplicó a la piel intacta de 5 machos y 5 hembras
de conejo albino. La dosis de Microcyn™ fue de 5050 mg/kg de peso corporal,
aplicada sobre la zona dorsal del tronco. El área de ensayo posteriormente se
cubrió con una gasa. Después 24 horas, el área se enjuagó con agua para eliminar
todo resto de sustancia de ensayo.
Conclusión: las observaciones realizadas durante 14 días después de la
aplicación de la sustancia de ensayo no mostraron signos de irritación dérmica
en los animales en ningún momento. Todos los animales tenían aspecto normal
durante el tiempo del estudio y la necropsia realizada a la finalización del
estudio no reveló anomalías observables. En base a este estudio, se concluye que
Microcyn™ no genera toxicidad dérmica. [Stillmeadow, Inc., Estados Unidos]
Toxicidad por inhalación aguda
El ensayo se realizó según el reglamento EPAOPPTS 870.1300 para determinar
la toxicidad aguda por inhalación de Microcyn™, según se requiere para el
cumplimiento de la norma ISO 10993-11:1996. Microcyn™ se aplicó en forma
de aerosol a 5 machos y 5 hembras de rata albina. La dosis de Microcyn™ fue de
2,16 mg / l de aire, aplicada por inhalación nasal durante 4 horas consecutivas.
Conclusión: las observaciones realizadas durante 14 días después de la
aplicación de la sustancia ensayada no revelaron signos de actividad
farmacológica o tóxica. Todos los animales sometidos al ensayo parecían
normales durante el periodo del estudio, y la necropsia realizada a la
finalización del estudio no revelaron anomalías observables. En base a este
estudio, se concluye que Microcyn™ no causa efectos tóxicos por inhalación.
[Stillmeadow, Inc., Estados Unidos]
Estudio de seguridad y eficacia de tratamiento para heridas cutáneas
Se realizó un estudio con 16 ratas para evaluar la tolerabilidad local de
Microcyn™ y sus efectos sobre la histopatología del lecho de las heridas en un
modelo de cicatrización de heridas dérmicas de espesor completo. Secciones
cutáneas teñidas con tricrómico de Masson y secciones teñidas con colágeno de
tipo II de heridas quirúrgicas tratadas con Microcyn™ o con solución salina
fueron evaluadas por un patólogo veterinario titulado. Las secciones se evaluaron
en cuanto a la cantidad de expresión de colágeno tipo 2 como manifestación de
la proliferación del tejido conjuntivo, la morfología de los fibroblastos y la
formación de colágeno, la presencia de neoepidermis en la sección transversal, la
inflamación y el grado de ulceración cutánea.
Conclusión: los resultados sugieren que Microcyn™ fue bien tolerado en ratas
administrado en las condiciones de este estudio, no hubo lesiones
histopatológicas relacionadas con el tratamiento en las secciones de piel, ni en
el lado izquierdo ni en el derecho (tratados con Microcyn™ y solución salina
respectivamente). No hubo diferencias histopatológicas relevantes entre las
heridas tratadas con solución salina y las tratadas con Microcyn™, lo que
indica que el tratamiento con Microcyn™- fue bien tolerado. No hubo
diferencias significativas en la expresión de colágeno tipo 2 entre las heridas
tratadas con solución salina y las tratadas con Microcyn™, incluyendo que
Microcyn™ no tiene efecto adverso sobre los fibroblastos o la elaboración de
colágeno bajo las condiciones de este estudio.
Compatibilidad con materiales
Se realizó un ensayo de corrosión de acuerdo con los requisitos de la norma
ASTM G60-01. Los materiales ensayados fueron: PVC, acero inoxidable 303,
acero inoxidable 316, aluminio HA, titanio, aluminio, poliéster, teflón,
polipropileno, caucho natural, HDPE, neopreno, nylon, silicona, policarbonato,
poliuretano, polietileno de baja densidad, polisulfona, UHMWP y acero
inoxidable 416. Se prepararon fragmentos representativos a partir de los
materiales de ensayo y se pusieron en contacto diario durante 30 minutos con
Microcyn™ durante 20 días consecutivos. Durante la prueba y al final de la
misma, los fragmentos se examinaron en cuanto a su aspecto visual y el peso.
Conclusiones: Los metales industriales como el aluminio sin tratar y el acero
inoxidable 416 mostraron signos de corrosión después de haber estado en
contacto con Microcyn™ durante 20 días. Todos los demás materiales
mantuvieron su aspecto visual y su peso a niveles constantes. En base a los
resultados de este estudio se determinó que Microcyn™ es compatible y no
corrosivo con todos los materiales ensayados, excepto aluminio y acero
inoxidable 416. Con estos dos últimos, se concluye que Microcyn™ tiene una
corrosividad similar a la del agua [Micromed Laboratories Inc., EE.UU.]
Control de calidad
Microcyn™ se fabrica conforme a la norma ISO 13485:2003. Todos los lotes de
producto fabricados son ensayados en la planta de producción en cuanto a
rendimiento antimicrobiano utilizando el método de suspensión contra esporas
de Bacillus subtilis (una reducción mínima de 106 es el requisito aplicable).
Además, se realiza un control del producto en cuanto a pH, potencial redox y
niveles de cloro libre disponibles como parte del control de calidad en el proceso
de producción.
Pruebas de estabilidad
Se ha demostrado que Microcyn™ se mantiene estable y eficaz cuando envejece.
La composición química del producto y la eficacia antimicrobiana tras
envejecimiento acelerado han sido ensayadas según las directrices pertinentes.
En base a estos datos, el producto tiene una vida útil de un (1) año.
™
AGUA ELECTROLIZADA H2O
CLORURO DE SODIO
CLNA
ACIDO HIPOCLOROSO HOCL
HIPOCLORITO DE SODIO NaOCL
DATOS CLÍNICOS
Indicaciones terapéuticas
Microdacyn60™ Wound Care es una solución electrolizada indicada para utilizarse en el
desbridamiento, la irrigación y la hidratación de las heridas, úlceras, cortes abrasiones y
quemaduras de naturaleza tanto aguda como crónica. Microdacyn60™ presenta también un
efecto antiinflamatorio directo sobre la herida. Es aplicable en cavidades como la boca,
nariz y oído. El Ácido Hipocloroso y el Hipoclorito Sódico son sustancias auxiliares que
pueden tener un efecto antimicrobiano local. Al reducir la cantidad de microorganismos y
contribuir a mantener un entorno húmedo, permite al organismo realizar su propio proceso
de cicatrización. Microdacyn60 Wound Care puede aplicarse de manera generalizada como
parte de un tratamiento integral de heridas.
MANIPULACIÓN
Microdacyn60™ Wound Care es biocompatible para su uso indicado, no irrita la piel, los
ojos ni la garganta humanos, y no es un sensibilizador de la piel. No se requieren
precauciones de manipulación especiales. Microdacyn60™ Wound Care está preparado
para su uso, no es necesario mezclarlo ni diluirlo. Aplique Microdacyn60™ Wound Care
directamente a la zona afectada. Utilice Microdacyn60™ en cada cambio de apósito de la
herida. Puede aplicarse de manera generalizada como parte de un tratamiento integral de
heridas.
CONSERVACION
Microdacyn60™ Wound Care debe conservarse en su recipiente hermético original a
condiciones ambiente. Conservar a temperatura ambiente y prevenir el congelamiento. No
es inflamable. Después del uso, el recipiente debe cerrarse de nuevo antes de guardarlo.
ESTABILIDAD
Hasta que se abre, la estabilidad y la esterilidad de Microdacyn60 Wound Care está
garantizada hasta la fecha de caducidad (el año y el mes de caducidad AAAAMM se indican
en el frasco). Cuando lo abra, anote la fecha en el frasco, en el apartado “fecha de apertura”.
La estabilidad y la esterilidad de la solución no utilizada está garantizada por un máximo de
30 días después de la apertura.
™
MODO DE EMPLEO:
Microdacyn60™ Wound Care está preparado para su uso, no es necesario mezclarlo ni
diluirlo. Aplique Microdacyn60™ Wound Care directamente a la zona afectada. Utilice
Microdacyn60™ en cada cambio de apósito de la herida. La saturación del apósito con
Microdacyn60 Wound Care facilitará la retirada del apósito.
TRATAMIENTO
Empape/sature el apósito con Microdacyn60 Wound Care en cada cambio de apósito, como
y cuando sea necesario. La inmersión se permite un máximo de 15 minutos diarios durante
el tratamiento inicial.
ADVERTENCIAS Y ASPECTOS QUE HAY QUE TENER EN CUENTA
Si el precinto a prueba de manipulación indebida está roto, no utilice el producto.
Utilice siempre solución nueva, no reutilice el producto.
Uso externo, no apto para inyección o consumo.
No utilice este producto si es alérgico a sus ingredientes.
No utilice Microdacyn60 Wound Care junto con otras soluciones tópicas sin el
asesoramiento de un profesional sanitario.
En caso de heridas graves, profundas, o si le preocupa algún otro aspecto del tratamiento
consulte con un profesional sanitario.
Si presenta signos de infección ( aumento de dolor, hemorragia, pus etc) o si la herida no
muestra signos de cicatrización, consulte a un profesional sanitario.
Si presenta una reacción adversa consulte con el profesional sanitario.
Además de Microdacyn60 Wound Care en algunos casos puede ser necesario el uso de
antibióticos sistémicos o locales.
Mantenga fuera del alcance y de la vista de los niños.
ELIMINACION
La solución no es tóxica y es segura para el medio ambiente. No se requieren condiciones
de eliminación especiales.
ESTERILIDAD
La esterilidad depende de los conservantes que contiene el líquido.
MICRODACYN60™ WOUND CARE SOLUCION
PRESENTACIONES
!
™
AGUA ELECTROLIZADA H2O
CLORURO DE SODIO
CLNA. SODIO MAGNESIO FLUORSILICATO
ACIDO HIPOCLOROSO HOCL HIPOCLORITO DE SODIO NaOCL
DATOS CLÍNICOS
Indicaciones terapéuticas
Microdacyn60™ Wound Care es un hidrogel electrolizado indicado para utilizarse en el
desbridamiento y la hidratación de las heridas, úlceras, cortes abrasiones y quemaduras de
naturaleza tanto aguda como crónica. Microdacyn60™ presenta también un efecto
antiinflamatorio directo sobre la herida. Es aplicable en cavidades como la boca, nariz y
oído. El Ácido Hipocloroso y el Hipoclorito Sódico son sustancias auxiliares que pueden
tener un efecto antimicrobiano local. Al reducir la cantidad de microorganismos y contribuir
a mantener un entorno húmedo, permite al organismo realizar su propio proceso de
cicatrización. Microdacyn60 Wound Care puede aplicarse de manera generalizada como
parte de un tratamiento integral de heridas.
MANIPULACIÓN
Microdacyn60™ hidrogel es biocompatible para su uso indicado, no irrita la piel, los ojos ni
la garganta humanos, y no es un sensibilizador de la piel. No se requieren precauciones de
manipulación especiales. Microdacyn60™ hidrogel está preparado para su uso, no es
necesario mezclarlo ni diluirlo. Aplique Microdacyn60™ hidrogel directamente a la zona
afectada. Utilice Microdacyn60™ hidrogel en cada cambio de apósito de la herida. Puede
aplicarse de manera generalizada como parte de un tratamiento integral de heridas.
CONSERVACION
Microdacyn60™ hidrogel debe conservarse en su recipiente hermético original a
condiciones ambiente. Conservar a temperatura ambiente y prevenir el congelamiento. No
es inflamable. Después del uso, el recipiente debe cerrarse de nuevo antes de guardarlo.
ESTABILIDAD
Hasta que se abre, la estabilidad y la esterilidad de Microdacyn60 hidrogel está garantizada
hasta la fecha de caducidad (el año y el mes de caducidad AAAAMM se indican en el
frasco). Cuando lo abra, anote la fecha en el frasco, en el apartado “fecha de apertura”. La
estabilidad y la esterilidad de la solución no utilizada está garantizada por un máximo de 30
días después de la apertura.
™
C.N.172398.7
MODO DE EMPLEO:
Microdacyn60™ hidrogel está preparado para su uso, no es necesario mezclarlo ni diluirlo.
Aplique Microdacyn60™ hidrogel directamente a la zona afectada. Utilice Microdacyn60™
en cada cambio de apósito de la herida. La saturación del apósito con Microdacyn60
hidrogel facilitará la retirada del apósito.
TRATAMIENTO
Limpie y seque el área. Aplique inmediatamente una capa delgada de Microdacyn60
hidrogel en la zona afectada. Utilice Microdacyn60 hidrogel una o dos veces al día y en
cada cambio de apósito, como y cuando sea necesario. Cubra con un apósito o vendaje.
ADVERTENCIAS Y ASPECTOS QUE HAY QUE TENER EN CUENTA
Si el precinto a prueba de manipulación indebida está roto, no utilice el producto.
Utilice siempre solución nueva, no reutilice el producto.
Uso externo, no apto para inyección o consumo.
No utilice este producto si es alérgico a sus ingredientes.
No utilice Microdacyn60 hidrogel junto con otras soluciones tópicas sin el asesoramiento de
un profesional sanitario.
En caso de heridas graves, profundas, o si le preocupa algún otro aspecto del tratamiento
consulte con un profesional sanitario.
Si presenta signos de infección (aumento de dolor, hemorragia, pus etc) o si la herida no
muestra signos de cicatrización, consulte a un profesional sanitario.
Además de Microdacyn60 hidrogel en algunos casos puede ser necesario eln uso de
antibióticos sistémicos o locales.
Si presenta una reacción adversa consulte con el profesional sanitario.
Mantenga fuera del alcance y de la vista de los niños.
ELIMINACION
Microdacyn60 hidrogel no es tóxico y es segura para el medio ambiente. No se requieren
condiciones de eliminación especiales.
ESTERILIDAD
La esterilidad depende de los conservantes que contiene el líquido.
Microcyn Technology ¿QUE ES?
DISRRUPTIVE TECHNOLOGY
La Tecnología Microcyn® se fabrica en Estados Unidos, está registrada y regulada por la
compañía Oculus Innovative Sciences, Inc.
La tecnología patentada Microcyn® mimetiza la misma composición en oxigeno y cloro
que fabrican los neutrófilos del sistema inmunitario del cuerpo humano. Los neutrófilos
son las células blancas más abundantes en los humanos y forman parte integral del
sistema inmunitario.
Los productos basados en la tecnología Microcyn® son tan seguros como la solución
salina, biocompatibles, y estables, y han demostrado en una amplia variedad de
investigaciones y estudios clínicos su capacidad de matar una amplia gama de
patógenos, incluyendo cepas resistentes a algunos antibióticos ( incluyendo MRSA y
VRE), virus, hongos y esporas, a la vez que reducen la inflamación y incrementan el
aporte sanguíneo a los tejidos, todo ello con un 100% de seguridad y no toxicidad para
los tejidos y células humanas.
Los productos basados en la tecnología Microcyn® pueden ser utilizados en la nariz, ojos
y boca.
La tecnología Microcyn® tiene aprobaciones legales gubernamentales globales
incluyendo múltiples aprobaciones de la F.D.A. en EEUU, múltiples aprobaciones de la
CE, y varias aprobaciones de la E.P. A. en Estados Unidos; además de aprobaciones de
los gobiernos de Canadá, México, Emiratos Árabes, Kuwait, Arabia Saudí, Iraq, Jordania,
y varios países Norte Africanos.
Es esta seguridad, efectividad, y no toxicidad, junto con su amplia eficacia en el mundo de
uso médico como desinfectante, germicida, bactericida, tuberculicida, esporicida y virucida
la que le ha proporcionado su revolucionario reconocimiento mundial.
Microdacyn® es un producto de alto desarrollo científico ampliamente utilizado a nivel
hospitalario, y también como desinfectante en cualquier superficie dura inanimada no
porosa.
Se fabrica en Estados Unidos por una compañía registrada y regulada por del
Departamento de Salud y Servicios Humanos Administración de Alimentos y
Medicamentos (FDA) , Oculus Innovative Sciences , la cual ha obtenido la certificación
ISO 13485:2003 ,y la TNO Certification BV, que otorga un instituto independiente
reconocido por el Consejo Holandés de Acreditación.
MECANISMO DE ACCIÓN. COMO ACTUA MICRODACYN®
En el mundo de la infección, los científicos han desarrollado una tecnología global que
mimetiza eficazmente la acción química del mecanismo de defensa del cuerpo humano.
La Tecnología Microcyn® es tan segura como la solución salina, sin ninguna toxicidad
para el cuerpo humano, pero puede erradicar bacterias y virus de cualquier tipo, en
cuestión de segundos.
Esta tecnología química basada en la oxidación y la electrólisis es la plataforma básica de
eficacia que se encuentra detrás de todos los productos de la gama Microdacyn® . A partir
de agua purificada y solución salina, cuando la corriente eléctrica pasa a través del agua
purificada, los átomos de hidrógeno y oxígeno de la molécula de agua se dividen en iones
de hidrógeno con carga positiva y iones hidróxido de carga negativa. Dado que estos
iones ya no son estables, buscan hacia fuera otros electrones que puedan estabilizarlos.
La solución resultante, súper oxidada, es una “asesina” potente de los organismos
unicelulares como las bacterias, virus y otros microorganismos que son potencialmente
letales para los seres humanos y el medio ambiente. Cuando Microdacyn® entra en
contacto con microorganismos unicelulares, los iones en alta concentración, corren hacia
la pared celular bacteriana, donde la concentración de iones es menor y por ósmosis
rompen la pared celular (bacteriana o viral) hidratandola hasta que la célula estalla y
explota eliminando así cualquier posibilidad de mutación.
El avance tecnológico de Oculus Innovative Sciences es que ha sido capaz de embotellar
estos iones inestables, el oxígeno y el cloro que forma de manera natural, manteniendo el
ph de la solución neutro, por lo que es inofensivo para los tejidos sanos.
Esta es la misma forma de Cloro que los neutrófilos (células blancas de la sangre) crean
naturalmente en el cuerpo durante el metabolismo para promover el sistema
inmunológico. En nuestro organismo contamos con varios litros de esta forma de cloro, el
cual forma parte esencial de nuestro sistema inmunitario y acelera la respuesta de
curación ante una infección.
De esta forma la tecnología Microcyn® ha adquirido su revolucionario posicionamiento
como líder global en el tratamiento de la infección, y el sobrenombre de “El sistema
inmunológico humano dentro de una botella”.
Esta solución tiene una estabilidad mínima de 24 meses.
El diagrama inferior muestra como los iones inestables y altamente concentrados en la
solución Microcyn, situada fuera de una bacteria o virus quiere ir dentro de la célula donde
hay una concentración inferior de iones. Los iones tratan de re-equilibrarse a si mismos de
esta manera. Cuando la membrana o la pared celular de la bacteria o virus es dañada,
los iones entran en el microbio y interrumpen su acción. El organismo, básicamente,
explota y no hay manera de que se produzca una mutación o desarrolle una resistencia al
microorganismo.
Esta elegante, sencilla y natural tecnología está ahora a su alcance de la mano de los
productos Microdacyn distribuidos en España por SDOMEDICAL.
http://www.youtube.com/watch?v=HTK4Lb3mzUY
International Immunopharmacology 7 (2007) 1013 – 1024
www.elsevier.com/locate/intimp
Super-oxidized solution inhibits IgE-antigen-induced degranulation
and cytokine release in mast cells ☆
J. Medina-Tamayo a , E. Sánchez-Miranda a , H. Balleza-Tapia a , X. Ambriz a , M.E. Cid a ,
D. González-Espinosa b , A.A. Gutiérrez b , C. González-Espinosa a,⁎
a
Pharmacobiology Department, Cinvestav, South Campus, Mexico City, Mexico
Cell Therapy Unit, National Institute of Rehabilitation, Mexico City, Mexico
b
Received 13 July 2006; received in revised form 2 March 2007; accepted 19 March 2007
Abstract
Activation of the high affinity IgE receptor (FcεRI) through IgE-antigen complexes induces mast cell degranulation, synthesis
of lipid mediators and cytokine production. These effects are involved in Type I hypersensitivity reactions and controlling them has
been the main objective of many anti-allergic therapies. Here we report that pretreatment of murine bone marrow derived mast cells
(BMMC) with super-oxidized solution (SOS) inhibits FcεRI dependent-β hexosaminidase and cytokine release. This effect is
exerted without altering total protein tyrosine phosphorylation, MAPK activation, cytokine mRNA accumulation or calcium
mobilization after FcεRI triggering. Our data suggest that this neutral pH-SOS acts like a mast cell-membrane stabilizer inhibiting
the cell machinery for granule secretion without altering the signal transduction pathways induced by IgE-antigen receptor
crosslinking.
© 2007 Elsevier B.V. All rights reserved.
Keywords: Mast cell; Degranulation; Cytokine production; Allergy; IgE receptor; Super-oxidized solution
1. Introduction
Abbreviations: SOS, super-oxidized solution; SCF, stem cell
factor; MCs, mast cells; BMMCs, bone marrow-derived mast cells;
CCL3/MIP1-α, macrophage inhibitory protein 1 alpha; IgE, Immunoglobulin E; FcεRI, High affinity-IgE receptor; NFAT, nuclear factor
of activated T cells; 7-AAD, 7 aminoactinomycin; PMA, phorbol 12
myristate 13 acetate; TNF-α, tumor necrosis factor alpha; DNP-HSA,
dinitrophenol-human serum albumin.
☆
AA Gutiérrez conducted the research in Mexico and had become a
paid employee of Oculus IS at the time of drafting this paper.
⁎ Corresponding author. Pharmacobiology Department, Cinvestav,
South Campus Calzada de los Tenorios 235 Col. Granjas Coapa,
14330 Mexico City 14330 Mexico. Tel.: +52 55 5061 2800x2875; fax:
+52 55 5603 3957.
E-mail address: cgonzal@cinvestav.mx (C. González-Espinosa).
1567-5769/$ - see front matter © 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.intimp.2007.03.005
Mast cells (MCs) have long been recognized as
effector cells of hypersensitivity Type I reactions and
protective responses against parasites [1,2]. These cells
begin their differentiation in the bone marrow from
CD34+ hematopoietic progenitors and migrate to the
bloodstream as committed cells. In peripheral tissues [3],
they acquire their distinctive phenotype under the
influence of stem cell factor (SCF), interleukin (IL)-3
and various other locally-produced mediators [4].
Although MCs do not represent a single homogenous,
functional-cell population, there is one characteristic that
unites them all with basophils which is the possession of
high affinity membrane receptors for immunoglobulin
1014
J. Medina-Tamayo et al. / International Immunopharmacology 7 (2007) 1013–1024
(Ig) E (FcεRI). When these receptors are activated by
IgE-antigen interactions, the FcεRI signal transduction
pathway can lead to 1) histamine and protease-containing granule release, 2) lipid-derived inflammatory
mediator production and 3) cytokine synthesis [5]. The
secretion of these mediators is responsible for early and
late phases of allergic responses [6]. Depending on the
anatomic site where activated mast cells are located, the
immediate secreted molecules can play a regulatory role
of smooth muscle contraction, immune cell chemotaxis,
endothelial cell layer permeability and mucus production. Mast cell activation, therefore, plays an important
role in a wide array of inflammatory disorders [7].
Investigation into the mechanisms that control histamine release by mast cells has constituted an important
milestone in immunopharmacology [8]. Based on this
knowledge, diverse pharmacological agents have been
developed to prevent or ameliorate the activation and
secretion of mast cells. Among them, β2 adrenoceptor
stimulants, methylxantines, glucocorticoids, antihistamines and mast cell stabilizers (chromones) are the main
classes of drugs widely used for allergic diseases [9].
These agents are frequently utilized as tools for basic
research too, and have helped to better understand mast
cell physiology and the FcεRI signal transduction system.
Pharmacological stabilization of mast cells is currently used for the therapy of asthma [10,11], rhinitis
[12], atopic dermatitis [13], seasonal conjunctivitis [14]
and even chronic leg ulcers [15]. This strategy has also
been applied to abrogate ocular allergic inflammation
[16], prevent adhesion formation after pelvic surgery
[17], and diminish inflammation and hyperalgesia induced by nerve injury [18]. Sodium cromoglycate and
nedocromyl are the most commonly used mast cell
stabilizers for inhibiting cytokine release from bronchial
mast cells [19]. When inhaled several times a day, cromoglycate will inhibit both, immediate and late asthmatic
responses elicited by antigen or exercise [11]. Given the
intimate relationship between mast cells and multiple
inflammatory diseases, stabilization of mast cell activity
would be expected to be therapeutically effective.
Interestingly, there are some reports showing beneficial effects of super-oxidized solutions in disorders
related to mast cell activation, suggesting that these
solutions might have a direct modulator activity on this
type of cells [20–22].
Super-oxidized solutions (also known as superoxidized water, SOW) are produced by the electrolysis
of purified water and sodium chloride. Water is broken
down into oxygen, ozone and other unstable oxidized
species. However, the main active chemical species
generated during this process are hypochlorite and
hypochlorous species. Despite solutions commercially
available are all produced by electrolysis and they differ in
the concentration of active components and pH [23].
Therefore, their biocidal activity and toxicity profiles also
vary depending on these two characteristics. Microbicidal
activity has been shown against bacteria, viruses, fungi
and spores in vitro [24,25]. In a rat-burn model, for example, the researchers applied SOS directly to the infected
lesion with Pseudomonas and were able to efficiently
reduce blood levels of endotoxin, systemic effects of septicemia and mortality rates [21]. Similarly in humans, skin
infections and ulcers [26], inflammatory skin disorders
(e.g. pemphigus, psoriasis) [27], burns [28] and peritonitis
[20,29] have all improved their outcomes with the use of
SOS treatment. But whether these better outcomes are
related to the antiseptic efficacy of the SOS, or to a synergystic anti-inflammatory effect, is unknown [29,30]. To
the best of our knowledge, there is no information on the
direct effects that a SOS might exert on the inflammatory
process itself or in the process of mast cell activation.
It is well established that studies on mast cell physiology are useful to identify possible therapeutic targets
for allergic/inflammatory diseases. Murine bone marrowderived mast cells (BMMCs) are one of the most common
cells used for this purpose. These cells are generated from
murine bone marrow cultured in the presence of IL-3 (for
the generation of mucosal-type mast cells) or IL-3 and
SCF (for the development of connective tissue-type mast
cells) [31]. Mucosal-type BMMCs are particularly useful
to analyze distinct molecular events leading to signal
transduction, degranulation, leucotriene production, and
cytokine mRNA expression and secretion [2,3].
We therefore explored the effects of a pH neutral-SOS
on the activation and secretion processes of mucosaltype BMMCs after FcεRI triggering using IgE-antigen.
For this purpose, cells were incubated in serial dilutions
of a pH neutral-SOS for a short period of time before
being activated. The SOS treatment was not toxic but
blocked both, IgE/antigen- and calcium ionophoreinduced mast cell degranulation in a concentration dependent manner. SOS pretreatment also significantly
inhibited the release of TNF-α, CCL-3, IL-13 and IL-6
from activated mast cells. Yet, the treatment did not
interfere with early stages of the signal transduction
mechanism of the FcεRI receptor, since protein tyrosine
phosphorylation, MAPK activation, calcium mobilization and cytokine mRNA production were observed after
receptor crosslinking. Altogether these data suggest that
SOS pretreatment is able to partially inhibit the secretion
of mediators of both, acute and late induced responses in
mast cells. The exact targets of SOS in mast cells are
unknown but clearly deserve further evaluation.
2. Materials and methods
Culture media, bovine fetal serum, essential amino acids,
and sodium pyruvate solutions for cell growth and differentiation were from Invitrogen (Carlsbad, California). Antibodies used for western blot analysis included anti-p38 (Cat. #
SC-535), ERK2 (Cat. # SC-154 ), and p-ERK2 (Cat. # 7976 )
from Santa Cruz Biotechnology (California, USA), p-p38
(Cat. # 9211S) from Cell Signaling (Beverly, MA), and anti-pTyr, clone 4G10, (Cat. # 05-321) from Upstate Biotechnology
(Lake Placid, NY). Monoclonal anti-DNP IgE (clone SPE-7),
calcium ionophore A23187, PMA and reagents for buffer
preparation, electrophoresis and calcium mobilization assays
were purchased from Sigma Chemical Co. (St. Louis MO).
Antigen stimulation of the cells was performed adding distinct
amounts of dinitrophenol-human serum albumin (DNP-HSA,
Sigma Chemical Co. Cat # A-6661) to overnight IgE
sensitized BMMC. The SOS used for this study was a stable,
neutral pH preparation commercially available in Mexico
(Microcyn®, Oculus Innovative Sciences, CA, USA).
2.1. Mice and BMMC culture
Bone marrow derived mast cells (BMMC) were isolated
from the tibia of 4–8 weeks old mice (strain 129S1/SvImJ),
from Jackson Laboratories (Maine, USA, stock # 002448).
Briefly, total bone marrow was isolated and cultured in RPMI
media containing IL-3 (20 ng/mL) and 10% Fetal Bovine
Serum (FBS) in order to differentiate mast cells, as previously
described [31]. After 4–6 weeks of culture, between 97 to 99%
of the cells were positive to FcεRI staining as measured by a
standard flow cytometry assay [32].
2.2. SOS treatments
A pH neutral, super-oxidized solution (Microcyn®) that
contains a small amount of free available chlorine (b80 ppm)
in the form of hypochlorous acid, sodium hypochlorite and
sodium chloride was used for this study. This solution is
1015
produced through the electrolysis of purified water containing
limited amounts of chloride ion in a unique multi-chamber cell
(Oculus Innovative Sciences). This stable, super-oxidized
solution was mixed with concentrated Tyrode's/BSA buffer
(see degranulation assay section) in order to obtain solutions
with different percentages of SOS (v/v) without significantly
altering the osmolarity or pH of Tyrode's/BSA buffer.
Sensitized cells (see Degranulation section) were preincubated
with Tyrode's/BSA buffer alone, or with 10% to 50% SOS
containing-Tyrode's/BSA buffers, at 37 °C for distinct periods
of time to test viability or during 15 min to test physiological
activation. After SOS pretreatments, cells were collected and
resuspended in fresh SOS free-Tyrode's/BSA in order to be
stimulated with antigen or with a mixture of calcium ionophore
and PMA, as a positive control for cell activation.
2.3. Viability assays
Cell viability analysis of SOS exposed mast cells was
carried out by three independent methodologies. Propidium
iodide incorporation, annexin V exposition and 7AAD positive
cells were measured as follows.
Mature BMMCs (5 × 105) were centrifuged at room
temperature during 5 min at 800 ×g. After removal of the
supernatant, cells were carefully resuspended in 0.5 mL of the
different SOS dilutions in Tyrode's/ BSA (see previous
section) and kept at 37 °C, 5% CO2. After different times of
exposure, treatment was stopped by addition of 0.5 mL of the
complete cell culture media. Cells were then pooled by centrifugation during 5 min at 800 ×g, the resultant pellets
were disaggregated and cells were resuspended and stained
with 7-aminoactinomycin D (7-AAD) according to the manufacturer's instructions (7-AAD; BD., Palo Alto, CA. USA).
For long-term cytotoxicity showed in Table 1, SOS dilutions
were made in complete RPMI media (see cell culture section).
Osmolarity was not significantly affected by dilution process,
since mean osmolarity of complete medium containing 50%
SOS of three different lots was 284.9 ± 1.05, 296.34 ± 0.78,
317.82 ± 0.48, determined using an Advanced 3D3 Osmometer
Table 1
Effect of 50% SOS or 0.0075% sodium hypochlorite on mast cell viability depending on exposure time
Cell viability
Treatment
determination method
t=0
t = 5 min
t = 15 min
t = 30 min
t = 60 min
t = 120 min t = 4 h
7AAD
7AAD
7AAD
Propidium iodide
Propidium iodide
Propidium iodide
Annexin C
Annexin C
Annexin C
99 ± 1%
99 ± 2%
99 ± 5%
99 ± 0.6%
98 ± 1.4%
99 ± 2.3%
99 ± 0.03%
99 ± 0.08%
99 ± 0.16%
99 ± 2%
99 ± 2%
99 ± 8%
99 ± 1.4%
99 ± 2.0%
99 ± 3.2%
99 ± 0.01%
99 ± 0.05%
99 ± 0.12%
99 ± 1%
99 ± 3%
99 ± 6%
99 ± 0.3%
99 ± 0.5%
98 ± 0.3%
99 ± 0.07%
99 ± 0.09%
95 ± 1.5% ⁎
99 ± 4%
99 ± 5%
95 ± 9%
98 ± 1.4%
97 ± 2.1%
88 ± 2.6% ⁎
99 ± 0.01%
98 ± 0.03%
86 ± 2.6% ⁎
99 ± 5%
97 ± 5%
90 ± 12% ⁎
98 ± 0.5%
96 ± 0.5% ⁎
86 ± 4%⁎
99 ± 0.02%
98 ± 0.03%
87 ± 3.6% ⁎
99 ± 5%
95 ± 4% ⁎
85 ± 12% ⁎
98 ± 0.7%
95 ± 0.7% ⁎
89 ± 6% ⁎
99 ± 0.03%
98 ± 0.09%
80 ± 14% ⁎
Buffer
50% SOW
0.0075% sodium hypochlorite
Buffer
50% SOW
Buffer
50% SOW
99 ± 6%
95 ± 11% ⁎
66 ± 12% ⁎
96 ± 2% ⁎
93 ± 4% ⁎
54 ± 19% ⁎
99 ± 0.10%
99 ± 0.07%
47 ± 16% ⁎
Time-dependent cytotoxicity of 50% SOS or 0.0075% sodium hypochlorite on mature BMMC's. Cell viability was determined using three different
reagents as described in Materials and methods section. Results are expressed as percentage of viable cells in each condition. No difference was
noticed between buffer treated or non-treated BMMCs. ⁎ denote significant differences from cells exposed to Tyrode's BSA/culture media mixture.
1016
from John Morris Scientific. As a control for long-term cytotoxicity, different dilutions of a Voluette Analytical Chlorine
Standard (HACH Company, Loveland, CO, USA) were
prepared in complete media and cells were pretreated during
distinct periods of time in order to test viability. Given the
presence of NaCl in complete media, after chlorine addition,
sodium hypoclorite (NaOCl) was produced and the amount of
NaOCl in the preparation was measured by using a molar
extinction coefficient of 350 M− 1 cm− 1 at 290 nm at pH 12 [33].
The ratio of necrosis and apoptosis were determined simultaneously in the cells using annexin V-FITC and propidium
iodide according to the manufacturer's protocol (Annexin-VFluos Staining kit, ROCHE, NJ, USA). Positive stain cells
were analyzed on a FACScalibur flow cytometer (BD., Palo
Alto, CA, USA). All experiments were conducted in triplicate.
2.4. Statistical analysis
Statistical analysis was performed by the t-test for
Dependent Samples. p b 0.05 was considered significant. The
Tukey honest significant difference test was used for the
analysis of variance (ANOVA) between groups. The Statistica™ version 6.00 software was used for these analyses.
2.5. Degranulation assays
Mature BMMCs were sensitized by overnight incubation in
media containing 300 ng/mL of monoclonal anti-DNP IgE
(clone SPE7). The following morning, cells were washed and
resuspended in SOS-free or SOS-containing Tyrode's/BSA
buffer (20 mM HEPES pH7.4, 135 mM NaCl, 5 mM KCl,
1.8 mM CaCl2, 1 mM MgCl2, 5.6 mM glucose, and 0.05%
bovine serum albumin) and kept at 37 °C during 15 min. Two
million cells in 1 mL buffer were stimulated with different
concentrations of DNP-HSA (antigen) or calcium ionophore/
PMA at 37 °C during 30 min for degranulation, or during 1 h
for total RNA isolation. After the indicated times, cells were
collected by centrifugation and supernatants were used for βhexosaminidase activity determination and pellets for total
RNA isolation, as previously described [34].
2.6. RNA isolation, RT-PCR and RPA assays
Pellets from non-stimulated and stimulated cells were used
for total RNA isolation. Briefly, the cell pellet obtained in
degranulation assays was resuspended in 1 mL of Trizol
following manufacturer's instructions (Invitrogen, Carlsbad,
CA, USA). RNA concentration was calculated by absorbance
at 260 nm and cDNA synthesis was performed using a first
strand DNA synthesis kit (Invitrogen, cat # 12371-019). PCR
amplification of cDNAs was conducted in the presence of
specific primers for distinct cytokines or GAPDH genes,
following the manufacturer's instructions (Mouse Inflammatory Cytokine Set2ms, BioSource™; Invitrogen Carlsbad, CA,
USA). RT-PCR products were separated in TBE-prepared 2%
agarose gels and analyzed in a UVP image analysis system
(Upland, CA, USA). Ribonuclease I Protection Assays (RPA)
were conducted using specific multiprobe RPA sets labeled
with 33P, following the instructions provided in the kits (In
vitro transcription and RPA kits, BD Pharmingen, cat. #
556850 and # 556134, respectively). Protected fragments were
separated on denaturing polyacrylamide gels, which were
dried and exposed to Kodak Biomax film at − 80 °C.
Representative results of at least four independent experiments
are shown.
2.7. Western blotting
Ten million sensitized BMMCs were pretreated with SOS
free-or SOS containing-Tyrode's/BSA buffers, during 15 min
at 37°. After this time, cells were collected and resuspended in
250 μl of fresh Tyrode's/BSA buffer. BMMCs were then
stimulated by the addition of 30 ng/mL DNP-HSA antigen for
10 min at 37 °C and the stimulus further stopped by adding
250 μl of 2× Laemmli buffer to each tube. Samples were
boiled during 5 min and 30 μl of the sample was separated on
10% Tris–glycine-SDS polyacrylamide gels. Proteins were
transferred to PVDF membranes using standard procedures.
Membranes were blocked 1 h at room temperature in 4% nonfat milk. First antibody incubation was performed overnight at
4 °C using recommended dilutions. The following day,
antibody excess was eliminated by washing the membrane
several times in TTBS buffer (50 mM Tris; 150 mM NaCl;
0.1% Tween 20). Secondary antibody incubations were
performed 1 h at RT using 1:10,000 dilutions of HRPconjugated specific antibodies. Chemiluminiscence was measured with a SuperSignal detection kit (Roche, NJ, USA).
2.8. Cytokine secretion
The concentration of murine cytokines in supernatants from
treated and non-treated, stimulated and naive cells, was evaluated by standard ELISA kits as recommended by the manufacturer (Biosource-Invitrogen, Carlsbad, CA). Evaluated cytokines
included TNFα (cat. KMC3011), CCL-3 (MIP1α) (cat.
KMC2201), IL-6 (cat. KMC0061) and IL-3 (cat. KMC0031).
Supernatants were obtained as follows: 40 million of sensitized
BMMC were preincubated with SOS free-or SOS containingTyrode's/BSA buffers for 15 min at 37 °C. After this time, cells
were collected and resuspended in 10 mL of fresh cell culture
media supplemented with a protease inhibitor cocktail (Roche,
NJ, USA). Cells were stimulated with 30 ng/ml of DNP-HSA at
37 °C for different periods of time, at the end of which 1 mL of
media was collected from the supernatant and frozen down at
−80 °C for cytokine determination. Supernatants of nonstimulated cells were used as negative controls. Between 20 to
60 μl of the supernatant was used for ELISA cytokine detection,
depending on the specific cytokine tested.
2.9. Calcium mobilization and NFAT transcription factor
activity
Calcium mobilization was measured as described elsewhere [35]. In brief, sensitized BMMC were loaded with
1017
5 mM Fura-2AM dissolved in Tyrode's/BSA at 37 °C for
30 min. After loading, cells were pre-incubated with SOS free
or SOS containing Tyrode's/BSA buffers, during 15 min at
37°. Cells were collected and resuspended in cold Tyrode's/
BSA until use. For stimulation, 4 million cells were placed in a
2 mL cuvette of a Jobin Yvon-Fluorolog Spectrofluorometer
and the ratio of fluorescence at 340/380 nm was recorded
during 100 s before adding antigen (30 ng/mL) or Calcium
ionophore/PMA (100 nM/1 μM) to the cells. Ratio of fluorescence was recorded for an additional 300 s and calibration was
performed by the addition of Triton X-100 (for maximal
fluorescence) and 10 mM EGTA (for minimal fluorescence) to
the cuvette. NFAT transcription factor activity was determined
using a commercial TransAM Kit for NFATc1 activation, from
Active Motif (Cat # 40269). Briefly, 10 million mast cells were
sensitized and pre-incubated with buffer, 25% SOS or 50%
SOS during 15 min. After this time, cells were washed once
and resuspended in Tyrode's/BSA buffer, prior to being
activated during 15 min using 9 or 27 ng/ml of DNP-HSA at
37 °C. Total nuclear extracts were performed and NFAT
activity was tested following instructions provided by the
manufacturer. Data are presented as optical density values at
450 nm in non-treated and treated BMMCs.
3. Results
3.1. SOS pretreatment does not affect BMMC viability
The neutral SOS herein tested is a solution with broad
antimicrobial activity commonly used in wound care treatment. Yet, its direct effects on cells mediating allergic or
inflammatory processes, like mast cells, had never been
explored. Thus, the cytotoxicity of this SOS was first
evaluated in IgE-sensitized BMMCs treated with Tyrode's/
BSA buffer containing distinct concentrations of SOS (i.e. 1%
to 50%, v/v). After incubation for 15 min at 37 °C, cells were
processed to simultaneously evaluate cell viability, necrosis
and apoptosis by flow cytometry.
Fig. 1 shows the concentration-response curves of BMMCs
cultures exposed to different dilutions of SOS. Cell viability
was analyzed by exclusion of 7AAD. Of all SOS dilutions
tested, only 50%-SOS induced a statistically significant
reduction in BMMCs' viability in comparison to the control
group ( p b 0.05). Despite this, the cell viability of BMMCs
pretreated with 50% SOS was ≥ 95%.
Apparently, 50% SOS induced cell death through necrosis
because ≥ 3% of the cells incorporated propidium iodide in the
flow cytometry analysis (Fig. 1B). This percentage, although
low, was also significantly higher than the rest of the groups
( p b 0.05). Apoptosis, on the contrary, does not seem to be the
mechanism by which 50% SOS induces cell death. In fact, the
percentages of cells exposing Annexin-V in the cellular
surface ranged from 0.4% to 0.9% in all groups (Fig. 1C).
These results show that mild cytotoxicity in BMMCs is only
induced by 50%-SOS in vitro. Instead, lower SOS concentrations (i.e. 1% to 25%-SOS) do not seem to affect BMMCs cell
membrane permeability as measured in these assays.
Fig. 1. Mast cell treatment with SOS (SOW) does not affect cellular
viability. BMMCs (5 × 105) were incubated at 37 °C for 15 min in
Tyrode's/BSA alone, or in the same buffer containing different
dilutions of neutral pH SOS (v/v). After this time, cells were analyzed
by flow cytometry looking for 7AAD (A), propidium iodide (B) and
Annexin (C) positive cells. SOS solutions were prepared as described
in the Materials and methods section. Results are expressed as the
mean from three independent experiments ±SD.
To establish the sustained effect of SOS on mast cellcytokine release, a time-course experiment was first conducted
to show that cell viability was not significantly modified for
several hours after a 15 min exposure to 50% SOS. As described in previous sections, cells were collected and incubated
for 15 min in complete media containing Tyrode's/BSA buffer,
50% SOS or 0.0075% sodium hypochlorite. Care was taken to
keep the osmolarity of the media in the range of 275 to
317 mOsm/L in all testing conditions. At the end of each
1018
exposure. These experiments show that hypochlorite is far
more toxic than SOS to mast cells, even when both solutions
contained a similar concentration of free available chlorine.
3.2. SOS pretreatment of BMMC inhibits FcεRI-induced
degranulation
Mast cell degranulation initiates the early phase of allergic
responses. In order to test the effect of SOS treatment on the
degranulation of mast cells, IgE-antigen-induced β-hexosaminidase release was measured in BMMCs pretreated with
either, SOS free-or SOS containing-Tyrode's/BSA buffer for
15 min at 37°. Pretreatment of the cells with 25% and 50% SOS
inhibited antigen-induced mast cell degranulation by 75–80%
(Fig. 2A). This effect was also observed when cell preincubation
Fig. 2. SOS (SOW) pretreatment of mast cells inhibits antigen and
calcium ionophore/PMA-induced degranulation. (A) Sensitized mature BMMCs were collected from culture media and resuspended in
normal Tyrode's/BSA buffer or in the same buffer containing different
dilutions of neutral pH SOS (v/v) at 37 °C for 15 min. After this time,
cells were collected, washed once and resuspended in SOS-free
Tyrode's/BSA (37°). Then they were stimulated with different
concentrations of DNP-HSA (antigen) during 30 min. After this
time, cells were collected and β-hexosaminidase activity was
determined in the supernatant. A pellet of non-stimulated cells was
lysed with 0.5% Triton and used as the positive control (i.e. 100%
enzymatic activity). Results are expressed as percent of the total βhexosaminidase activity. (B) Degranulation stimulated by antigen or
A23187/PMA was inhibited by SOS containing Tyrode's/BSA. Cells
were treated as in panel A but β-hexosaminidase release was measured
after antigen (30 ng/ml) or calcium ionophore/PMA (100 nM/1 μM)
stimulation. The graph shows the mean degranulation values obtained
from 5 independent experiments ±SE.
incubation time, new fresh RPMI media was added to each
tube and cell viability was determined. Propidium iodide (PI)
incorporation, annexin V exposition and 7AAD staining at
different times of incubation at 37 °C were the techniques used
for cell viability determination. As shown in Table 1, viability
in 50%SOS-treated cells dropped to 95% after 2 and 4 h post
exposure as evaluated by 7AAD. Instead, 0.0075% hypochlorite significantly reduced mast cell viability down to 90%, 85%
and 66% at 1, 2 and 4 h post exposure, respectively. Another
difference was that hypochlorite induced cell death through
both, necrosis and apoptosis, as demonstrated by increasing PI
incorporation and annexin V exposition from minute 30 post-
Fig. 3. SOS (SOW) pretreatment of mast cells does not prevent antigendependent protein tyrosine phosphorylation and MAPK activation.
Mature, sensitized BMMCs were collected from culture media and
resuspended in SOS free- or SOS containing-Tyrode's/BSA buffers at
37 °C during 15 min. After this time, cells were washed once in SOS-free
Tyrode's/BSA (37 °C) and stimulated with 30 ng/ml DNP-HSA during
3 min. Reaction was stopped by addition of boiling 2× Laemmli buffer
and total proteins were analyzed using phospho-tyrosine (A), or phospho
ERK and phospho p38 (B) specific antibodies. A representative image of
three independent experiments is shown. When SOW was added alone,
the final concentration was 50%.
1019
was conducted in 1% SOS. Of note, the inhibition of antigeninduced mast cell degranulation was not avoided by addition
of increasing antigen doses. Furthermore, the blockage of
β-hexosaminidase release induced by other stimuli, like
calcium ionophore and PMA, was also inhibited by 90 ± 10%
in cells pretreated with 50% SOS (Fig. 2B). These results
suggest that SOS blockage of β hexosaminidase release is a
non-specific effect on the secretion process.
3.3. SOS pretreatment does not affect FcεRI-induced tyrosine
phosphorylation and MAPK activation
FcεRI receptor crosslinking rapidly induces tyrosine
phosphorylation of a variety of proteins inside mast cells
leading to degranulation and cytokine production. Since some
tyrosine kinase-inhibitors are able to halt β-hexosaminidase
release [35], we tested the effect of SOS pretreatment on
antigen induced-tyrosine phosphorylation of proteins in mast
cells. Neither of the two SOS dilutions tested (i.e. 25–50%)
prevented total tyrosine phosphorylation after FcεRI activation, as judged by western blot using an antiphosphotyrosine
Fig. 4. SOS (SOW) pretreatment of mast cells does not inhibit calcium
mobilization after antigen or calcium ionophore stimulation. Sensitized, mature BMMCs were collected from culture media and
resuspended in FURA-2 AM containing Tyrode's/BSA buffer at
37 °C during 30 min. Then, cells were washed once and resuspended
in normal Tyrode's/BSA buffer or in 50% SOS-containing buffer at
37 °C during 15 min. After this incubation, cells were washed again
and resuspended in SOS-free Tyrode's/BSA buffer before to be
transferred to a spectrofluorometer cuvette. Fluorescence 340:380 ratio
was recorded during 100 s and after this time (A) 30 ng/ml of DNPHSA (Antigen, Ag) or (B) 100 nM calcium ionophore (A23187) was
added to the cells. Traces were followed during 200 s after stimuli
addition. Traces shown are representative from three independent
experiments with similar results.
Fig. 5. SOS (SOW) pretreatment of mast cells does not significantly
inhibit antigen-dependent cytokine mRNA accumulation. Mature,
sensitized BMMCs were collected from culture media and resuspended
in normal Tyrode's/BSA buffer or in SOS-containing buffer at 37 °C
during 15 min. After this time, cells were washed once in SOS-free
Tyrode's/BSA (37 °C) and stimulated with 30 ng/ml DNP-HSA during
1 h. Total RNA isolation, RT-PCR or RPA was performed as described in
the Materials and methods section. mRNA accumulation of GAPDH,
IL-2, IL-3, IL-4 and IL-6 was determined by RT-PCR (A), and GAPDH,
TNF-α and IL-13 mRNA accumulation was determined by RPA (B).
When SOW was added alone, the final concentration was 50%.
1020
(4G10) antibody (Fig. 3A). Yet, total tyrosine-phosphorylated
proteins decreased after antigen stimulation if mast cells were
pretreated with 25% or 50% SOS. Since IgE receptor
crosslinking is able to induce MAPK activation, we also
tested the effect of the same SOS dilutions on p38 and ERK2
MAP kinase phosphorylation levels in mast cells (Fig. 3B). In
the absence of antigen-induced stimulation, the sole exposure
of BMMCs to 50% SOS induced ERK2 and p38 phosphorylation. Antigen stimulation for 10 min further elevated SOS
induced-MAPK activation in BMMCs. According to these
results, it is possible that SOS pretreatment can activate MAPK
without impairing the capacity of the FcεRI receptor to further
stimulate MAPK activity.
3.4. SOS pretreatment does not inhibit FcεRI-induced calcium
mobilization or NFAT-transcription factor activation in mast
cells
Mast cell degranulation and the synthesis of some cytokines, are absolutely dependent on calcium mobilization
[36,37]. Given the fact that SOS pretreatment inhibits the
degranulation capabilities of mast cells, we examined the rise
of intracellular calcium in 50% SOS pretreated-mast cells
during IgE-antigen or calcium ionophore stimulation. Under
these experimental conditions, calcium mobilization was not
affected in stimulated mast cells with either agent if they were
pretreated in 50% SOS for 15 min (Fig. 4A,B). Since NFATtranscription factor is activated after IgE-antigen stimulation
and calcium rise in mast cells, we also investigated NFAT
binding activity in 50% SOS-treated cells. As it can be observed in Fig. 4C, no statistical difference on NFAT activation
was observed between SOS treated- and non-reated-BMMCs
after antigen stimulation. Thus, SOS does not seem to interfere
with calcium mobilization or calcium activated-effectors in
mast cells.
3.5. SOS pretreatment does not prevent IgE-antigen-induced
cytokine mRNA accumulation in mast cells
Murine BMMCs, through activation of distinct Src family
kinases, are able to synthesize many different cytokines and
chemotactic factors in response to antigen stimulation,
including: IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-10, IL-12,
IL-13, TNF-α, TGF-β, GM-CSF, IFN-γ, CCL2, CCL3 and
CCL4, among others [38]. It is known that FcεRI crosslinking
Fig. 6. SOS (SOW) pretreatment of mast cells significantly inhibits
antigen-induced cytokine secretion. A total of 40 million mature,
sensitized BMMCs were collected from culture media and resuspended
in normal Tyrode's/BSA buffer or in SOS-containing buffer at 37 °C
during 15 min. After this time, cells were washed, resuspended in 10 ml
of SOS-free, complete media at 37 °C and stimulated with 30 ng/ml
DNP-HSA (antigen). Samples of the supernatant were taken at
indicated times and cytokine content was determined by cytokinespecific ELISA kits. Results of three independent experiments ±SE are
presented.
activates a signal transduction system that modulates the activity of a number of different transcription factors (i.e. NFAT,
NFκB, AP-1). These, in turn, are responsible for de novo
synthesis of cytokine mRNA [39]. Once secreted, cytokines
induce recruitment and proliferation of T cells, macrophages,
eosinophils and other cellular types that initiate the inflammatory response of late phase-allergic reactions. We, therefore,
tested the effect of 25% and 50% SOS-preincubation on
cytokine mRNA accumulation in BMMCs. For this purpose,
RT-PCR or RPA assays were used to measure IL-2, IL-3, IL-4,
IL-6, TNF-α and IL-13 specific transcripts in mast cells
pretreated with SOS free-and SOS-containing Tyrode's BSA
for 15 min at 37 °C (Fig. 5). In the absence of antigenic
stimulation, the sole exposure of mast cells to 50% SOS did
not induce detectable cytokine mRNA synthesis. Pretreatment
of mast cells with 25% or 50% SOS, however, did not prevent
FcεRI-induced cytokine mRNA synthesis.
3.6. SOS pretreatment diminishes cytokine secretion in mast
cells.
Since SOS pretreatment of BMMC had inhibited FcεRIinduced degranulation but not FcεRI-induced cytokine mRNA
synthesis, we further evaluated cytokine release in control and
SOS-preincubated cells by ELISA. For these experiments, IgEsensitized cells were preincubated in SOS free- or SOS
containing-Tyrode's/BSA buffer for 15 min at 37 °C. After
this time, cells were washed and resuspended in SOS-free culture
media containing 30 ng/ml DNP-HSA, as described in
“Materials and methods”. Cells were then incubated at 37 °C
and samples taken from the supernatant at different time points to
determine the amount of cytokine release after IgE-antigen
stimulation. Cytokines detected included TNF α, CCL3 (MIP1α), IL-6 and IL-13 (Fig. 6). The extent of inhibition of cytokine
release in SOS-pretreated cells was found to be concentration
dependent and molecule specific. In general, 50%-SOS was
more effective than 25% SOS pretreatment in the inhibition of
antigen-induced cytokine release, except for IL-6 secretion.
After pretreatment of mast cells with 50% SOS, the inhibitory
effect was more noticeable in TNF-α release (83 ± 10% max.
inhibition), followed by IL-13 and MIP-1α (50 ± 7%) and IL-6
(40 ± 6%). Interestingly, the inhibitory effect of SOS-pretreatment was sustained from 2 to 24 h and there were not significant
changes in the concentration of all four cytokines tested in the
supernatant of BMMCs' cultures, during this period of time.
4. Discussion
Inhibition of degranulation of mast cells has been
proposed as a feasible therapeutic target for allergic and
inflammatory diseases [8,9]. In this study we report that
pretreatment of a model of mucosal-type mast cells
(BMMCs) with different dilutions of a neutral pH superoxidized solution (SOS), does neither significantly
reduce the viability of the cells nor interfere on early
1021
FcεRI signal transduction processes. Yet, SOS pretreatment importantly inhibits the early secretion of granule
content and the late secretion of at least four regulatory
and chemoattractant cytokines. These results are intriguing and suggest that SOSs might be potent stabilizers of mast cell activity with potential therapeutic
applications.
We first evaluated the toxicity of SOS on mast cells.
As expected, the treatment of BMMCs with different
SOS dilutions did not significantly affect cell viability as
assayed by three independent methods (i.e. 7AAD and
propidium iodide exclusion and annexin V detection)
(Fig. 1, Table 1). These results are in accordance with
the lack of toxicity in primary irritancy and sensitization
studies conducted with this same SOS in skin and
mucosas, as well as in in vitro experiments (i.e. agarose
overlay using fibroblasts) [30]. SOS pretreatment,
however, was able to block the degranulation of mast
cells induced by IgE-antigen crosslinking of the FcεRI
receptor. This effect was concentration dependent, with
reductions of allergen induced-histamine release ranging from 86 ± 8% and 27 ± 5% in pretreated cells with
50% and 1% SOS, respectively. Since calcium ionophore and PMA-induced degranulation were affected to
the same extent, we concluded that the effects of SOS
pretreatment on histamine release in mast cells are
receptor-independent (Fig. 2A).
In order to further explore the potential mechanism of
action of SOS on degranulation, we evaluated the total
tyrosine phosphorylation and MAPK phosphorylation
in antigen activated-BMMCs (Fig. 3). It is known that
molecular crosslinking of the FcεRI receptor activates a
complex series of biochemical reactions involving the
activation of distinct Src-family kinases (Fyn and Lyn)
[38], activation of Syk kinase, phosphorylation of
adapter proteins (like LAT, and Gab2), activation of
Phospholipase C and PI3K enzymes and intracellular
calcium mobilization [5]. This complex transduction
system also involves the activation of MAP kinases,
phosphorylation of transcription factors, and synthesis
of new cytokine mRNA [5]. We therefore evaluated the
global tyrosine phosphorylation level after FcεRI
activation, as judged by western blot (using 4G10
antibody) and the phosphorylation levels of ERK2 and
p38 MAP kinases. Total tyrosine phopshorylation after
FcεRI triggering seems to decrease in mast cells
pretreated with 25% or 50% SOS. In contrast, the sole
exposure of the cells to 25% or 50% SOS-containing
buffers elicited the phosphorylation of ERK2 and p38
proteins (Fig. 2B). These phenomena could be due to the
induction of a mild cellular stress by the low
concentration of chlorine species found in this SOS
1022
(b80 ppm). These species are not themselves free
radicals but these oxygen-containing molecules can
facilitate free-radical formation [43]. In fact, oxidative
damage is known to induce ERK and p38 activation,
and even cell death, depending on the time of exposure
and concentration of the oxidizing agent [40]. Due to the
low concentration of chlorine species found in this
particular SOS, the mast cells could have been stressed
without compromising the viability. Taken together,
these results suggest that SOS pretreatment does not
significantly affect the signaling machinery depending
on tyrosine phosphorylation of the FcεRI receptor.
Another required condition for IgE-antigen inducedmast cell degranulation is intracellular calcium mobilization. Unexpectedly, cells pretreated with 50% SOS
did not show inhibition of calcium mobilization nor in
NFAT activation after allergen-or calcium ionophorestimulation (Fig. 4). This result supports the hypothesis
that SOS pretreatment does not interfere with the signal
transduction process required for calcium mobilization
and it does not seem to modify the membrane capacity
of calcium influx. However, it does suggest that SOS
pretreatment can induce uncoupling of calcium flux
and granule secretion in this cells, since it has been
widely understood that calcium mobilization is an
essential requisite for IgE-antigen induced degranulation [41].
Cytokine mRNA expression was also determined in
control and SOS-treated cells after 1 h of IgE-antigen
stimulation. As measured by RT-PCR and RPA, we did
not detect a significant effect of 50% SOS pretreatment
on IL-2, IL-3, IL-4, IL-6, TNF-α and IL-13 mRNA
accumulation either in basal or IgE-antigen induced
conditions (Fig. 5). In contrast, cytokine secretion was
severely inhibited by SOS pretreatment in a concentration dependent and molecule specific way. TNF-α
secretion, for example, was inhibited by 80%, whereas
CCL3 and IL-13 release were blocked by 50%, and IL-6
by only 40%. According to these results, SOS
pretreatment seems to be able to inhibit the cytokine
secretory pathway(s) in mast cells, without altering the
transcription machinery.
Altogether, our study suggests that this particular
neutral pH super-oxidized solution induces most of the
effects of a classical mast cell stabilizer. Cromolyn
sodium and nedocromil sodium are typical membrane
stabilizers because they produce blockage on mast cell
degranulation without affecting other parameters of
cell activation [42]. Similarly, the SOS herein used was
able to strongly inhibit both antigen and calcium
ionophore-induced mast cell degranulation without
affecting cell viability or even FcεRI signal transduc-
tion processes. The precise mechanism(s) by which
this SOS inhibits degranulation without disturbing
RNA synthesis and early signal transduction is unknown. It is possible that the components of this SOS
partially modify cytoskeleton or plasma membrane
targets that uncouple calcium rise from granule secretion. Instead, this SOS does not appear to inhibit intracellular signaling processes depending on tyrosine
phosphorylation.
At this point, however, it is not possible to make a
generalization about the effects of SOS in mast cells
because not all super-oxidized solutions have the same
properties [23]. The more acidic or alkaline the
solutions are, the more corrosive and toxic they become
[43, 44]. Another major problem with previous SOSs
formulations, had been the lack of stability for long
periods of time. Basically, most of SOSs available today
are stable for only few hours or days. But, apparently,
neither one of these two problems seem to be of major
concern with the neutral pH-SOS herein tested. In aging
studies, for example, it was demonstrated that this SOS
was stable for up to 2 years. Preclinical data also
showed that this SOS does not irritate or sensitize skin
and mucosas (e.g. ocular, peritoneal, nasal, oral) [30].
Finally, pilot human studies have been successfully
conducted in various clinical conditions, including
those associated with mast cell activation [25–28].
The clinical outcomes in cases of non-infected-bullous
(pemphigus) and hyperkeratotic (psoriasis) lesions, for
example, have suggested that this SOS could exert a
direct anti-inflammatory effect [27]. However, the use
of neutral pH super-oxidized solution in any allergic
and inflammatory condition will have to be evaluated in
proper controlled studies.
In summary, our data suggest that SOS is able to
inhibit the cell machinery for granule secretion without
altering the main signal transduction pathway induced
by IgE-antigen receptor crosslinking. This is a relevant
finding because the identification of the mechanism(s)
of action of SOSs on mast cells could help to identify
novel targets in the intricate pathways that control
allergic and inflammatory reactions.
This work was financed by CONACyT (Grant #
39726-Q) and the Third World Academy of Sciences
(Grant # 02-073 RG/BIO/LA). CGE thanks Dr. Rafael
Villalobos Molina from Cinvestav Sede Sur for his
support allowing the authors to use of diverse equipment
for cell culture and electrophoresis and Mr. Armando
Resendiz for technical assistance. AAG thanks Dr Eileen
Thatcher from Sonoma S University for reviewing the
manuscript and Carlos Landa for technical support with
flow cytometry analysis.
References
[1] Galli SJ, Nakae S, Tsai M. Mast cells in the development of
adaptive immune responses. Nat Immunol 2005;6:135–42.
[2] Galli SJ, Kalesnikoff J, Grimbaldeston MA, Piliponski AM,
Williams CM, Tsai M. Mast cells as “tunable” effector and
immunoregulatory cells: recent advances. Annu Rev Immunol
2005;23:749–86.
[3] Kitamura Y. Heterogeneity of mast cells and phenotypic changes
between subpopulations. Annu Rev Immunol 1989;7:59–76.
[4] Lantz CS, Boesiger J, Song CH, Mach N, Kobayashi T, Mulligan
RC, et al. Role of Interleukin 3 in mast cell and basophil
development and parasite immunity. Nature 1998;392:90–3.
[5] Gilfillan AM, Tkaczyk Ch. Integrated signalling pathways for
mast cell activation. Nat Rev Immunol 2006;6:218–30.
[6] Charlesworth EN. The role of basophils and mast cells in acute
and late reactions in the skin. Allergy 1997;52:31–43.
[7] Galli SJ, Metcalfe DD, Arber DA, Dvorak AM. Basophils and
mast cells and their disorders. In: Beutler E, Litchman MA,
Coller BS, Kipps TJ, Seligsohn U, editors. Williams hematology.
New York: McGraw-Hill; 2005. p. 538–92.
[8] Foreman JC. In: Foreman JC, editor. Immunopharmacology
of mast cells and basophils. New York: Academic Press; 1997.
p. 1–3.
[9] Undem BJ, Lichtenstein LM. Drugs used in the treatment of
asthma. In: Hardman JG, Limbird LL, Goodman Gilman A, editors.
Goodman and Gilman's the pharmacological basis of therapeutics.
Tenth edition. New York: Mc Graw-Hill; 2001. p. 733–54.
[10] Barnes PJ. New drugs for asthma. Nat Rev Drug Discov 2004;3:
831–44.
[11] Spooner CH, Spooner GR, Rowe BH. Mast-cell stabilising
agents to prevent excercise-induced bronchoconstriction.
Cochrane Database Syst Rev 2003;4:CD002307.
[12] Ratner PH, Ehrlich PM, Fineman SM, Meltzer EO, Sekoner DP.
Use of intranasal cromolyn sodium for allergic rhinitis. Mayo
Clin Proc 2002;77:350–4.
[13] Moore C, Ehlayel MS, Junprasert J, Sorensen RU. Topical sodium
cromoglycate in the treatment of moderate-to-severe atopic
dermatitis. Ann Allergy Asthma Immunol 1998;81(5 Pt1):452–8.
[14] Owen CG, Shah A, Henshaw K, Smeeth L, Sheikh A. Topical
treatments for seasonal allergic conjunctivitis: systematic review
and beta-analysis of efficacy and effectiveness. Br J Gen Pract
2004;54:451–6.
[15] Hubner K, Darlath W. Therapy of leg ulcers with disodium
cromoglycate (DNCG)-case reports. Z Hautkr 1982;57:1037–43.
[16] Cook EB, Sathl JL, Barney NP, Graziano FM. Mechanisms of
antihistamines and mast cell stabilizers in ocular allergic inflammation. Curr Drug Targets Inflamm Allergy 2002;1:167–80.
[17] Kucukozkan T, Ersoy B, Uygur D, Gundogdu C. Prevention of
adhesions by soidum chromoglycate, dexametasone, saline and
aprotinin after pelvic surgery. ANZ J Surg 2004;74:1111–5.
[18] Zuo Y, Perkins NM, Tracey DJ, Geczy CL. Inflammation and
hyperalgesia induced by nerve injury in the rat: a key role of mast
cells. Pain 2003;105:467–79.
[19] Pearce FL, Al-Laith M, Bosman L, Borstoff J, Cunniffe TM, Flint
KC, et al. Effects of sodium chromoglycate and nedocromil
sodium on histamine secretion from mast cells from various
locations. Drugs 1989;37:37–43.
[20] Inoue Y, Endo S, Kondo K, Ito H, Omori H, Saito K. Trial of
electrolyzed strong acid aqueous solution lavage in the treatment
of peritonitis and intraperitoneal abscess. Artif Organs 1997;21:
28–31.
1023
[21] Nakae H, Inaba H. Effectiveness of electrolyzed oxidized water
irrigation in a burn-wound infection model. J Trauma 2000;49:
511–4.
[22] Ohno H, Higashidate M, Yokosuka T. Mediastinal irrigation with
super-oxidized solution after open heart surgery: the safety and
pitfalls of cardiovascular surgical application. Surg Today 2000;30:
1055–6.
[23] Sampson MN, Muir AV. Not all the super-oxidized solutions are
the same. J Hosp Infect 2002;52:228–9.
[24] Landa-Solis C, Gonzalez-Espinosa D, Guzman-Soriano B,
Snyder M, Reyes-Teran G, Torres K, et al. Microcyn™: a
novel super-oxidized solution with neutral pH and disinfectant
activity. J Hosp Infect 2005;61:291–9.
[25] Tanaka H, Hirakata Y, Kaku M, Yoshida R, Takemura H,
Mizukane R, et al. Antimicrobial activity of super-oxidized solution. J Hosp Infect 1996;34:43–9.
[26] Dalla Paola L, Brocco E, Senesi A, Merico M, De Vido D,
Assaloni R, et al. Super-oxidized solution (SOS) therapy for
infected diabetic foot ulcers. Wounds 2006;18:262–70.
[27] Bogiovanni C, Bomengen RW, Hughes MD. Superoxidized
solution: spectrum of clinical applications. Diabetic Foot Global
Conference Hollywood, Ca. USA 23rd–25th March; 2006.
[28] Miranda-Altamirano A. Reducing bacterial infectious complications from burn wounds. A look at the use of Oculus Microcyn60
to treat wounds in Mexico. Wounds Jan. 2006:17–9 (Suppl).
[29] Goretti C, Mazzurco S, Ambrosini Nobili L, Macchiarini S,
Tedeschi A, Palumbo F, et al. Use of a novel antiseptic superoxidised solution (SOS) in the management of wide post-surgical
lesion in the infected diabetic foot. Int J Low Extrem Wounds
2007;6:22–7.
[30] Gutiérrez AA. The science behind stable, super-oxidized
solution. Exploring the various applications of super-oxidized
solutions. Wounds. Jan 2006 (Suppl), 7–10.
[31] Huff TF, Lantz CS, Ryan JJ, Leftwich JA. Mast cell-committed
progenitors. In: Kitamura Y, Yamamoto S, Galli SJ, Greaves MW,
editors. Biological and molecular aspects of mast cell differentiation and function. New York: Raven Press; 1995. p. 105–17.
[32] Saitoh S, Arudchandran R, Manetz TS, Sommers CL, Zhang W,
Love PE, et al. LAT is essential for FcεRI-mediated mast cell
activation. Immunity 2000;12:525–35.
[33] Hidalgo E, Domínguez C. Growth-altering effects of sodium
hypochlorite in cultured human dermal fibroblasts. Life Sci
2000:1331–4.
[34] Gonzalez-Espinosa C, Odom S, Olivera A, Hobson PJ, CidMartinez ME, Oliveira-dos-Santos A, et al. Preferential signaling
and induction of allergy-promoting lymphokines upon weak
stimulation of the high affinity IgE receptor on mast cells. J Exp
Med 2003;197:1453–65.
[35] Hallet MB, Hodges R, Cadman M, Blanchfeld H, Dewitt S, Pettit
EJ, Blanchfeld H, et al. Techniques for measuring and manipulating free Ca2+ in the cytosol and organelles of neutrophils.
J Immunol Methods 1999;232:77–88.
[36] Barker SA, Lujan D, Wilson BS. Multiple roles for PI3-Kinase in
the regulation of PLC gamma activity and Ca2+ mobilization in
antigen-stimulated mast cells. J Leukoc Biol 1999;65(3):321–9.
[37] Common and distinct signaling pathways mediate the induction
of TNF-α and IL-5 in IgE plus antigen-stimulated mast cells.
J Immunol 1998;160(1):273–83.
[38] Rivera J, Furumoto Y, Gonzalez-Espinosa C, Kovarova M,
Odom S, Parravicini V. Functional coupling of FcεRI employs
two proximal Src family kinases. A new paradigm in mast cell
activation. In: Bienenstock J, Ring J, Togias AG, editors. Allergy
1024
frontiers and future. Proceedings of the 24th Symposium of the
Collegium Internationale Allergologicum. Cambridge, MA:
Hogrefe and Huber; 2004. p. 152–6.
[39] Gordon JR. FcεRI-induced cytokine production and gene
expression. In: Hamawy MM, editor. IgE receptor (FcεRI)
function in mast cell and basophils. Austin, Tx: RG Landes
Company; 1997. p. 209–42.
[40] Carvalho H, Evelson P, Sigaud S, Gonzalez-Flecha B. Mitogenactivated protein kinases modulate H(2)O(2)-induced apoptosis
in primary rat alveolar epithelial cells. J Cell Biochem 2004;92:
502–13.
[41] Blank U, Rivera J. The ins and outs of mast cell exocytosis.
Trends Immunol 2004;25:266–73.
[42] Mancel E, Drouet M, Sabbah A. Membrane stabilizers (chromones
and ketotifen). Allerg Immunol (Paris) 1999;31:103–5.
[43] Suzuki T, Masuda M, Friesen MD, Fenet B, Ohshima H. Novel
products generated from 2'-deoxyguanosine by hypochlorous
acid or a myeloperoxidase -H2O2-Cl-system: identification of
diimino-imidazole and amino-imidazolone nucleosides. Nucleic
Acids Res 2002;30:2555–64.
[44] Len SV, Hung YC, Erickson M, Kim C. Ultraviolet spectrophotometric characterization and bactericidal properties of electrolyzed oxidizing water as influenced by amperage and pH. J Food
Prot 2000;63:1534–7.
Microdacyn International Accreditations
CE MicroSafe
USA FDA (1) Bacterialcidal
USA FDA (2) Virucidal - Human Corona Virus
USA FDA (3) Sporicidal
USA FDA (4) Clostridium difficile
USA FDA (5) Fungicidal
USA FDA (6) Tuberculicidal
FDA Press release
Journals Of Hospital Infection
United States
E.P.A.(1)
2006
MicroSafe Disinfectant (MSD)
Bactericidal / Tuberculocidal / Virucidal /
Sanitizer Disinfectant / Disinfectant Cleaner
(Hospital –Grade / Households / Industrial
Areas)
United States
E.P.A.(2)
2007
MicroSafe Sanitizer (MSS)
Food Contact Sanitizer
2004
Debriding, irrigating and moistening acute and
chronic wounds in comprehensive
wound treatmentby reducing microbial load and
creating moist environment
European Union CE Mark
Mexico
ProductRegistration 2003 Antiseptic disinfection solution for high level
disinfection of medical instruments,
and/or equipmentand clean-rooms, areas of
medical instruments, equipment and clean rooms.
Mexico
Product Registration 2004 Antiseptic treatment of wounds and
infected areas.
United Arab
Emitates
Registred – Ministry 2012 Management via debridement of wounds such as
of Health UAE
stage I-IV pressure ulcers, partial and full
thickness wounds, diabetic foot ulcers, postsurgical wounds, first, second and thrid degree
burns, grafted and donor sites
Canada
Class II Medical
Device
2004
Moistening, irrigating, cleansing and
debriding acute and chronic dermal
lesions, diabetic ulcers and post-surgical wounds.
!
United States Fulbright Scholar in Law
United States Fulbright Senior Specialist Program
Chairman
American Board of Healthcare Law and Medicine
"
1935 South Plum Grove Rd. #311
Newport Beach, California 92660
949-260-8487
760-683-3187
"
4630 Campus Drive, Suite #200
Palatine, Illinois 60067
949-260-8487
760-683-3187
!
#
"
&
$
*
/
(
%
+
"
&
,% ! &
"
"
(%
'
-
(
"
+ &
4
*
2 "
)
"
!
!0
234 56(
67
2
;/ "
!
5'/7
!
" "
:!
"
1 9
!
"
8
1
(
"
"
2
<
1
1
"
91
!
&
!0
8
<1 9+ 4
(
/
0#
!
%&
& + <+
(%
"
!
%
!
!
>
$
<
?
.
*
&
0 4*
$
(
A B
@ !
4
2
%
"(
(
&
&
8
&
(
"
(
=
? 0
@ !
* + 4
+
&
(
.
1
Chairman, American Board of Healthcare Law and Medicine
United States Fulbright Scholar in Law
United States Fulbright PEER Review Committee – Global / Public Health
UCLA Visiting Scholar in Public Health, UCLA School of Public Health
Department of Health Services, Division of Healthcare Management and Policy
President, Aristotle University
Dean and Professor of Public Health, Aristotle University School of Public Health
Fellow, International College of Surgeons
*
*
&
.@
3D E E F
0
/
.'
!
! )
!
0
1
"
"
4
"
7
!
( !
( !
=
?
!
-#
&
5
(
=
(
9+2
&
&
"-
)
.
&
0(
!
( . /
D G C HH.
!
I
C.
.
Microdacyn60 Wound Care
Tecnología Patentada
El método más eficaz para el tratamiento de heridas crónicas y agudas
NUEVAS INDICACIONES
MUCOSAS: ORAL, NASAL, OCULAR Y VAGINAL
NUEVAS PRESENTACIONES:
HIDROGEL, SPRAY, NWT
Beneficios:
1. Acción bactericida. También es efectivo contra los
biofilms.
2. Efecto antiinflamatorio
3. Regeneración tisular activa
4. Se necesitan menos antibióticos
5. Seguro para las células sanas de la piel
Microdacyn Wound Care
Microdacyn ocupa una posición especial dentro de la categoría
significa una curación más rápida de la herida. El producto no
de productos para el tratamiento de heridas, debido a que su
sólo es eficaz sino también muy fácil de usar.
acción no se basa en componentes químicos sintéticos
No es irritante de la piel, los ojos o la garganta y elimina el olor.
específicos.
Microdacyn es un tratamiento biológicamente activo para el
desbridamiento, irrigación, humidificación y disminución de la
carga microbiana de las heridas agudas y crónicas que son
difíciles de curar, están infectadas y otras. Es totalmente
seguro, tanto para el paciente como para el personal sanitario.
Microdacyn está listo para su uso y es respetuoso con el medio
ambiente. Tras su uso, los ingredientes activos se reducen a 0,
lo que significa que no es necesario eliminar el producto como
desecho hospitalario. Microdacyn se puede utilizar fácilmente en
combinación con otras formas de tratamiento de heridas.
Microdacyn disminuye la carga microbiana patógena eliminando
Microdacyn60 ha demostrado su eficacia en el tratamiento de
los microorganismos unicelulares patógenos, sin efectos tóxicos
heridas en mucosas: boca, nariz, ojos y vagina. Con esta nueva
o nocivos sobre los tejidos humanos. Además, Microdacyn
indicación amplía su campo de acción, facilitando así la labor de
contribuye a crear un entorno húmedo en la herida, lo que
los profesionales.
Descripción y uso del producto
Microdacyn es la marca internacional de productos para el
Microdacyn60 solución y Microdacyn gel son productos
cuidado de heridas basados en la tecnología Microcyn,
superoxidados que se producen mediante la electrólisis de agua
desarrollada por la empresa estadounidense Oculus Innovative
ultrapura y NaCl.
Microdacyn desnaturaliza la pared celular del organismo
unicelular patógeno, causándole fugas y provocando su
desintegración.
Los estudios demuestran que Microdacyn tiene efecto tanto
antiinflamatorio como antialérgico, que acelera la curación de la
herida. (Estudios disponibles )
Propiedades y ventajas para el paciente y durante el tratamiento:
Antiséptico
Utilizable en mucosas: boca, ojos, nariz y vagina.
No citotóxico
Combinable con otras formas de tratamiento de heridas.
pH neutro
Acción antiinflamatoria.
No irritante
Muy económico.
Elimina el olor
Reepitelizante.
RECOMENDADO POR EL:
AMERICAN BOARD OF HEALTHCARE
POR SU EFICACIA Y SEGURIDAD
En otro estudio comparativo, se observó también que el grupo
de pacientes tratados con Microdacyn mostró una epitelización
más rápida.
Resultados de las investigaciones
1. Efecto antibacteriano
En estudios in vitro se ha demostrado que Microdacyn mata
bacterias, hongos, esporas y virus rápidamente, con una
reducción logarítmica significativa.
2. También es eficaz contra las películas biológicas
La investigación ha demostrado que Microdacyn tiene un efecto
bactericida en cepas de pseudomonas y E. coli que producen
biofilms. Después de 30 minutos de exposición a Microdacyn,
la mayoría de microorganismos habían sido eliminados.
3. Efecto antiinflamatorio
Ensayos in vitro han demostrado que 15 minutos de exposición
al producto son suficientes para suprimir la liberación de
histamina en un 90%. Además, Microdacyn inhibe la liberación
de otras moléculas que prolongan la inflamación (entre otras
interleucinas, interferón gamma y TNF-alfa), gracias a lo cual las
citoquinas "buenas" tienen mayor capacidad para iniciar el
proceso de cicatrización de la herida.
4. Regeneración tisular activa
En un estudio clínico, se demostró que Microdacyn era casi dos
veces más eficaz en el proceso de curación de úlceras de pie
diabético que un grupo de ensayo tratado con una solución
salina fisiológica (NaCl 0,9%). Los investigadores también
observaron una reducción de la carga microbiana y un aumento
en la formación de tejido de granulación.
Indicaciones
5. Se necesitan menos antibióticos
En dos estudios recientes se ha demostrado que los pacientes
con úlceras de pie diabético que fueron tratados con Microdacyn
necesitaron antibióticos durante un periodo considerablemente
más corto que un grupo de control que se trató con povidona
yodada. En uno de estos estudios, la diferencia fue de casi el
43% (74 frente a 129 días). Además, el cierre de la herida en el
grupo de Microdacyn se produjo en promedio 2 meses antes
que en el grupo de yodo (144 frente a 212 días, una reducción
del 32%).
6. Seguro para las células sanas de la piel
En comparación con otros productos (por ejemplo, a base de
peróxido de hidrógeno) Microdacyn NO es citotóxico y por lo
tanto es completamente seguro para el tejido humano. La
investigación ha demostrado que incluso la exposición
prolongada de fibroblastos humanos a Microdacyn no conduce
a la muerte celular. A diferencia de los virus, esporas y
bacterias, las células humanas tienen un mecanismo que regula
la absorción de los ingredientes activos de Microdacyn. Esto
evita daños en los tejidos. En comparación con otros
tratamientos, como yodo, clorhexidina y sulfadiazina de plata,
Microdacyn demuestra ser uno de los productos más seguros y
suaves para piel.
Más información www.sdomedical.com o sdomedical@sdomedical.com
Heridas oncológicas
Heridas agudas (profiláctico)
Heridas traumáticas infectadas y
necróticas
Heridas quirúrgicas
Úlceras crónicas
Úlceras del pie diabético
Ulcera crural (arterial y venosa)
Heridas por decúbito infectadas
Quemaduras (1 º y 2 º grado)
Contraindicaciones
No se conoce ninguna condición en la
cual no se deba aplicar Microdacyn.
Aplicación - Instrucciones de uso:
Microdacyn Wound Care Solución directamente sobre la herida con la ayuda de unas gasas empapadas, en fomento,
Aplicar
durante 5-15 minutos.
Microdacyn Wound Care Solución dos veces al día de la forma habitual, y cada vez que se cambie el apósito. No es nece Utilizar
sario limpiar la herida tras su uso.
Aplicar Microdacyn Hidrogel directamente sobre la herida y cubrir con un apósito de cura húmeda. Repetir cada 24-48 hrs.
Aplicar Microdacyn Spray y Microdacyn líquido directamente en la herida o inmersión siguiendo la pauta indicada.
NUEVAS PRESENTACIONES
Microdacyn60 Wound Care
Microdacyn Hidrogel
Descripción del producto
Código Nacional Precio Venta Recomendado
120 ml / SPRAY, 6 botellas por caja (caja individual)
172386.4
15,75 € (10% IVA incluido)
250 ml / SPRAY, 12 botellas por caja (caja individual)
172388.8
500 ml / Solución, 24 botellas por caja (caja individual)
172389.5
990 ml/ Irrigación/NWT, 6 botellas por caja
---
---
5 L / Garrafa, 4 garrafas por caja
---
---
172398.7
120 g / 6 botellas por caja (caja individual)
SDOMEDICAL Gran de Sant Andreu 159, 1º 2ª · 08030 Barcelona, Spain
The International Journal of Lower Extremity
Wounds
http://ijl.sagepub.com/
Super-Oxidized Solution (Dermacyn Wound Care) as Adjuvant Treatment in the Postoperative
Management of Complicated Diabetic Foot Osteomyelitis : Preliminary Experience in a Specialized
Department
Javier Aragón-Sánchez, Jose L. Lázaro-Martínez, Yurena Quintana-Marrero, Irene Sanz-Corbalán, Maria J.
Hernández-Herrero and Juan J. Cabrera-Galván
International Journal of Lower Extremity Wounds published online 26 February 2013
DOI: 10.1177/1534734613476710
The online version of this article can be found at:
http://ijl.sagepub.com/content/early/2013/02/01/1534734613476710
Published by:
http://www.sagepublications.com
Additional services and information for The International Journal of Lower Extremity Wounds can be found at:
Email Alerts: http://ijl.sagepub.com/cgi/alerts
Subscriptions: http://ijl.sagepub.com/subscriptions
Reprints: http://www.sagepub.com/journalsReprints.nav
Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Feb 26, 2013
What is This?
Downloaded from ijl.sagepub.com at INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS on February 27, 2013
476710
IJLXXX10.1177/1534734613476710The
International Journal of Lower Extremity WoundsAragón-Sánchez et al.
© The Author(s) 2011
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
Case Report
The International Journal of Lower
Extremity Wounds
XX(X) 1–8
© The Author(s) 2013
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534734613476710
ijl.sagepub.com
Super-Oxidized Solution
(Dermacyn Wound Care) as
Adjuvant Treatment in the
Postoperative Management of
Complicated Diabetic Foot
Osteomyelitis: Preliminary
Experience in a Specialized
Department
Javier Aragón-Sánchez, MD, PhD1, Jose L. Lázaro-Martínez, DPM, PhD2,
Yurena Quintana-Marrero, RN1, Irene Sanz-Corbalán, DPM2,
Maria J. Hernández-Herrero, MD1, and Juan J. Cabrera-Galván, MD, PhD1,3
Abstract
Surgery is usually used to treat diabetic foot osteomyelitis (DFO), whether primarily or in cases in which antibiotics are not
able to control infection. In many cases, the bone is only partially removed, which means that residual infection remains in
the bone margins, and the wound is left open to heal by secondary intent.The use of culture-guided postoperative antibiotic
treatment and adequate management of the wound must be addressed. No trials exist dealing with local treatment in the
postoperative management of these cases of complicated DFO. We decided to test a super-oxidized solution, Dermacyn
Wound Care (DWC; Oculus Innovative Sciences Netherlands BV, Sittard, Netherlands) to obtain preliminary experience in
patients in whom infected bone remained in the surgical wounds. Our hypothesis was that DWC could be useful to control
infection in the residual infected bone and surrounding soft tissues and would thus facilitate healing. Fourteen consecutive
patients who underwent conservative surgery for DFO, in whom clean bone margins could not be assured, were treated
in the postoperative period with DWC. Eleven cases were located in the forefoot, 6 on the first ray and the rest in lesser
toes, 1 in the Lisfranc joint, and 2 on the calcaneus. No side effects appeared during treatment. Neither allergies nor skin
dermatitis were found. Limb salvage was successfully achieved in 100% of the cases. Healing was achieved in a median period
of 6.8 weeks.
Keywords
diabetic foot, osteomyelitis, super-oxidized solution, diabetic foot infections
Background
The systematic surgical treatment of bone infection in the
feet of patients with diabetes is currently under debate
because some patients achieve remission exclusively with
antibiotics.1 However, surgery is the usual approach for
treating diabetic foot osteomyelitis (DFO), whether primarily or in cases in which antibiotics are not able to control
the infection.2 The choice of surgical technique to treat
DFO is not well standardized, and the goal is to remove the
infected bone without reducing the functionality of the foot.
Some teams perform amputations to removed the infected
bone,3 whereas others use conservative surgery to conserve
the architecture of the foot.4,5 When infection remains in
1
La Paloma Hospital, Las Palmas de Gran Canaria, Spain
Complutense University, Madrid, Spain
3
Las Palmas de Gran Canaria University, Las Palmas de Gran Canaria,
Spain
2
Corresponding Author:
Javier Aragón-Sánchez, Hospital La Paloma, C/Maestro Valle, 20, 35005 Las
Palmas de Gran Canaria, Canary Islands, Spain
Email: javiaragon@telefonica.net
2
The International Journal of Lower Extremity Wounds XX(X)
bone and/or soft tissues, the wound should not be closed.6-8
The open wound caused by surgery will undergo postoperative care to achieve healing by secondary intention or
before undergoing reconstructive techniques.
Our approach to treating DFO is to remove the infected
bone, leave the wound open to heal by secondary intention,
and use culture-guided postoperative antibiotic treatment.5,9
In many cases, we cannot be sure that all the infected bone
has been removed and thus believe that wide drainage
through the open wound and postoperative culture-guided
antibiotics should be used to eradicate the infection.
Theoretically, adjuvant treatment with topical antibiotics or
antiseptics could help reduce the bacterial load, which is
located in the residual infected bone and soft tissues. This
could also help reduce the timing of postoperative antibiotic
treatment but this has not been confirmed.
In our experience, management of the postoperative
wound following surgery for diabetic foot infections is
always determined in an individualized way, and we frequently use silver-based dressings. However, this choice is
empiric because no trials exist dealing with local treatment
in the postoperative management of DFO. Based on the
experience of other groups,10,11 we decided to test a superoxidized solution, Dermacyn Wound Care (DWC; Oculus
Innovative Sciences Netherlands BV, Sittard, Netherlands),
in order to obtain preliminary experience in patients in
whom infected bone remained in the surgical wounds. Our
hypothesis was that DWC could be useful for controlling
infection in the residual infected bone and surrounding soft
tissues and could thus facilitate healing.
The aim of this work is thus to present our preliminary
experience with a super-oxidized solution as adjuvant treatment in the postoperative wound management of complicated DFO in patients presenting a high risk of amputation
in order to establish its safety and usefulness prior to designing a clinical trial.
Patients and Methods
Fourteen consecutive patients who underwent conservative
surgery for DFO, in whom clean bone margins could not be
assured, were treated in the postoperative period with
DWC. All were assumed to have infected but viable bone
remaining in the wounds after removing most of the
infected bone. Conservative surgery in this case was
defined as a procedure in which only the infected bone and
nonviable soft tissue were removed, but no amputation of
any part of the foot was undertaken. Conservative surgery
preserves the soft-tissue envelope and more distal tissues,
which means resection of the infected bone while preserving the soft-tissue envelope.5 Only cases with osteomyelitis
without soft tissue infection were included in this preliminary study. Soft tissue infections were diagnosed either
preoperatively or during surgical procedures according to
previously published criteria.12,13
Diagnosis of osteomyelitis was based on our flow chart
comprising a sequential combination of the probe-to-bone
test and plain X-rays, as published elsewhere.14 A neurological examination was undertaken using SemmesWeinstein filaments (5.07 = 10 g). Neuropathy was
diagnosed when the patient did not feel 3 or more sites.
Peripheral arterial disease was diagnosed if the patient met
the following criteria: absence of both distal pulses and/or
ankle brachial index below 0.9. Ulcers in patients diagnosed
for neuropathy were defined as neuropathic ulcers. If both
neuropathy and peripheral arterial disease were present, the
ulcer was defined as neuroischemic.
During surgical intervention, bone samples were
extracted for analysis by the microbiology and pathology
laboratories. Only aerobic cultures were grown in this study.
Surgical wounds were copiously irrigated with DWC in the
operating room. DWC was irrigated daily through the
wound with the purpose of washing the residual bone.
According to our treatment protocol, cases with persistent
postoperative infection either in bone or soft tissue that precluded wound healing and/or produced clinical infectious
symptoms were reoperated. Reoperations included minor
and major amputations if required. Based on our previous
experience, infection control was considered successful
once the surgical wound and the index ulcer that acted as
the point of entry of the infection had healed.5,9 Patients
were followed-up to detect recurrence of the infection, reulceration (whether complicated or not with new osteomyelitis), and the need for amputation. Limb salvage was
achieved when the patient did not require a major amputation, which was defined as amputation through or above the
ankle joint.
The major endpoint to be evaluated was healing without
recurrence of the infection and need for amputation. Any
side effect associated with the treatment was assessed.
Patients gave informed consent for surgery, photography, and inclusion in the study. The ethical research committee of the Materno-Insular Hospital of Las Palmas de
Gran Canaria reviewed and approved the study protocol
and gave consent for publication.
Results
Histopathology reports confirmed osteomyelitis in every
case. Eleven cases were located in the forefoot, 6 on the
first ray and the rest in lesser toes, 1 in the Lisfranc joint,
and 2 on the calcaneus. Cases are presented in Table 1.
Eight patients had previously undergone surgery for the
same infection, which had not been resolved. Other teams
had treated 6 patients, and amputations (2 major) had been
indicated. Four patients had undergone surgery in our hospital but infection was not adequately resolved. DWC was
not used in the postoperative period following the initial
surgery. Cultures were negative in 3 cases, were not available in another one, and bacteria were isolated in the
Table 1. Case Series
Point of Entry to
the Infection
Case 1
Case 2
Neuroischemic
interdigital
ulcer
Spreading of
forefoot
infection
along plantar
aponeurosis
Case 3
Neuroischemic
plantar ulcer
beneath
the first
metatarsal–
phalangeal
joint
Case 4
Neuropathic
plantar ulcer
beneath
the first
metatarsal–
phalangeal
joint
Case 5
Location of Bone
Infection
Proximal phalanx
Previous Surgery Due
to the Same Infection
No
Yes. Forefoot
Calcaneus.
infection had been
Attachment of
operated. Calcaneus
plantar aponeurosis
osteomyelitis was
to the calcaneus
a consequence of
spreading of the
infection along
plantar aponeurosis.
DWC was not
applied at the first
surgery
Medial sesamoid bone Yes. DWC was not
surgery
Surgical Procedure
Bacteria Involved
Ostectomy of the
phalanx
NA
Calcaneus curettage Escherichia coli,
Streptococcus
spp.
DWC Use
Lavage of the open
wound and soaked
gauzes with DWC
Close lavage with
DWC through the
wound
Need for Reoperation
Postoperative
and/or Amputation
Antibiotic Treatment
No
3 weeks
No
7.1 weeks
Time to
Healing
Sesamoidectomy.
Keller’s
arthroplasty.
Internal fixation
Escherichia coli,
Methicillinresistant
Staphylococcus
aureus
Infection of the
surgical wound.
Closed lavage with
DWC through the
surgical wound and
gauzes soaked in
DWC
Yes
8.5 weeks
Medial sesamoid bone Yes. DWC was not
surgery
Sesamoidectomy.
Keller’s
arthroplasty.
Internal fixation
Staphylococcus
aureus
No
8.5 weeks
Neuroischemic
ulcer of the
big toe as a
consequence
of critical
ischemia
Distal phalanx of the
big toe. Big toe
amputation had
been indicated by
another team
Methicillinresistant
Staphylococcus
aureus
No
4.3 weeks
3 weeks
Case 6
Neuroischemic
ulcer on the
dorsum of the
foot
Case 7
Neuropathic
ulcer on the
fifth toe
Yes. Another team
Osteomyelitis of the
performed
Lisfranc joint. Major
debridement
amputation had
been indicated by
another team
No
Osteomyelitis of
the proximal
interphalangeal
joint. Fifth toe
amputation had
been indicated by
another team
Removal of the
distal phalanx.
After the first
procedure
recurrence
was found and
treated with new
curettage and
DWC
Curettage of the
Lisfranc joint
Infection of the
surgical wound and
reopening of the
ulcer. Closed lavage
with DWC through
the index ulcer and
gauzes soaked in
DWC
Lavage of the open
wound and gauzes
soaked in DWC
Yes. DWC was not
surgery
Curettage of the
interphalangeal
joint
Follow-Up
8.5 weeks Patient died 1 month
after healing following
heart attack
7.1 weeks 13 months without
recurrence
8.5 weeks Recurrence 2 months
after apparent healing.
Patient underwent
new conservative
surgical procedures.
No amputation has
been required in the
year since the first
surgery
recurrence
6 months without
recurrence
Yersinia
enterocolitica
Close intraosseus
lavage with DWC
through the wound
No
4.1 weeks
recurrence
No growth
Lavage of the open
wound and gauzes
soaked in DWC
No
0.3 weeks
recurrence
(continued)
3
4
Table 1. (continued)
Point of Entry to
the Infection
Case 8
Neuropathic
ulcer on the
big toe
Case 9
Neuropathic
ulcer over the
first metatarsal–
phalangeal joint
Location of Bone
Infection
interphalangeal joint
of the hallux. Big toe
amputation had been
indicated by another
team
Osteomyelitis of
the first metatarsalphalangeal joint.
Transmetatarsal
amputation had been
indicated by another
team
distal phalanx
Case 10 Neuropathic
ulcer on the
tip of the third
toe
Case 11 Interdigital
middle phalanx of
neuroischemic
the fourth toe
ulcer
Previous Surgery Due
to the Same Infection
Bacteria Involved
DWC Use
Need for Reoperation
Postoperative
and/or Amputation
Antibiotic Treatment
Time to
Healing
Follow-Up
No
Curettage of the
Escherichia coli
Lavage of the open
wound and gauzes
soaked in DWC
No
5.4 weeks
recurrence
Yes. Another
team performed
debridement during
admission in another
hospital
Curettage of the
first metatarsalphalangeal joint.
External fixator. The
index ulcer was left
open to allow joint
lavage
Ostectomy of the
distal phalanx
Proteus morganii,
Staphylococcus
aureus
Lavage through the
ulcer and gauzes
soaked in DWC
No
4.4 weeks
recurrence
No growth
Lavage of the wound
and gauzes soaked
in DWC
No
2.7 weeks
recurrence
Yes. Progressive
involvement of
soft tissue with
necrosis requiring
amputation of the
fourth toe
No
NA
NA
NA
7.1 weeks
11.4
weeks
Three months without
recurrence
No
No
Open arthroplasty
Acinetobacter
baumanii
Lavage of the open
wound and gauzes
soaked in DWC
Yes. Another team
performed
debridement.
Negative pressure
with silver was
applied during
admission in another
hospital
No
Curettage of the
calcaneus and
Chopart joint
No growth
Close intraosseus
lavage with DWC
through the wound
Open arthroplasty
Serratia
marcescens
Lavage of the open
wound and gauzes
soaked in DWC
No
4.8 weeks
3.8 weeks Five months without
recurrence
Partial distal
phalanx removal
Serratia
marcescens
Debridement of the
ulcer. Lavage of the
open wound and
bone exposed and
gauzes soaked in
DWC for 5 days.
Bone surgery and
closure of the
wound
No
3 weeks
2.1 weeks Three months without
recurrence
Case 12 Neuropathic
ulcer on the
heel
Osteomyelitis of
the calcaneus and
Chopart joint.
Major amputation
had been indicated
by another team
Case 13 Interdigital
neuropathic
ulcer
Osteomyelitis of
the proximal
of the fourth toe
Yes. DWC was not
distal phalanx of the
surgery
big toe
Case 14 Neuropathic
plantar ulcer
on the big toe
Surgical Procedure
Abbreviation: DWC, Dermacyn Wound Care (DWC; Oculus Innovative Sciences Netherlands BV, Sittard, Netherlands); NA, Not available.
5
Aragón-Sánchez et al.
Figure 1. Case 2. Abscess on the heel after undergoing
debridement of the plantar central compartment. Bone could be
probed through the incision
Figure 3. The wound was closed after new curettage of the
calcaneus, leaving a Foley’s catheter inside for performing
instilation with DWC
Figure 2. X-ray of the case 2.Yellow arrow shows cortical
defect where the abscess was drained
Figure 4. Total healing of the surgical wound
remainder, as illustrated in Table 1. Gram-negative bacteria
were isolated in 8 cases and methicillin-resistant
Staphylococcus aureus (MRSA) in 2 cases. Postoperative
antibiotic treatment was given for a median of 4.4 weeks.
DWC was used in different ways: closed lavage through
a catheter inserted in the cavity or by inserting the tip of a
syringe between the stitches, open lavage, or by placing
gauzes soaked in DWC. Case 2 is shown in Figure 1. The
patient had undergone debridement of the plantar central
compartment and was readmitted for abscess on the heel.
X-ray showed signs of osteomyelitis in the calcaneus (Figure 2,
yellow arrow). He underwent debridement and bone curettage, which did not resolve the infection. He underwent a
reoperation consisting of new curettage of the calcaneus and
the wound was closed, leaving a Foley’s catheter inside
(Figure 3). Postoperative culture-guided antibiotics were
administered and lavage with DWC was carried out 3 times
a day. The catheter was removed and healing was achieved
without complications (Figure 4). Lavage through the
stitches due to wound infection in case 3 is shown in Figure 5.
The Kirschner wire was not removed due to infection. The
Kirschner wire was removed 6 weeks after surgery, and the
patient was discharged with only a minor defect in wound
healing in order to undergo outpatient care (Figure 6A, white
arrow). However, recurrence 3 months after apparent healing was found in case 3 (Figure 6B). The latter patient underwent new conservative surgical procedures using DWC in
the postoperative period. No amputation has been required
in the year since the first operation. One patient (case 11,
Figure 7) required amputation of the toe due to uncontrolled
infection by Acinetobacter baumanii and progressive
destruction of the soft tissue envelope. Neither recurrence of
6
Figure 5. Lavage through the stitches due to wound infection in
case 3
the infection nor subsequent amputation was found in the
rest of the patients. Limb salvage was successfully achieved
in 100% of the cases. Healing was achieved in a median
period of 6.8 weeks.
No side effects appeared during treatment. Neither allergies nor skin dermatitis were found. Pain was not evaluable
because of the neuropathic etiology of the ulcers.
Discussion
The role of antiseptics in wound care is controversial
because in vitro studies have shown the cytotoxicity of such
products.15,16 Despite these in vitro studies, the clinical relevance of this cytotoxic effect on wound healing is
unknown and could be compensated for by their control of
bacterial burden.17 Recently, the cytotoxic effect of 12 commonly used antiseptics on topical application in vitro to 2
human skin substitutes and a full-thickness autograft was
assessed. Dermacyn was not cytotoxic in that study.18
Cytotoxicity was not assessed in the present study. However,
we consider that time to healing could be considered as an
indirect way to test the possible deleterious effect of DWC
on wound healing. In our first series dealing with DFO,
open wounds healed by secondary intention over a median
period of 12.8 weeks. The median wound healing time in
patients with successful conservative surgery was 11.4
weeks compared with 17.1 weeks for those who had minor
amputations (P = .003).5 Wound healing was achieved by
secondary intention after a median of 8 weeks in our more
recent series.9 Healing time in cases of wide postsurgical
wounds was 10.5 ± 5.9 weeks in the group treated with
DWC versus 16.5 ± 7.1 weeks in the group treated with
povidone iodine (P = .007).11 The median time to healing in
the current investigation using DWC was 6.8 weeks, and
this figure can be considered favorable. Even though we
cannot state categorically that the improvement in healing
time was due to the use of DWC, at least the healing time
was not prolonged due to possible cytotoxicity.
Our approach to dealing with DFO is to remove the
infected bone if possible and leave the wound open to healing by secondary intention in most cases.2,5,19-21 We hypothesized that using a product that reduces the bacterial burden
in bone and soft tissues could be beneficial. Two small single-center randomized controlled trials showed that superoxidized solution was useful for treating foot infections and
wide postsurgical lesions.10,11 Another group reported that
super-oxidized solution was at least as effective as oral
levofloxacin for mild diabetic foot infections.22
In this small series, DWC was always in contact with the
residual infected bone. It was applied by means of pulse
irrigation or by filling the wound cavity with soaked gauzes.
We also used closed lavage in cases in which the surgical
wound had been closed; in 2 of these cases a wire had been
inserted. Intraosseus lavage with DWC was used in midfoot
and calcaneus osteomyelitis. This is a novel approach in our
experience and the outcomes were favourable. Limb salvage was achieved in 100% of patients and only one
required a minor amputation. Infection was eradicated in
every patient included in this series and every wound
healed. Only 1 recurrence was detected but the patient was
treated with new conservative procedures, including the use
of DWC through the wound. No amputation has been
required to date in this complicated case.
One of the possible advantages of using DWC as adjuvant treatment to surgery and antibiotics could be its potential to reduce the period of postoperative antibiotic
treatment. IDSA guidelines recommend that in cases in
which residual infected (but viable) bone remains, antibiotics should be administered for 4 to 6 weeks initially parenterally but possibly switching to oral administration
depending on conditions.23 Definitive conclusions cannot
be drawn from our preliminary experience but 4.4 weeks
seems to be a short period compared with other investigations. Moreover, the microbiological isolates in this series
were a little atypical. They included a high proportion
of MRSA and gram-negative bacteria unlike most series
in which Methicillin Sensitive Staphylococcus aureus
(MSSA) was the most frequent isolate.1 Postoperative antibiotic treatment was given for a median of 5.1 weeks in our
previously reported prospective series.9 The duration of
antibiotic therapy was 10.1 ± 6.1 weeks in the group treated
with DWC compared with 15.8 ± 7.8 weeks in the group
treated with povidone iodine (P = .016) reported by
Piaggesi’s group.11
The weaknesses of this study were the following: there
was no control group, only short-term follow-up was conducted in 3 cases, and in our experience, at least 6 months
should be considered to state that the bone infection has
been eradicated. No bacteriological postoperative controls
7
Aragón-Sánchez et al.
Figure 6. (A) Minor defect in wound healing when the patient was discharged from hospital. (B) Recurrence of osteomyelitis after
apparent wound healing was detected after 3 months of follow-up
Figure 7. Progressive destruction of the soft tissue envelope and necrosis in case 11 requiring toe amputation
were carried out. The strengths of the study are that it is
the first time that DMC has been used in cases of residual
bone infection after surgery for DFO, bone infections
were always histopathologically confirmed, and patients
underwent specialized treatment in cases with a high risk
of amputation. Indeed, other teams had indicated several
amputations, including 2 major. The good outcomes
obtained in this preliminary study have encouraged us to
design a trial to test the use of DWC in cases of bone
infection.
In conclusion, using DWC as adjuvant treatment in the
postoperative period of surgery for DFO when the wound is
open and bone margins may have residual infection is safe
and may help eradicate the infection when combined with
antibiotic treatment. Additional controlled studies are necessary to determine the precise role of DWC in the management of patients who have a high risk of amputation.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Free samples of Dermacyn Wound Care (Oculus Innovative
Sciences Netherlands BV, Sittard, Netherlands) were received
from the company to be tested in a series of patients. No payments
or grants were received from the company.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Game F. Management of osteomyelitis of the foot in diabetes
mellitus. Nat Rev Endocrinol. 2010;6:43-47.
2. Aragon-Sanchez J. Treatment of diabetic foot osteomyelitis: a surgical critique. Int J Low Extrem Wounds.
2010;9:37-59.
3. Karchmer AW, & Gibbons GW. Foot infections in diabetes: evaluation and management. Curr Clin Top Infect Dis.
1994;14:1-22.
4. Ha Van G, Siney H, Danan JP, Sachon C, & Grimaldi A.
Treatment of osteomyelitis in the diabetic foot. Contribution
of conservative surgery. Diabetes Care. 1996;19:1257-1260.
5. Aragon-Sanchez FJ, Cabrera-Galvan JJ, & Quintana-Marrero Y,
et al. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement. Diabetologia. 2008;51:1962-1970.
8
6. Frykberg RG, Wittmayer B, & Zgonis T. Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg. 2007;24:469-482.
7. Zgonis T, Stapleton JJ, & Roukis TS. A stepwise approach to
the surgical management of severe diabetic foot infections.
Foot Ankle Spec. 2008;1:46-53.
8. Aragon-Sanchez J. Seminar review: a review of the basis
of surgical treatment of diabetic foot infections. Int J Low
Extrem Wounds. 2011;10:33-65.
9. Aragon-Sanchez J, Lazaro-Martinez JL, & HernandezHerrero C, et al. Does osteomyelitis in the feet of patients
with diabetes really recur after surgical treatment? Natural history of a surgical series. Diabet Med. 2012;29:813818.
10. Martinez-De Jesus FR, Ramos-De la Medina A, & RemesTroche JM, et al. Efficacy and safety of neutral pH superoxidised solution in severe diabetic foot infections. Int Wound J.
2007;4:353-362.
11. Piaggesi A, Goretti C, & Mazzurco S, et al. A randomized
controlled trial to examine the efficacy and safety of a new
super-oxidized solution for the management of wide postsurgical lesions of the diabetic foot. Int J Low Extrem Wounds.
2010;9:10-15.
12. Aragon-Sanchez J, Quintana-Marrero Y, & Lazaro-Martinez
JL, et al. Necrotizing soft-tissue infections in the feet of
patients with diabetes: outcome of surgical treatment and factors associated with limb loss and mortality. Int J Low Extrem
Wounds. 2009;8:141-146.
13. Eneroth M, Larsson J, & Apelqvist J. Deep foot infections in
patients with diabetes and foot ulcer: an entity with different
characteristics, treatments, and prognosis. J Diabetes Complications. 1999;13:254-263.
14. Aragon-Sanchez J, Lipsky BA, & Lazaro-Martinez JL. Diagnosing diabetic foot osteomyelitis: is the combination of
probe-to-bone test and plain radiography sufficient for highrisk inpatients? Diabet Med. 2011;28:191-194.
15. Lineaweaver W, Howard R, & Soucy D, et al. Topical antimicrobial toxicity. Arch Surg. 1985;120:267-270.
16. Cooper ML, Laxer JA, & Hansbrough JF. The cytotoxic effects
of commonly used topical antimicrobial agents on human
fibroblasts and keratinocytes. J Trauma. 1991;31:775-782.
17. Hermanns JF, Paquet P, Arrese JE, Pierard-Franchimont C,
& Pierard GE. The beneficial cytotoxicity of antiseptics. The
controversial paradox of cutaneous ulcer treatment. Rev Med
Liege. 1999;54:600-605.
18. Duc Q, Breetveld M, Middelkoop E, Scheper RJ, Ulrich MM,
& Gibbs S. A cytotoxic analysis of antiseptic medication on
skin substitutes and autograft. Br J Dermatol. 2007;157:
33-40.
19. Aragon-Sanchez J. Evidences and controversies about recurrence of diabetic foot osteomyelitis: a personal view and an
illustrated guide for understanding. Int J Low Extrem Wounds.
2012;11:88-106.
20. Garcia-Morales E, Lazaro-Martinez JL, Aragon-Sanchez J,
Cecilia-Matilla A, Garcia-Alvarez Y, & Beneit-Montesinos
JV. Surgical complications associated with primary closure in
patients with diabetic foot osteomyelitis. Diabet Foot Ankle.
2012;3. doi:10.3402/dfa.v3i0.19000.
21. Aragon-Sanchez J, Lazaro-Martinez JL, & HernandezHerrero C, et al. Surgical treatment of limb- and life-threatening
infections in the feet of patients with diabetes and at least one
palpable pedal pulse: successes and lessons learnt. Int J Low
Extrem Wounds. 2011;10:207-213.
22. Landsman A, Blume PA, Jordan DA Jr, Vayser D, & Gutierrez A.
An open-label, three-arm pilot study of the safety and efficacy
of topical Microcyn Rx wound care versus oral levofloxacin
versus combined therapy for mild diabetic foot infections.
J Am Podiatr Med Assoc. 2011;101:484-496.
23. Lipsky BA, Berendt AR, & Cornia PB, et al. 2012 Infectious
Diseases Society of America clinical practice guideline for
the diagnosis and treatment of diabetic foot infections. Clin
Infect Dis. 2012;54:e132-e173.
vviVÌÃÊvÊ«Ê iÕÌÀ>]Ê-Õ«iÀ"Ý`âi`Ê-ÕÌÊ"ÊÕ>ÊiÀ>ÊLÀL>ÃÌÃÊ
฀
â?iâÊ£]Ê*jÀiâÊ£]ÊÕâ?Ê£]ÊÀ>ÃÊ£]ÊÊ}Û>Ê
Ó]ÊÕÌjÀÀiâÊÊÎ
฀
฀ ฀
฀
฀ ฀
฀
฀
฀
,"1 \
฀
฀
฀
"
/6\Ê
฀
฀
/"-\
Ê
UÊ
฀฀
฀
฀฀
฀
฀฀
฀
฀฀
฀
฀฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀ ฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
-β
฀
฀
฀
฀
฀
฀
฀ ฀฀ ฀
฀
฀
฀ ฀
฀
฀
฀
฀ ฀
฀ ฀
฀
฀ ฀ ฀
฀ ฀
฀ ฀
฀
฀
฀ ฀
฀
฀
฀ ฀ ฀
฀
฀
฀
฀
฀
,-1/-\
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀ ฀
฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀฀
฀
฀
฀ ฀ ฀
฀
฀
฀ ฀
฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀ ฀
฀ ฀
฀
฀
฀
฀ ฀
฀
฀ ฀
฀
฀ ฀
฀ ฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀
฀
฀ ฀ ฀
฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀ ฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀
฀฀
฀
฀
฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀ ฀
฀฀
฀
฀
β
฀ ฀
฀
" 1-" \Ê
฀
฀
฀
฀
฀ ฀
฀ ฀
฀β
฀฀
฀ ฀
฀
฀ ฀ ฀
฀
฀
฀
฀ ฀
฀
฀
฀ ฀
฀
฀
฀
฀
฀ ฀
฀
฀
฀฀ ฀
฀
฀
฀
฀
฀
฀ ฀ ฀ ฀
฀
฀
฀
฀
฀
฀ ฀
฀
฀ ฀
฀
฀ ฀
฀ ฀
฀
฀ ฀
฀
฀
฀
฀
฀
฀
฀
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*
)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*
3%)3)5&$'3-*2$*6$%&2)1**
"#$!%&'(%&)*+,$!-&.!/0#-$1&#*2!3!.2(!'&(0.*$-2(!
).4#+)2(!-&!0#$!#2,&-2($!(2.0)+5#!$#*+(6%*+)$!
(0%&'27+-$-$!&#!&.!*'$*$1+&#*2!-&!8&'+-$(!
*
!
!
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
I*
9#-+)&!!
*
*
*
:2.0)+5#!$#*+(6%*+)$!(0%&'27+-$-$!;+)'2)3#!<&8#2.2=3!!
&#!8&'+-$(!-&!.$(!&7*'&1+-$-&(!+#/&'+2'&(!!
B'3%-2.((&J'*K*$"#$%&$'(&)*3$5#%)')*LLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLLL*#M0&')*N**
>$,+-!?@!A..+&B!;>!!
C)%2&-/)1(.+)%*B'13&3.3$*-O*36$*8-.36**
;)O)K$33$7*;-.&1&)')**
*
*
C$(&!)+&#*4/+)$!-&.!$=0$!(0%&'27+-$-$!&(*$D.&!
!"#+-%)(&J'*2$*+)1*2&/$%1)1*)#+&()(&-'$1*2$*+)1*1-+.(&-'$1*1.#$%-"&2)2)1**LLLLLLLLLLLLLLLLLLLLLLL*#M0&')*P**
A#-'6(!A@!E0*+6''&FB!;>B!G8>!!
?(.+.1*B''-/)3&/$*8(&$'($1**
:$3)+.5)7*C)+&O-%'&)**
*
*
H0+-$-2!-&!8&'+-$(!$,$#F$-2!)2#!$=0$!(0%&'27+-$-$!&(*$D.&!!
CJ5-*.'*3%)3)5&$'3-*(-54&')2-*#.$2$*-#3&5&Q)%*+)*(&()3%&Q)(&J'*2$*+)1*6$%&2)1**LLLLLLLL*#M0&')*II*
<21!A@!I2.,2(B!;>B!JAH:!!
8(-3312)+$*R$)+36()%$*S-.'2*<)')0$5$'3*8$%/&($1**
8(-3312)+$7*@%&Q-')**
*
*
<'$*$1+&#*2!-&!K.)&'$(!-&.!%+&!-+$D6*+)2!)2#!$=0$!(0%&'27+-$-$!!
9')*/&1&J'*2$*+-1*)/)'($1*$'*$13$*3%)3)5&$'3-*)3J"&(-*2$*#R*'$.3%-**LLLLLLLLLLLLLLLLLLLLLLLLLLLL*#M0&')*IT**
L0)$!>$..$!G$2.$B!;>!!
A$#)%3)5$'3-*2$+*:&$*A&)4U3&(-7*C+,'&()*2$*:&$*K*>-4&++-**
R-1#&3)+*@4)'-*>$%5$7*@4)'-*>$%5$7*B3)+&)**
*
*
M&-0)+5#!-&!.$(!)21%.+)$)+2#&(!+#/&))+2($(!D$)*&'+$#$(!-&!.$(!8&'+-$(!%2'!
N0&1$-0'$!!
9')*/&1&J'*2$+*.1-*2$*?(.+.1*<&(%-(K'HG*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*$'*<U"&(-**LLLLLLL*#M0&')*IP**
A'+&.!;+'$#-$!A.*$1+'$#2B!;>!!
9'&2)2*2$*V.$5)2.%)1*:$2&M3%&()17**
R-1#&3)+*C&/&+7*W.)2)+)X)%)7*<U"&(-*
*
*
!
:2.0)+5#!$#*+(6%*+)$!(0%&'27+-$-$!
;+)'2)3#!<&)8#2.2=3!&#!8&'+-$(!-&!
.$(!&7*'&1+-$-&(!+#/&'+2'&(!!
*
B'3%-2.((&J'*K*$"#$%&$'(&)*3$5#%)')*
>$,+-!?@!A..+&B!;>!
!
@*
+* (-'1&2$%)%* $+* $1#$(3%-* 2$* +)1* 6$%&2)1* 2$* +)1*
$"3%$5&2)2$1* (%J'&()1* $'* +)1* Y.$* +)* &'O$((&J'* X.$0)* .'*
#)#$+* (+,'&(-7* &'5$2&)3)5$'3$* /&$'$'* )* +)* 5$'3$* +)*
&1Y.$5&)* (%,3&()* 2$* +)1* $"3%$5&2)2$1* ZBC![7* \+($%)1* 2$+* #&$*
2&)4U3&(-* Z9:A[7* )5#.3)(&-'$1* #-%* 2$4)X-* 2$* +)* %-2&++)* Z@AE[7*
83)#6K+-(-((.1* ).%$.1* %$1&13$'3$1* )* +)* 5$3&(&+&')* Z<E8@[7* $*
&'1.O&(&$'(&)* /$'-1)* (%J'&()* ZBC][L* !+* #)#$+* 2$* +)* &'O$((&J'* $'*
$13)1* (-'2&(&-'$1* #.$2$* /)%&)%* 2$12$* +$/$* )* 1$/$%-7* #$%-*
#%-4)4+$5$'3$*X.$0)*.'*#)#$+*1&0'&O&()3&/-*$'*+)*5)K-%,)*2$*+-1*
()1-1L* !13$* 1.#+$5$'3-* &'3%-2.(&%M* .')* '-/$2-1)* 1-+.(&J'*
)'3&1U#3&()* +-()+* 1.#$%-"&2)2)7* <&(%-(K'^* >$(6'-+-0K* Z?(.+.1*
B''-/)3&/$* 8(&$'($17* :$3)+.5)7* C)+&O-%'&)[7* K* $13.2&)%M* +)* 4)1$*
(&$'3,O&()* $'* 3-%'-* )* 1.* 5$()'&15-* 2$* )((&J'* \'&(-* K* +)1*
#%&5$%)1* $"#$%&$'(&)1* (+,'&()1* $'* ($'3%-1* 2$* B3)+&)7* <U"&(-* K*
!13)2-1* 9'&2-1L* !+* &5#)(3-* (+,'&(-* K* $(-'J5&(-* 2$* +)1*
&'O$((&-'$1* )0.2)1* K* (%J'&()1* $'* +)1* 6$%&2)1* 2$* +)1*
$"3%$5&2)2$1* &'O$%&-%$1* $1* 1&'* 2.2)* &5#-%3)'3$7* #$%-* $13$*
&5#)(3-* 1$* /$* $5#$Y.$_$(&2-* )+* (-'1&2$%)%* $+* &5#)(3-* 0+-4)+*
(+,'&(-*K*$(-'J5&(-*1-4%$*+)*1)'&2)2*2$*+)1*&'O$((&-'$1*)*3%)/U1*
2$*3-2-*$+*$1#$(3%-*2$*6$%&2)1*(.3M'$)1*)0.2)1*K*(%J'&()1*Z#-%*
$X$5#+-7* \+($%)1* #-%* #%$1&J'7* Y.$5)2.%)17* 3%).5)3&15-17*
&'O$((&-'$1* Y.&%\%0&()17* )('U[7* )1,* (-5-* &'O$((&-'$1*
%$1#&%)3-%&)1* )0.2)1* K* (%J'&()1* Z(-5-* 1&'.1&3&17* 4%-'Y.&3&17*
'$.5-'&3&1*-*0%&#$*)/&)%[L**
*
;)* %$)+&2)2* 2$* +)1* &'O$((&-'$1* K* +)* #U%2&2)* 2$*
$"3%$5&2)2$1**
!'3%$* FFGLGGG* K* FTGLGGG* )5#.3)(&-'$1* 2$* +)1* $"3%$5&2)2$1*
&'O$%&-%$1* 1$* %$)+&Q)'* )'.)+5$'3$* $'* +-1* !13)2-1* 9'&2-1* K*
Ià
!.%-#)* )* ().1)* 2$* &'1.O&(&$'(&)* )%3$%&)+7* 2&)4$3$1* $* BC!L * !'*
!13)2-1* 9'&2-17* +)* 3)1)* 2$* )5#.3)(&J'* 1$* 6)* &'(%$5$'3)2-* 2$*
Ib* )* NG* #-%* IGGLGGG* #$%1-')1c)_-* 2.%)'3$* +)1* \+3&5)1* F*
2U()2)17*2$4&2-*#%&'(&#)+5$'3$*)*.'*).5$'3-*2$*+)*2&)4$3$1*K*
H`P
+)* $2)2* )/)'Q)2)L * !'* +-1* #)(&$'3$1* 5)K-%$1* 2$* da* )_-1* 2$*
$2)27* 1$* 6)* %$#-%3)2-* .')* 3)1)* 2$* )5#.3)(&J'* 2$* ITG* #-%*
!
IGGLGGG* #$%1-')1c)_-7* 5&$'3%)1* Y.$* +)* )5#.3)(&J'* #%&5)%&)*
Z@:[* 3-2)/,)* (-'++$/)* .')* 3)1)* 2$* 5-%3)+&2)2* 2$5)1&)2-*
P`b
IG
$+$/)2)* 2$* INÌPeL * !'* +-1* #)(&$'3$1* 2$* 5)K-%* %&$10-7 * +)*
5-%3)+&2)2* #$%&-#$%)3-%&)* )* NG* 2,)1* 2$1#.U1* 2$* +)* )5#.3)(&J'*
#.$2$* 1$%* 2$* T`NGe7* K* +)* 5-%4&+&2)2* FG`NPe7* 2$4&2-* )* Y.$*
5.(6-1* #)(&$'3$1* (-'* BC!* $'* O)1$* 3$%5&')+* #)(&$'3$1* 1.O%$'*
&'O$((&J'7* 1$#1&1* $* &'1.O&(&$'(&)* %$')+* #%-0%$1&/)L* ;)*
%$6)4&+&3)(&J'*(-'*U"&3-*3%)1*.')*@fE*1$*(-'1&0.$*$'*5$'-1*2$*
2-1* 3$%(&-1* 2$* +-1* #)(&$'3$1g* 2$1#.U1* 2$* )5#.3)(&-'$1* #-%*
$'(&5)* 2$* +)* %-2&++)7* $13)* O%)((&J'* $1* &'O$%&-%* )* +)* 5&3)2* 2$* +-1*
#)(&$'3$1L* !'* 0$'$%)+7* 5$'-1* 2$+* aGe* 2$* 3-2-1* +-1* #)(&$'3$1*
IIÌa
Y.$* %$Y.&$%$'* )5#.3)(&J'* '.'()* +-0%)* +)* #+$')* 5-/&+&2)2L
*
<\+3&#+$1*&'O-%5$1*6)'*2-(.5$'3)2-*$+*5)+*#%-'J13&(-*0$'$%)+*
2$*+-1*#)(&$'3$1*(-'*BC!7*(-'*3)1)1*2$*5-%3)+&2)2*1.#$%&-%$1*)+*
aGe*)+*()4-*2$*N*)_-1*K*.')*3)1)*2$*5-%3)+&2)2*2-4+$*2$1#.U1*
2$* @fE* $'* (-5#)%)(&J'* (-'* +)* %$0&13%)2)* 1)+/)'2-* +)*
IG7IH
$"3%$5&2)2L
* !1* $/&2$'3$* Y.$* $+* &5#)(3-* (+,'&(-* 2$* +)* BC!* K*
+)1*)5#.3)(&-'$1*$1*3%$5$'2-7*K*$+*#)#$+*0+-4)+*2$*+)*&'O$((&J'*
$'*+)*#U%2&2)*2$*+)*$"3%$5&2)2*$1*#-(-*(-'-(&2-*K*(&$%3)5$'3$*
#-(-*)#%$(&)2-L*
*
*
;)*%$6)4&+&3)(&J'*(-'*U"&3-*3%)1*.')*
)5#.3)(&J'*#-%*2$4)X-*2$*+)*%-2&++)*
1$*+-0%)*$'*5$'-1*2$*2-1*3$%(&-1*2$*
+-1*#)(&$'3$1L*
*
:.'3-*2$*/&13)*$(-'J5&(-*
!+*(-13$*3-3)+*2$+*3%)3)5&$'3-*2$*+)*BC!*$'*!13)2-1*9'&2-1*1$*
$13&5)*$'*IG`FG*5&+*5&++-'$1*2$*h*)+*)_-L*N*8$*$13&5)*Y.$*1J+-*
.'*Fae*2$*%$2.((&J'*2$*+)1*)5#.3)(&-'$1*#-2%,)*)6-%%)%*2$*F7b*
)*N7G*5&+$1*2$*5&++-'$1*2$*h*$'*$+*0)13-*1)'&3)%&-*2$*+-1*!13)2-1*
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
3*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
N
9'&2-1L *?3%-1*2)3-1*$(-'J5&(-1*Y.$*O)/-%$($'*+)*1)+/)(&J'*2$*
+)* $"3%$5&2)2* 1-'* $+* 5)K-%* (-13$* 2$* +)1* )5#.3)(&-'$1* K* 2$+*
(-%%$1#-'2&$'3$* #%-($2&5&$'3-* 2$* %$6)4&+&3)(&J'7* $'*
(-5#)%)(&J'* (-'* +)* 1)+/)(&J'* 2$* +)* $"3%$5&2)2L* @2$5M17* $+*
(-13$*)'.)+*2$+*1$0.&5&$'3-*-*2$*+)*)3$'(&J'*)*+)%0-*#+)Q-*K*$+*
3%)3)5&$'3-* 2$* .'* )5#.3)2-* 1$* 6)* $13&5)2-* $'*
)#%-"&5)2)5$'3$*TbLGGG*h*1&*#$%5)'$($*$'*()1)*K*$'*bGLGGG`
IGGLGGG*h*1&*2$4$*&'0%$1)%*$'*.')*%$1&2$'(&)*ZIa`FGe*2$+*3-3)+*
N7IG7IHÌd
2$*)5#.3)2-1[*O%$'3$*)*HGG*h*1&*1$*1)+/)*+)*$"3%$5&2)2L
*
<M1*2$*a*5&++-'$1*2$*#)(&$'3$1*1.O%$'*2$*6$%&2)1*(%J'&()1*$'*
!!L99L* ()2)* )_-7* (-'* .'* (-13$* )'.)+* 3-3)+* 2$* 5M1* 2$* FG* 5&+*
Ib7FG
* 8J+-* +-1* (-13$1* 2$+* 3%)3)5&$'3-* 2$* \+($%)1*
5&++-'$1* 2$* hL*
#-%* #%$1&J'* 1-'* 1.#$%&-%$1* )* 5&+* 5&++-'$1* 2$* h* )+* )_-7* K* $'3%$*
I7a* K* N* 5&++-'$1* 2$* )2.+3-1* $'* !13)2-1* 9'&2-1* $'* ($'3%-1* 2$*
FI
)3$'(&J'* )* +)%0-* #+)Q-* %$Y.&$%$'* 3%)3)5&$'3-* )'.)+5$'3$L *
B'2.2)4+$5$'3$7*+)*&'O$((&J'*2$1$5#$_)*.'*0%)'*#)#$+*(+,'&(-*
K* $(-'J5&(-* $'* $+* (.&2)2-* 2$* 6$%&2)1* (%J'&()17* K* +-1*
)'3&4&J3&(-1* ++$/)'* )1-(&)2)1* (-5#+&()(&-'$17* $O$(3-1*
1$(.'2)%&-1*K*(-13$1*$(-'J5&(-1*1&0'&O&()3&/-1L*
!+*(-13$*6-1#&3)+)%&-*2&)%&-*)*'&/$+*')(&-')+*#)%)*#)(&$'3$1*2$*
<$2&()%$* #%-5$2&)* FLNHG* hg* #-%* +-* 3)'3-7* (.)+Y.&$%* $13%)3$0&)*
#)%)* $13$%&+&Q)%* %M#&2)5$'3$* +)1* 6$%&2)17* 2&15&'.&%* $+* .1-* 2$*
)'3&4&J3&(-1*#-%*/,)*&'3%)/$'-1)*K*-%)+7*%$2.(&%*6-1#&3)+&Q)(&-'$17*
K* O)(&+&3)%* 3&$5#-* #)%)* +)* (&()3%&Q)(&J'* 2$* 6$%&2)1* 3$'2%,)* .'*
FF
&5#)(3-*(+,'&(-*K*$(-'J5&(-*1&0'&O&()3&/-L **!1*#%-4)4+$*Y.$*+-1*
(-13$1* 0+-4)+$1* 2$* +)* &'O$((&J'* $'* $+* #)'-%)5)* 5.'2&)+* 2$* +)*
1)+.2* 1.#$%$'* +-1* IGG* 5&++-'$1* 2$* h* )'.)+$1L* ;-1* 2)3-1* K* +)1*
$"#$%&$'(&)1* &'&(&)+$1* 1.0&$%$'* Y.$* $+* 3%)3)5&$'3-* 2$* 6$%&2)1*
(-'* A$%5)(K'* ZO-%5.+)2-* (-'* 3$('-+-0,)* <&(%-(K'[* #.$2$*
3$'$%* .'* &5#)(3-* O)/-%)4+$* $'* $+* (.&2)2-* 2$* 6$%&2)17*
$1#$(&)+5$'3$* $'* +)* (-'1$(.(&J'* 2$* .')* 5M1* %M#&2)*
$13$%&+&Q)(&J'* 2$* +)1* 6$%&2)17* O)(&+&3)'2-* #-%* 3)'3-* +)*
(&()3%&Q)(&J'L*8&'*$54)%0-7*1$%M'*'$($1)%&-1*2)3-1*#%-1#$(3&/-17*
)+$)3-%&Q)2-17* 5.+3&(U'3%&(-1* 4)1)2-1* $'* +)* $/&2$'(&)* #)%)*
$/)+.)%* (&$'3,O&()5$'3$* +-1* 5U%&3-1* 2$* $13$* #%-5$3$2-%*
3%)3)5&$'3-*$5$%0$'3$*$'*$+*(.&2)2-*2$*6$%&2)1L*
*
Z;!k?E7* '* i* T[L* 8$* -41$%/J* Y.$* $+* 3%)3)5&$'3-* (-'* A$%5)(K'*
$%)*1$0.%-7*1$'(&++-*K*4&$'*3-+$%)2-*#-%*+-1*#)(&$'3$1L*;)*%M#&2)*
$13$%&+&Q)(&J'* (+,'&()* 2$* 3-2)1* +)1* 6$%&2)1* O)(&+&3J* $'* 0$'$%)+* +)*
(.%)(&J'* 2$* +)1* 6$%&2)1* K* +)* #%$#)%)(&J'* 2$* +)1* 5&15)1* #)%)*
3$%)#&)1* )2K./)'3$1* 5M1* 2$O&'&3&/)17* (-5-* +)* #&$+* )%3&O&(&)+*
@#+&0%)O*Zl&0.%)*I[L**
*
!1*#%-4)4+$*Y.$*+-1*(-13$1*3-3)+$1*2$*
+)*&'O$((&J'*$'*$+*#)'-%)5)*1)'&3)%&-*
5.'2&)+*1$)'*1.#$%&-%$1*)*IGG*
5&++-'$1*2$*h*)'.)+$1L*
**
;)* $"#$%&$'(&)* 3$5#%)')* ZT* 5$1$1[* 2$+* ).3-%* (-'* A$%5)(K'*
$'* (.)'3-* )* 1$0.%&2)2* K* /&)4&+&2)2* 6)* 1&2-* O)/-%)4+$* $'* $+*
3%)3)5&$'3-*2$*.')*1$%&$*2$*6$%&2)1*(-5#+$X)1*&'O$(3)2)1*$'*+)1*
$"3%$5&2)2$1* Z'* i* TG[7* &'(+.K$'2-* BC!* Z'* i* Fd[7* BC]* Z'* i* H[7*
3%).5)*Z'*i*F[7*K*2$6&1($'(&)*Y.&%\%0&()*Z'*i*T[L*@*#$1)%*2$*+)1*
+&5&3)(&-'$1*2$*$13$*)'M+&1&1*'-*)+$)3-%&Q)2-*K*%$3%-1#$(3&/-*2$*
#$Y.$_)1* 1$%&$17* '-* 1$* %$0&13%)%-'* (-5#+&()(&-'$1* %$+)(&-')2)*
(-'*A$%5)(K7*K*+)*3)1)*2$*1)+/)(&J'*2$*+)1*$"3%$5&2)2$1*O.$*2$+*
IGGeL*>-2)1*+)1*6$%&2)1*(&()3%&Q)%-'*Z3&$5#-*5$2&-*i*FN*2,)1[7*K*
1$* .3&+&Q)%-'* 2&/$%1)1* 3$%)#&)1* )2K./)'3$17* (-5-* #&$+* )%3&O&(&)+*
2$* 4&-3$('-+-0,)* Z@#+&0%)O7* ?%0)'-0$'$1&17* B'(L7* C)'3-'7*
<)11)(6.11$3317*'*i*d[7*$+*3%)3)5&$'3-*2$*+)*6$%&2)*#-%*#%$1&J'*
'$0)3&/)* Z]@C* >6$%)#K7* j&'$3&(* C-'($#317* B'(L7* 8)'* @'3-'&-7*
>$")17*'*i*T[7*K*+)*1.13&3.(&J'*+-()+*2$*-",0$'-*$'*+)*$"3%$5&2)2*
!
*
*
l&0.%)*IL*m+($%)*&'O$(3)2)*#-%*&'1.O&(&$'(&)*(%J'&()*/$'-1)*2$*I*
)_-*2$*2.%)(&J'Z@[L*;$(6-*2$*6$%&2)*1)')*'-*&'O$(3)2)*2$1#.U1*
2$*+)*$13$%&+&Q)(&J'*2$*+)*6$%&2)*(-'*A$%5)(K'*N*/$($1*)+*2,)*K*
2$14%&2)5&$'3-*5$'-%*Zf[L*>$%)#&)*5\+3&#+$*(-'*(U+.+)1*2$*2-1*
()#)1*)#+&()2)*(-5-*3%)3)5&$'3-*)2K./)'3$*ZC[L*C.%)(&J'*
(-5#+$3)*)*+-1*F*5$1$1*ZA[L**
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
T*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
*
;)* &'O$((&J'* )(3&/)* $1* .')* (-'3%)&'2&()(&J'* (-'-(&2)* )* +)*
.3&+&Q)(&J'*2$*+)*#&$+*)%3&O&(&)+*@#+&0%)O*K*2$*+)*3$%)#&)*2$*#%$1&J'*
'$0)3&/)L* ?3%-1* 6)++)Q0-1* (+,'&(-1* 2$* $13)* 1$%&$* &'(+.K$'* .')*
2&15&'.(&J'*2$+*.1-*2$*)'3&4&J3&(-)*ZB]*K*-%)+$1[*K*+)*%$2.((&J'*
2$*+)1*6-1#&3)+&Q)(&-'$1*#)%)*$+*3%)3)5&$'3-*2$*6$%&2)1L*
*
9'&/$%1&2)2* 2$* W.)2)+)X)%)* K* p$O$* 2$* +)* 9'&2)2* 2$* V.$5)2-1*
:$2&M3%&(-1* 2$+* R-1#&3)+* C&/&+7* #%$1$'3)* +-1* &5#%$1&-')'3$1*
HG
%$1.+3)2-1* 2$* 2&(6-* ($'3%-* .3&+&Q)'2-* <&(%-(K' * 2$* ?(.+.1* $'*
.')*)5#+&)*/)%&$2)2*2$*#)(&$'3$1*#$2&M3%&(-1*(-'*Y.$5)2.%)1L*
*
:$%1#$(3&/)1*2$*O.3.%-*
;)* %$1&13$'(&)* )* +-1* )'3&4&J3&(-1* 1$* 6)* (-'/$%3&2-* $'* .'*
&5#-%3)'3$* #%-4+$5)* 1)'&3)%&-* $'* $+* 3%)3)5&$'3-* 2$* 5.(6-1*
#)(&$'3$1* 6-1#&3)+&Q)2-1* K* )54.+)3-%&-1L* !1* #)%3&(.+)%5$'3$*
#%-4+$5M3&()* $'* \+($%)1* 2$+* #&$* 2&)4U3&(-L* !'* (-'(%$3-7* +-1*
)0$'3$1* #)3J0$'-1* <E8@* 6)'* 1&2-* )1-(&)2-1* (-'* .'* ).5$'3-*
1&0'&O&()3&/-* 2$* +)* &'(&2$'(&)7* &'(%$5$'3-* 2$* +)* $13)'(&)*
6-1#&3)+)%&)* K* 2$* +-1* (-13$17* K* %$1.+3)2-1* (+,'&(-1* 5M1* #-4%$1*
(-'* )+3)1* 3)1)1* 2$* )5#.3)(&J'* K* 3)1)1* 2$* 5-%3)+&2)2* 5M1*
Fa7FH
)+3)1L
* ;)* /)'(-5&(&')* $1* ()2)* /$Q* 5$'-1* $O&()Q* (-'3%)* +-1*
<E8@7* 2)'2-* +.0)%* )* +)* )#)%&(&J'* 2$* '.$/-1* )'3&4&J3&(-1* Y.$*
1-'* ()%-1* K* 3&$'$'* %&$10-1* 1&0'&O&()3&/-1L* !1* $/&2$'3$* Y.$* .')*
1-+.(&J'* 3J#&()* +-()+* Y.$* 3$'0)* .')* $"($+$'3$* $O&()(&)* O%$'3$* )*
<E8@* K* -3%-1* #)3J0$'-1* 4)(3$%&)'-1* K* '-* 4)(3$%&)'-1* (-'*
(-5#+&()(&-'$1* 5,'&5)1* -O%$($%,)* .'* #-3$'(&)+* 2$* 5$X-%)*
1&0'&O&()3&/)* 1-4%$* +-1* 3%)3)5&$'3-1* )(3.)+$1* #)%)* +)*
2$1&'O$((&J'*K*(&()3%&Q)(&J'*2$*6$%&2)1L !*
*
!'*$13$*1.#+$5$'3-7*Y.$*$1*.')*%$#%-2.((&J'*2$*.'*1&5#-1&-*
2$* (.&2)2-* 2$* 6$%&2)1* #%$1$'3)2-* $'* +)* C-'O$%$'(&)* 1-4%$*
=.$/-1*R-%&Q-'3$1*C)%2&-/)1(.+)%$1*K*W$13&J'*2$+*:&$*A&)4U3&(-*
$'* <&)5&7* l+-%&2)7* $'* -(3.4%$* 2$* FGGa7* /)%&-1* 5U2&(-1*
%$#.3)2-1* #%$1$'3)'* 1.1* #%&5$%)1* $"#$%&$'(&)1* (-'* +)*
3$('-+-0,)* 1.#$%-"&2)2)* <&(%-(K'* $'* .')* 1$%&$* 2$* $1($')%&-1*
(+,'&(-1*(-5-*\+($%)1*2$+*#&$*2&)4U3&(-7*\+($%)1*#-%*BC!7*6$%&2)1*
3%).5M3&()1*(-5#+$X)17*K*Y.$5)2.%)1L*R)K*5M1*2$*Id*5&++-'$1*
2$* #)(&$'3$1* $13)2-.'&2$'1$1* Y.$* 1.O%$'* 2$* 2&)4$3$17* Y.$*
)6-%)* $1* +)* 1$"3)* ().1)* #%&'(&#)+* 2$* 5.$%3$* K* +)* #%&'(&#)+*
FN
(-'3%&4.K$'3$* $'* 5M1* 2$+* aGe* 2$* +)1* )5#.3)(&-'$1L *
@#%-"&5)2)5$'3$* $+* dG`dae* 2$* 3-2)1* +)1* )5#.3)(&-'$1* /)'*
#%$($2&2)1* 2$* .')* \+($%)* Z#-%* $X$5#+-7* &1Y.U5&()7* 2$+* #&$*
2&)4U3&(-7* #-%* BC!7* 5&"3)[7* K* +)1* &'O$((&-'$1* #%-O.'2)1* K* +)*
-13$-5&$+&3&1* 3&$'$'* 1&'* 2.2)* .'* #)#$+* &5#-%3)'3$* $'* 5.(6)1*
FT
)5#.3)(&-'$1L **
!+* >'@! A#-'6(! E0*+6''&F* (-5$'3)* +)* 4)1$* (&$'3,O&()* K* $+*
5$()'&15-* 2$* )((&J'* 2$* <&(%-(K'* >$(6'-+-0K* #)%)* +-0%)%* +)*
%M#&2)* $13$%&+&Q)(&J'* %M#&2)* 2$* 6$%&2)1* 1&'* )#)%$'3$* 2)_-* )* +)1*
(U+.+)1* '-%5)+$1L* >)54&U'* #%$1$'3)* 2)3-1* &'3$%$1)'3$1* $*
&5#%$1&-')'3$1* 2$* <U"&(-* $'* $+* 3%)3)5&$'3-* 2$* .')* )5#+&)*
/)%&$2)2* 2$* 6$%&2)1* )0.2)1* K* (%J'&()17* )1,* (-5-* #+)'$1* #)%)*
.')* .+3$%&-%* %$(-#&+)(&J'* K* )'M+&1&1* 2$* 2)3-1* )+$)3-%&Q)2-1* Y.$*
-O%$Q()'*.')*5$X-%*#$%1#$(3&/)L**
!+* >'@! <21! I2.,2(7* (&%.X)'-* K* $1#$(&)+&13)* $'* $+* (.&2)2-* 2$*
6$%&2)1* $'* 0$'$%)+7* #%$1$'3)* 1.* $"#$%&$'(&)* (-'* A$%5)(K'*
S-.'2*C)%$*$'*.')*/)%&$2)2*2$*6$%&2)1*(-5#+$X)1*K*)/)'Q)2)17*
&'(+.K$'2-* .')* $"#$%&$'(&)* \'&()* $'* +)* (-54&')(&J'* 2$*
A$%5)(K'* (-'* 3$%)#&)* 2$* #%$1&J'* '$0)3&/)* 2$* +)* 6$%&2)* (-'* $+*
]@C*K*$+*]@C*B'83&++7*Y.$*#$%5&3$*+)*&'13&+)(&J'*2$*+,Y.&2-1*$'*+)*
6$%&2)L* ;)1* 6$%&2)1* )/)'Q)2)1* %$#-%3)2)1* #-%* $+* A%L* S-+/-1*
&'(+.K$'* 0%)'2$1* \+($%)1* #-%* 2$(\4&3-7* 0%)'2$1* 2$6&1($'(&)1*
#-13-#$%)3-%&)1* 2$* +)* 6$%&2)* (-'* 5)++)* 2$* +)* #)%$2* )42-5&')+*
$"#.$13)* K* (-5#+$X)1* 6$%&2)1* Y.&%\%0&()1* 3%).5M3&()1* K*
#-13-#$%)3-%&)1L**
!+* >'@! L0)$! >$..$! G$2.$7* $'2-(%&'J+-0-* K* $1#$(&)+&13)* $'* $+*
(.&2)2-*2$*6$%&2)17*#%$1$'3)%M*1.*$"#$%&$'(&)*(-'*A$%5)(K'*$'*
$+*R-1#&3)+*@+4)'-*>$%5$7*$'*@+4)'-*>$%5$7*B3)+&)L*!+*A%L*:)-+)*
#%$1$'3)%M* +-1* 2)3-1* $'* #)(&$'3$1* (-'* BC!* )/)'Q)2)* Y.$*
%$Y.&%&$%-'* .')* %$/)1(.+)%&Q)(&J'* (-5#+$X)7* 2$14%&2)5&$'3-*
Y.&%\%0&(-7* K* (-'3%-+* 2$* &'O$((&J'* K* 2&)4$3$1* #)%)* +-0%)%* +)*
1)+/)(&J'*2$*+)*$"3%$5&2)2*n$'*FId*#)(&$'3$1oL*!+*0%.#-*3%)3)2-*
(-'*A$%5)(K'*$"#$%&5$'3J*5$'-1*#%-($2&5&$'3-1*Y.&%\%0&(-1*
5)K-%$1* K* )5#.3)(&-'$17* (-'* 3&$5#-1* 5M1* (-%3-1* #)%)* +)*
(.%)(&J'* ZTa* 2,)1* O%$'3$* )* ad* 2,)1[* Y.$* $+* 0%.#-* 2$* (-'3%-+L* !+*
0%.#-* 2$* (-'3%-+* $"#$%&5$'3J* .'* IHe* 2$* %$)((&-'$1* )2/$%1)1*
2$* +)* #&$+7* 5&$'3%)1* Y.$* $'* $+* 0%.#-* 2$* A$%5)(K'* '-* 6.4-*
%$)((&-'$1*)2/$%1)1*2$*+)*#&$+L**
;)1* +$1&-'$1* 3U%5&()1* #%$1$'3)'* .')* 6$%&2)* )0.2)* )3,#&()*
$1#$(&)+* Y.$* 3&$'$* .'* &5#)(3-* (+,'&(-* K* 1-(&)+* 1&0'&O&()3&/-7*
$1#$(&)+5$'3$* $'* +)* #-4+)(&J'* 2$* #)(&$'3$1* #$2&M3%&(-1L* !+* >'@!
A'+&.! ;+'$#-$! A.*$1+'$#27* .'* (&%.X)'-* #+M13&(-* 2$* +)*
!
?3%-1*)1#$(3-1*)*(-'1&2$%)%*
@#%-"&5)2)5$'3$*$+*dG`dae*2$*
3-2)1*+)1*)5#.3)(&-'$1*/)'*
#%$($2&2)1*2$*.')*\+($%)*Z#-%*
$X$5#+-7*&1Y.U5&()7*2$+*#&$*2&)4U3&(-7*
#-%*BC!7*5&"3)[7*K*+)1*&'O$((&-'$1*
#%-O.'2)1*K*+)*-13$-5&$+&3&1*3&$'$'*
1&'*2.2)*.'*#)#$+*&5#-%3)'3$*$'*
5.(6)1*)5#.3)(&-'$1L**
*
*
f&4+&-0%)O,)*
IL** 98*A$#)%35$'3*-O*R$)+36*)'2*R.5)'*8$%/&($1L*=)3&-')+*C$'3$%*O-%*R$)+36*
83)3&13&(1L* =)3&-')+* R-1#&3)+* A&1(6)%0$* 8.%/$Kq* @''.)+* 8.55)%K* r&36* A$3*
@%'-+2*:.4+&()3&-'gIbbHqIHFsIPaL**
bL** R-41-'* ES* F'27* ;K'(6* >W7* p)5&+* t7* $3* )+L* E$1.+31* -O* %$/)1(.+)%&Q)3&-'* )'2*
)5#.3)3&-'* &'* 1$/$%$* +-r$%* $"3%$5&3K* &1(6$5&)q* )* O&/$`K$)%* (+&'&()+*
$"#$%&$'($L*p*])1(*8.%0L*IbdagFZI[qIPTsIdaL**
IGL* A-%5)'2K* p@7* E.36$%O-%2* EfL* <)')0$5$'3* -O* #$%&#6$%)+* )%3$%&)+* 2&1$)1$*
Z:@A[L*>@8C*S-%u&'0*W%-.#L*>%)'1@3+)'3&(*B'3$%`8-(&$3K*C-'1$'1.1*Z>@8C[L*p*
])1(*8.%0L*FGGGgNIZI*:3*F[q8Is8FbHL**
IIL* W%$00* E?L* fK#)11* -%* )5#.3)3&-'v* C-'(-5&3)'3* %$/&$r* -O* 4K#)11* )%3$%&)+*
0%)O3&'0*)'2*5)X-%*)5#.3)3&-'1L*@5*p*8.%0L*IbdagITbZN[qNbPsTGFL**
IFL*<)(u$K*SC7*<(C.++-.06*p;7*C-'+-'*>:7*$3*)+L*>6$*(-131*-O*1.%0$%K*O-%*+&54`
36%$)3$'&'0*&1(6$5&)L*8.%0$%KLIbdHgbbZI[qFHsNaL**
INL* E)/&-+)* C@7* =&(63$%* ;87* f)u$%* pA7* $3* )+L* C-13* -O* 3%$)3&'0* )2/)'($2* +$0*
&1(6$5&)L*fK#)11*0%)O3*/1*#%&5)%K*)5#.3)3&-'L*@%(6*8.%0L*IbddgIFNZT[qTbas
TbHL**
ITL* :))1u$* S:7* ;).131$'* pL* l$5-%-2&13)+* 4K#)11* 0%)O3&'0q* Y.)+&3K* -O* +&O$* )'2*
1-(&-$(-'-5&(*)1#$(31L*!.%*p*])1(*!'2-/)1(*8.%0L*IbbagIGZF[qFFHsFNGL**
IaL*S-+O$*pR7*SK)33*<WL*C%&3&()+*)'2*1.4(%&3&()+*&1(6)$5&)L*!.%*p*])1(*!'2-/)1(*
8.%0L*IbbPgINZH[qaPdsadFL**
IHL* :$'3$(-13* <p7* C%&Y.&* <R7* A-%%-1* W7* $3* )+L* W.&2$+&'$1* O-%* #$%&#6$%)+*
#$%(.3)'$-.1* 3%)'1+.5&')+* )'0&-#+)13K* -O* 36$* )42-5&')+* )-%3)* )'2* +-r$%*
$"3%$5&3K* /$11$+1L* @* 13)3$5$'3* O-%* 6$)+36* #%-O$11&-')+1* O%-5* )* 1#$(&)+*
r%&3&'0*0%-.#*-O*36$*C-.'(&+1*-'*C)%2&-/)1(.+)%*E)2&-+-0K7*@%3$%&-1(+$%-1&17*
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
a*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
C)%2&-`>6-%)(&(*)'2*])1(.+)%*8.%0$%K7*C+&'&()+*C)%2&-+-0K7*)'2*!#&2$5&-+-0K*
)'2* :%$/$'3&-'7* 36$* @5$%&()'* R$)%3* @11-(&)3&-'L* C&%(.+)3&-'L*
IbbTgdbZI[qaIIsaNIL**
IPL* <.%)2&'* W87* <K%&)5* R.'&'u* <WL* C-13* )'2* #)3$'(K* %)3$* 3)%0$31* O-%* 36$*
2$/$+-#5$'3* -O* $'2-/)1(.+)%* 2$/&($1* 3-* 3%$)3* O$5-%-#-#+&3$)+* )%3$%&)+*
2&1$)1$L*E)2&-+-0KL*FGGIgFIdZF[qTHTsTHbL**
IdL* <.%)2&'* W87* f-1(6* p;7* 83&X'$'* >7* R.'&'u* <WL* f)++--'* 2&+)3&-'* )'2* 13$'3*
&5#+)'3)3&-'* O-%* 3%$)35$'3* -O* O$5-%-#-#+&3$)+* )%3$%&)+* 2&1$)1$q* 5$3)`
)')+K1&1L*E)2&-+-0KL*FGGIgFFIZI[qINPsITaL**
IbL*E)51$K*8A7*=$r3-'*j7*f+-.06*A7*$3*)+L*B'(&2$'($7*-.3(-5$17*)'2*(-13*-O*O--3*
.+($%1*&'*#)3&$'31*r&36*2&)4$3$1L*A&)4$3$1*C)%$L*IbbbgFFZN[qNdFsNdPL**
FGL* !25-'21* <!7* f+.'2$++* <:7* <-%%&1* <!7* $3* )+L* B5#%-/$2* 1.%/&/)+* -O* 36$*
2&)4$3&(* O--3q* 36$* %-+$* -O* )* 1#$(&)+&Q$2* O--3* (+&'&(L* V* p* <$2L*
IbdHgHGZFNF[qPHNsPPIL**
FIL* A)'0* C=7* :%)1)2* wA7* f-.+3-'* @p7* p.2$* !fL* <$36&(&++&'`%$1&13)'3*
83)#6K+-(-((.1* ).%$.1* &'* 36$* 2&)4$3&(* O--3* (+&'&(q* )* r-%1$'&'0* #%-4+$5L*
A&)4$3*<$2L*FGGNgFGZF[qIabsIHIL**
*
FFL*S)0'$%*@7*E$&u$*R7*@'0$+u-%3*fL*R&06+K*%$1&13)'3*#)36-0$'1*&'*#)3&$'31*r&36*
2&)4$3&(* O--3* 1K'2%-5$* r&36* 1#$(&)+* %$O$%$'($* 3-* 5$36&(&++&'`* %$1&13)'3*
83)#6K+-(-((.1* ).%$.1* &'O$(3&-'1L* A31(6* <$2* S-%(6$'1(6%L*
FGGIgIFHZTd[qINaNsINaHL**
FNL* >6$3)* E$#-%31L* @2/)'($2* r-.'2* ()%$* 4&-+-0&(1q* r-%+2* 5)%u$3* )')+K1&1L*
@.0.13*I7*FGGFL*A&1#-'&4+$*$'q*633#qccrrrL5)%u$3%$1$)%(6L(-5c#%-2.(3c*
*
2&1#+)KL)1#v#%-2.(3&2idGIFTbx8BAidTHIFHHG`NNbdGNPFT`FbGIdPNdTL*
@(($2&2-*$+*Ib*2$*2&(&$54%$*2$*FGGaL**
FTL*<-33)*WL*y>6$*O&%13*HG*2)K1*-O*::8q*5)')0&'0*r-.'2*()%$*5$2&()+*1.##+&$1Lz*
>6$*
E$5&'03-'*
E$#-%3L*
=-/cA$(LFGGGL*
633#qccrrrLr-.'2()%$L-%0c'$r1/-+a'Nc)%IGL635*L**
FaL*;K2$%*CR7*86)''-'*E7*!5#+$-`l%)Q&$%*?7*$3*)+L*@*(-5#%$6$'1&/$*#%-0%)5*3-*
#%$/$'3* #%$11.%$* .+($%1* &'* +-'0`3$%5* ()%$q* $"#+-%&'0* (-131* )'2* -.3(-5$1L*
?13-5K*S-.'2*<)')0$L*FGGFgTdZT[qaFsHFL**
FHL*98*C$'1.1*f.%$).L*83)3&13&()+*@413%)(3*-O*36$*9'&3$2*83)3$1q*IbbHL*IIH36*$2L*
98*A$#)%35$'3*-O*C-55$%($7*S)16&'03-'7*ACg*IbbHL***
!
!
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
H*
C$(&!)+&#*4/+)$!-&.!$=0$!(0%&'27+-$-$!
&(*$D.&!
*
!"#+-%)(&J'*2$*+)1*2&/$%1)1*)#+&()(&-'$1*2$*+)1*1-+.(&-'$1*1.#$%-"&2)2)1*
A#-'6(!A@!E0*+6''&FB!;>B!G8>!!
!
;*
)* $+$(3%J+&1&1* $1* .'* #%-($1-* $'* $+* (.)+* 1$* 6)($* #)1)%* .')*
(-%%&$'3$* $+U(3%&()* )* 3%)/U1* 2$+* )0.)* -* .')* 1-+.(&J'7*
0$'$%)'2-* 2&/$%1)1* $1#$(&$1* Y.,5&()1* %$)(3&/)1* Y.$*
2$#$'2$'* 2$+* 1-+.3-* K* $+* 5)3$%&)+* 2$* +-1* $+$(3%-2-1* .3&+&Q)2-1*
#)%)*#%-2.(&%*+)*$+$(3%J+&1&1L*;)*5)K-%,)*2$*1-+.(&-'$1*Z-*)0.)1[*
1.#$%-"&2)2)1* 1-'* 1-+.(&-'$1* )(.-1)1* #%-($1)2)1*
$+$(3%-Y.,5&()5$'3$*O)4%&()2)1*)*#)%3&%*2$*)0.)*#.%)*K*(+-%.%-*
2$* 1-2&-L* !'* 0$'$%)+7* $+* (-'($#3-* 2$* +)* $+$(3%J+&1&1* $1*
%$+)3&/)5$'3$*1&5#+$q*$+*)0.)*(-%%&$'3$*$1*#.%&O&()2)*5$2&)'3$*
J15-1&1* &'/$%1)* K* 1$* )0%$0)* (+-%.%-* 2$* 1-2&-* 2$* 0%)2-* 98:*
0%)2-* )'3$1* 2$* 1-5$3$%+)* )* .'* ()5#-* $+U(3%&(-L* A.%)'3$* $13$*
#%-($1-*2$*$+$(3%J+&1&17*+)1*5-+U(.+)1*1$*1$#)%)'*$'*.')*(M5)%)*
(-'* #-+-1* #-1&3&/-* K* '$0)3&/-7* K* 1$* O-%5)'* $1#$(&$1* 2$*
6&#-(+-%&3-1* -* 6&#-(+-%-1)17* )1,* (-5-* %)2&()+$1* +&4%$1L* !+*
%$1.+3)2-* O&')+* $1* .')* 5$Q(+)* 2$* $1#$(&$1* %$)(3&/)1* 2$* (+-%-* K*
-",0$'-*(-'*'.5$%-1)1*)#+&()(&-'$1*$'*5$2&(&')*K*2$1&'O$((&J'L*
!'*$13$*)%3,(.+-*$13.2&)%$5-1*)+0.')1*2$*$13)1*)#+&()(&-'$1*#-%*
+-*Y.$*1$*%$O&$%$*)+*(.&2)2-*2$*+)1*6$%&2)1*L*
*
!+*')(&5&$'3-*2$*.')*'.$/)*1-+.(&J'**
B'/$13&0)2-%$1* 2$* !13)2-1* 9'&2-17* E$&'-* 9'&2-* K* p)#J'* 6)'*
&'/$13&0)2-*1-+.(&-'$1*1.#$%-"&2)2)1*(-5-*2$1&'O$(3)'3$1*#)%)*
I`N
&'13%.5$'3-1* K* 1.#$%O&(&$1* 2.%)1* &')'&5)2)1* $'* 6-1#&3)+$1L *
:-%* $X$5#+-7* +)1* 1-+.(&-'$1* 1.#$%-"&2)2-1* 6)'* 2&15&'.&2-* $+*
3&$5#-7*+)*3-"&(&2)2*K*+-1*(-13$1*2$*5)3$%&)+*2$*2$1&'O$((&J'*2$*
T
$'2-1(-#&-1L * ;)* 4&4+&-0%)O,)* 3)54&U'* 2$1(%&4$* $+* .1-* 2$*
1-+.(&-'$1* 1.#$%-"&2)2)1* $'* 1$%$1* 6.5)'-1* #)%)* 2&/$%1)1*
&'2&()(&-'$17* &'(+.K$'2-* $+* 3%)3)5&$'3-* 2$* \+($%)1* -* 2$O$(3-1*
(.3M'$-1* &'O$((&-1-17* +)* &%%&0)(&J'* 2$+* 5$2&)13&'-* 3%)1* (&%.0,)* )*
(-%)QJ'* )4&$%3-7* K* $+* 3%)3)5&$'3-* 2$* #$%&3-'&3&1* K* )41($1-1*
a`d
&'3%)#$%&3-'$)+$1L * ;)1* 1-+.(&-'$1* 1.#$%-"&2)2)1* 3)54&U'* 1$*
6)'* %$(-5$'2)2-* #)%)* $+* +)/)2-* 2$* 5)'-1* 2$+* #$%1-')+*
b
5U2&(-L **
:-%* 2$10%)(&)7* +)* &'$13)4&+&2)2* K* #-3$'(&)+* (-%%-1&/-* 2$* +)1*
#%&5$%)1* 1-+.(&-'$1* 2$13%.K$%-'* (-5#+$3)5$'3$* $+* 5$%()2-* )*
O&')+$1* 2$* +)* 2U()2)* 2$* IbbGL* !'* $1$* 5-5$'3-7* ?(.+.1*
B''-/)3&/$* 8(&$'($1* (%$J* <&(%-(K'^* >$(6'-+-0K* Z.')* 1-+.(&J'*
#)%)*&%%&0)(&J'*2$*6$%&2)1*2U%5&()1*1.#$%-"&2)2)7*'-*3J"&()7*'-*
&%%&3)'3$7* K* 1&'* )(+)%)2-[7* Y.$* #-2,)* 1$%* .3&+&Q)2)* #)%)* $+*
!
3%)3)5&$'3-* K* (.&2)2-* 2$* +)1* 6$%&2)1L* ;)1* ($+2)1* $+$(3%-+,3&()1*
.1)2)1* #)%)* #%-2.(&%* $13)* 1-+.(&J'* 1.#$%-"&2)2)* 1-'*
1&0'&O&()3&/)5$'3$* 2&O$%$'3$1* 2$* +)1* 2&1$_)2)1* )'3$%&-%5$'3$*
#-%* -3%)1* (-5#)_,)1L* !13)* 1-+.(&J'* 1$* #%-2.($* 5$2&)'3$* +)*
$+$(3%J+&1&1* 2$* )0.)* K* (+-%.%-* 2$* 1-2&-* 2$* 0%)2-* 98:L* !+*
#%-2.(3-*O&')+*$1*.')*1-+.(&J'*1.#$%-"&2)2)*2$*#R*'$.3%-*(-'*
.')* ()2.(&2)2* 5M1* +)%0)* Z{* IF* 5$1$1[* Y.$* (.)+Y.&$%* -3%)*
1-+.(&J'* 1.#$%-"&2)2)* #%-4)2-* 6)13)* +)* O$(6)L* !13M* &'2&()2)*
#)%)* $+* 3%)3)5&$'3-* 3J#&(-* 2$* 6$%&2)1* &'O$((&-1)1* (%J'&()1* K*
)0.2)1L* w* +-* 5M1* &5#-%3)'3$* $1* Y.$* '-* $1* &%%&3)'3$* '&*
1$'1&4&+&Q)'3$L**
*
B'/$13&0)2-%$1*2$*!13)2-1*9'&2-17*
E$&'-*9'&2-*K*p)#J'*6)'*&'/$13&0)2-*
1-+.(&-'$1*1.#$%-"&2)2)1*(-5-*
2$1&'O$(3)'3$1*#)%)*&'13%.5$'3-1*K*
1.#$%O&(&$1*2.%)1*&')'&5)2)1*$'*
6-1#&3)+$1L*
*
@(3&/&2)2*)'3&5&(%-4&)')*&'*/&3%-*
;-1* #%&5$%-1* %$1.+3)2-1* 2$* +)* )(3&/&2)2* )'3&5&(%-4&)')* 2$*
<&(%-(K'* >$(6'-+-0K* 6)'* 1&2-* %$(&$'3$5$'3$* #.4+&()2-1* #-%*
II
&'/$13&0)2-%$1* &'2$#$'2&$'3$1L * @2$5M1* 7* 1$* 6)'* %$)+&Q)2-*
5.(6-1*-3%-1*$'1)K-1*#-%*#)%3$*2$*+)4-%)3-%&-1*&'2$#$'2&$'3$17*
2$*)(.$%2-*(-'*+)1*f.$')1*:%M(3&()1*2$*;)4-%)3-%&-*Zf:;[7*1$0\'*
1$* $1#$(&O&()* $'* FI* ClE* :)%3$* adL* 8$* 2$1(%&4$'* )+0.'-1*
$X$5#+-1*L**
()*+,+-.-! /.)*01+)+-.! 2! 3456+)+-.! 78140/.9! -0! 9498059+:5;<* 8$*
%$)+&QJ* .')* $/)+.)(&J'* 2$+* 3&$5#-* 2$* $+&5&')(&J'* &'* /&3%-* (-'*
<&(%-(K'* >$(6'-+-0K* O%$'3$* )* 1.1#$'1&-'$1* 2$* $'1)K-* 2$* aG*
($#)1*2&13&'3)1* 2$*5&(%--%0)'&15-1*ZFa*($#)1*2$*(-'3%-+* @>CC*
Z@5$%&()'*>K#$*C.+3.%$*C-++$(3&-'[*K*Fa*)&1+)5&$'3-1*(+,'&(-1*2$*
$1)1* 5&15)1* $1#$(&$1[* (-5-* 1$* 2$1(%&4$* $'* $+* 4-%%)2-%* 2$*
IF
<-'-0%)O,)* l&')+L * >%)1* .')* $"#-1&(&J'* 2.%)'3$* NG* 1$0.'2-17*
1$*-41$%/J*.')*%$2.((&J'*2$*+)*()%0)*4)(3$%&)')*{*a*+-0IG*$'*+)1*
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
7*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
<$D.$!O!P!M&(01&#!.2(!&(*0-+2(!-&!*27+)2.2=4$!!
<+%2!-&!?(*0-+2!!
Q2'1$!!
?(%&)+&!!
B%%&3)(&J'*2U%5&()*)0.2)**
B8?*IGbbN`GIqFGGF*
C-'$X-**
>-"&(&2)2*2U%5&()*)0.2)**
98*!:@*?::>8*dPGLIFGG**
C-'$X-**
8$'1&4&+&Q)(&J'*(.3M'$)**
98*!:@*?::>8*dPGLFHGG**
C-4)K)*
>-"&(&2)2*)0.2)*1&13U5&()**
98*!:@*?::>8*dPG**
E)3J'**
>-"&(&2)2*)0.2)*-%)+**
*98*?::>8*dPGLIIGG**
E)3)**
B%%&3)(&J'*-(.+)%**
B8?*IGbbNÌGqFGGF**
C-'$X-*
>-"&(&2)2*)0.2)*#-%*B'6)+)(&J'**
!:@*?::>8*dPGLINGG**
E)3)**
W$'-3-"&(&2)2*$'1)K-*2$*5&(%-'\(+$-1**
A&%$(3%&Q*?CA!*'}*TPT**
B8?*IGbbN`NqFGGN**
E)3J'**
*
1&0.&$'3$1* $1#$(&$1q* :1$.2-5-')1* )$%.0&'-1)7* !1(6$%&(6&)*(-+&7*
!'3$%-(-((.1* 6&%)$7* @(&'$3-4)(3$%* 4).5)''&&7* @(&'$3-4)(3$%*
1##7*f)(3$%-&2$1*O%)0&+&17*!'3$%-4)(3$%*)$%-0$'$17*!'3$%-(-((.1*
O)$()+&17* !'3$%-(-(-1* %$1&13$'3$1* )* +)* /)'(-5&(&')* Z]E![7*
R)$5-#6&+.1* &'O+.$'Q)$7* j+$41&$++)* -"K3-()7* j+$41&$++)*
#'$.5-'&)$7* <&(%-(-((.1* +.3$.1* 7* :%-3$.1* 5&%)4&+&17* 8$%%)3&)*
5)%($1($'17*
83)#6K+-(-((.1*
).%$.17*
83)#6K+-(-((.1*
$#&2$%5&2&17* 83)#6K+-(-((.1* 6)$5-+K3&(.17* 83)#6K+-(-((.1*
#K-0|'$* K* C)'2&2)* )+4&()'1* Zf&-8(&$'($* ;)417* f-Q$5)'7*
<-'3)')[L*
*
9')*2$*+)1*#%&'(&#)+$1*
#%$-(.#)(&-'$1*(.)'2-*1$*.3&+&Q)'*
1-+.(&-'$1*1.#$%-"&2)2)1*$1*+)*
&'2.((&J'*#-3$'(&)+*2$*-"&2)(&J'*2$+*
@A=7*$+*$'/$X$(&5&$'3-*)($+$%)2-*K*
+)*0$'-3-"&(&2)2L*
*
()*+,+-.-! /.)*01+)+-.! 2! 3456+)+-.! 7059.2=9! -0! 8=1*.-=1;<* !'*
/)%&)1*#%.$4)17*1$*6)'*$'1)K)2-*+)1*#%-#&$2)2$1*4)(3$%&(&2)1*K*
O.'0&(&2)1* 2$* <&(%-(K'* >$(6'-+-0K* 2$* )(.$%2-* (-'* +)1*
2&%$(3%&($1* !:@* AB8c>88L* !'* $13)1* (-'2&(&-'$1* 7* <&(%-(K'*
>$(6'-+-0K*&'6&4&J*3-3)+5$'3$*$+*(%$(&5&$'3-*2$*+-1*1&0.&$'3$1*
5&(%--%0)'&15-1q* <K(-4)(3$%&.5* 4-/&1* Z?>* '}* IGaTGI[* $'* a*
5&'.3-1g* :L* )$%.0&'-1)* Z@>CC* '}* IaTTF[7* 8L* ).%$.1* Z@>CC* '}*
HaNd[* 7* 8)+5-'$++)* (6-+$%)$1.&1* Z@>CC* '}* * IGPGd[7* 8L* ).%$.1*
%$1&13$'3$1* )* +)* 5$3&(&+&')* Z<E8@* 7* @>CC* '}* NNabF* [* K*
>%&(6-#6K3-'*5$'3)0%-#6K3$1*Z@>CC*'}*baNN[*$'*IG*5&'.3-17*K*
!'3$%-(-((.1*O)$()+&1*%$1&13$'3$*)*+)*/)'(-5&(&')*Z]E!*7*@>CC*'}*
aIFbb*[*$'*Ia*5&'.3-1*Z@>8*;)41*7*!)0)'*7*<&''$1-3)[*L**
()*+,+-.-! ,+14)+-.>* <&(%-(K'* >$(6'-+-0K* 6)* 1&2-* $'1)K)2-*
#)%)* 2$3$%5&')%* +)1* ()%)(3$%,13&()1* /&%.(&2)1* (-'3%)* $+* /&%.1* 2$*
&'5.'-2$O&(&$'(&)* 6.5)')*3&#-* I* Z* ]BR* `*B[* ($#)* R>;]* `*BBBf*2$*
)(.$%2-* (-'* +)1* 2&%$(3%&($1* 2$* +)* !:@* 2$* !13)2-1* 9'&2-1*
AB8c>88`GPL* !'* .'* $13.2&-* &'2$#$'2&$'3$7* +)* %$2.((&J'* $'* $+*
IG
3,3.+-*/&%)+*O.$*~*N*+-0 *2$1#.U1*2$*.')*$"#-1&(&J'*2$*a*5&'.3-1*
II
)*<&(%-(K'*>$(6'-+-0KL **
!
()*+,+-.-! 098=1+)+-.<* <&(%-(K'* >$(6'-+-0K* 6)* 1&2-* $'1)K)2-*
#)%)* 2$3$%5&')%* +)1* ()%)(3$%,13&()1* $1#-%&(&2)1* (-'3%)* $1#-%)1*
2$* f)(&++.1* )3%-#6)$.1* Z@>CC* '}* HHNN[* L* ;)* #%.$4)* 1$* %$)+&QJ*
(-'O-%5$*)+*4-%%%)2-%*2$*+)*'-%5)*f8*!=*ITNTPqFGGFL*A$1#.U1*
2$*Ia*5&'.3-1*2$*$"#-1&(&J'7*+)*%$2.((&J'*2$*$1#-%)1*O.$*2$*H7a*
IG
+-0 *$'*#%-5$2&-7*(.5#+&$'2-*2$*$13$*5-2-*+-1*%$Y.&1&3-1*2$+*
5U3-2-*2$*$'1)K-*)#+&()2-*Z<&(%-<$2*;)4-%)3-%&$17*:$3)+.5)7*
C)+&O-%'&)[L*
*
!13.2&-1*2$*>-"&(-+-0,)**
;)* 1$0.%&2)2* 3)54&U'* 6)* 1&2-* .'* 3$5)* &5#-%3)'3$* $'* +)*
O-%5.+)(&J'* 2$* <&(%-(K'* >$(6'-+-0KL* 8$* 6)'* %$)+&Q)2-* .')*
1$%&$* 2$* $'1)K-1* #)%)* 2$5-13%)%* Y.$* $+* .1-* 2$* <&(%-(K'*
>$(6'-+-0K* '-* ().1)* 3-"&(&2)27* &%%&3)(&J'* -* 1$'1&4&+&2)2* Z>)4+)*
I[L* >-2)1* $13)1* #%.$4)1* 1$* 6)'* %$)+&Q)2-* 2$* )(.$%2-* (-'*
'-%5)1* 2$* +)* lA@* -* +)* ?%0)'&Q)(&J'* B'3$%')(&-')+* 2$*
=-%5)+&Q)(&J'*ZB8?[*$'*&'13)+)(&-'$1*W;:*L*
9')* 2$* +)1* #%&'(&#)+$1* #%$-(.#)(&-'$1* (.)'2-* 1$* .3&+&Q)'*
1-+.(&-'$1* 1.#$%-"&2)2)1* $1* +)* &'2.((&J'* #-3$'(&)+* 2$*
0$'-3-"&(&2)2L*:%*$++-7*.'*$'1)K-*2$*5&(%-'\(+$-1*%$)+&Q)2-*2$*
)(.$%2-* (-'* +)1* '-%5)1* B8?* 6)* 2$5-13%)2-* Y.$* <&(%-(K'*
>$(6'-+-0K*'-*$1*0$'-3J"&(-L**
;-1*$O$(3-1*2$*<&(%-(K'*>$(6'-+-0K*1-4%$*+)*/&)4&+&2)2*2$*+-1*
O&4%-4+)13-1* K* +)* (&()3%&Q)(&J'* 2$* +)1* 6$%&2)1* 3)54&U'* 1$* 6)'*
)4-%2)2-* $'* F* $13.2&-1* '-* #.4+&()2-1* 2$* +)4-%)3-%&-1*
&'2$#$'2&$'3$17* $'* =-%36* @5$%&()'* 8(&$'($* @11-(&)3$17* B'(L*
Z=@<8@[7* =-%36r--2* 7* ?6&-7* K* C-5#)%)3&/$* f&-1(&$'($17* B'(L7*
8.''K/)+$7*C)+&O-%'&)7*$'*FGGTL*!'*$+*#%&5$%*$13.2&-7*$+*$'1)K-*
2$* (&3-3-"&(&2)2* 1-4%$* O&4%-4+)13-1* 1$* %$)+&QJ* 2$* (-'O-%5&2)2*
(-'*+)*'-%5)*B8?*IGbbNàqIbbbL*8$*(-+-(J*.'*2&1(-*2$*O&+3%-*(-'*
G7I* 5+* 2$* <&(%-(K'* >$(6'-+-0K* 1-4%$* .')* 1.#$%O&(&$* )0)%-1)7*
1.#$%#-'&$'2-* 2&%$(3)5$'3$* .')* 5-'-()#)* 2$* (U+.+)1* 2$*
O&4%-4+)13-* 2$* %)3J'* Z;* `FbF[L* 8$* -41$%/)%-'* +)1* 5.$13%)1*
#%$#)%)2)1* $'* (.)'3-* )+* 2)_-* (&3-3J"&(-* 2$1#.U1* 2$* FT* 6-%)1L*
!'* $13)1* (-'2&(&-'$17* +)1* 5.$13%)1* Y.$* (-'3$',)'* <&(%-(K'*
>$(6'-+-0K* '-* 5-13%)%-'* '&'0.')* $/&2$'(&)* 2$* +&1&1* ($+.+)%* -*
3-"&(&2)2*Z=@<8@[L**
!+* 1$0.'2-* $13.2&-* 1$* %$)+&QJ* (-'* IH* %)3)1* #)%)* $/)+.)%* +)*
3-+$%)4&+&2)2*+-()+*2$*<&(%-(K'*>$(6'-+-0K*K*1.1*$O$(3-1*1-4%$*
+)* 6&13-#)3-+-0,)* 2$* +$(6-1* 2$* 6$%&2)1* $'* .'* 5-2$+-* 2$*
(&()3%&Q)(&J'*2$*6$%&2)1*2U%5&()1*2$*$1#$1-%*3-3)+L*w)*1$*6)4,)*
2$5-13%)2-*Y.$*+)1*1-+.(&-'$1*1.#$%-"&2)2)1*2$*#R*'$.3%-*'-*
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
d*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
*
1J+-* '-* $%)'* 3J"&()1* #)%)* +)1* 6$%&2)17* 1&'-* Y.$* &'(+.1-* #-2,)'*
IN
&'2.(&%* 1.* (&()3%&Q)(&J'L * !'* $13$* $13.2&-7* .'* #)3J+-0-*
/$3$%&')%&-* ($%3&O&()2-* $/)+.J* (-%3$1* (-'* 3&'(&J'* 3%&(%J5&()* 2$*
<)11-'*K*(-%3$1*(-'*3&'(&J'*2$*O&4%)1*2$*(-+M0$'-*2$*3&#-*BB*2$*
+)1*6$%&2)1*Y.&%\%0&()1*3%)3)2)1*(-'*<&(%-(K'*>$(6'-+-0K*K*(-'*
1.$%-* 1)+&'-L* C-5-* $%)* 2$* $1#$%)%7* '-* 6.4-* 2&O$%$'(&)1*
6&13-#)3-+J0&()1*%$+$/)'3$1*$'3%$*+-1*0%.#-1*2$*3%)3)5&$'3-7*+-*
Y.$* &'2&()* Y.$* $+* 3%)3)5&$'3-* (-'* <&(%-(K'* >$(6'-+-0K* O.$*
4&$'* 3-+$%)2-L* =-* 6.4-* 2&O$%$'(&)1* 1&0'&O&()3&/)1* $'3%$* +-1*
0%.#-1*$'*+)*$"#%$1&J'*2$*(-+M0$'-*2$*3&#-*BBL*8$0\'*+-*#%$/&13-7*
<&(%-(K'* >$(6'-+-0K* '-* 3./-* $O$(3-* )2/$%1-* 1-4%$* +-1*
O&4%-4+)13-1*-*$'*+)*#%-2.((&J'*2$*(-+M0$'-*$'*+)1*(-'2&(&-'$1*
2$*$13$*$13.2&-*ZC-5#)%)3&/$*f&-1(&$'($1[L*
*
@#%-4)(&-'$1*2$*3-2-*$+*5.'2-*
!'* FGGT* 7* 1$* -43./-* .')* )#%-4)(&J'* $.%-#$)* ZC!* j!<@* `*
:%-2.(3-* <U2&(-* 2$* C+)1$* BB4[L* A$%5)(K'* S-.'2* C)%$*
ZO-%5.+)2-* (-'* <&(%-(K'* >$(6'-+-0K[* $1* .')* 1-+.(&J'*
1.#$%-"&2)2)* 2$13&')2)* )* 1$%* .3&+&Q)2)* $'* +)* 6&2%)3)(&J'7*
&%%&0)(&J'7* +&5#&$Q)* K* %$2.((&J'* 2$* +)* ()%0)* 5&(%-4&)')* 2$*
6$%&2)1* )0.2)1* K* (%J'&()17* \+($%)17(-%3$17* )4%)1&-'$1* K*
Y.$5)2.%)1L*!'*!13)2-1*9'&2-17*1$*-43./&$%-'*F*)#%-4)(&-'$1*
aIGZu[*2$*+)*lA@*$'*5)K-*2$*FGGaq*
I* L* A$%5)(K'* •* !+* )#J1&3-* 2$* 6$%&2)1* $13M* &'2&()2-* #)%)* 1.*
.1-* $'* +)* 6.5$(3)(&J'* K* +.4%&()(&J'* 2$* )#J1&3-1* )41-%4$'3$1*
#)%)* 6$%&2)1* 3%).5M3&()1* 7* (-%3$1* 7* )4%)1&-'$1* K* Y.$5)2.%)1*
5$'-%$1**
F*L*A$%5)(K'•*S-.'2*A%$11&'0*$13M*2$13&')2-*)*+)*+&5#&$Q)7*
2$14%&2)5&$'3-*K*$+&5&')(&J'*2$*5)3$%&)1*$"3%)_)1*2$*+$1&-'$1*
2U%5&()1*)0.2)1*K*(%J'&()1*(-5-*\+($%)1*#-%*#%$1&J'*0%)2-*B`*B]7*
\+($%)1* 2&)4U3&()17* 6$%&2)1* #-13Y.&%\%0&()17* Y.$5)2.%)1* 2$*
#%&5$%* K* 1$0.'2-* 0%)2-7* )4%)1&-'$1* $* &%%&3)(&-'$1* 5$'-%$1* 2$*
+)*#&$+*L*
*
<&(%-(K'^* >$(6'-+-0K* 6)* 1&2-* $O&()Q*
K*1$0.%-*)#+&()2-*$'*2&/$%1-1*5-2-1*
Z#-%* $X$5#+-7* 1#%)K7* &'5$%1&J'7*
&%%&0)(&J'[7* )1,* (-5-* $'* (-54&')(&J'*
(-'*-3%)1*3$('-+-0,)1*
*
!13.2&-1*(+,'&(-1*
<&(%-(K'* >$(6'-+-0K* 6)* 1&2-* $O&()Q* K* 1$0.%-* )#+&()2-* $'*
2&/$%1-1* 5-2-1* Z#-%* $X$5#+-7* 1#%)K7* &'5$%1&J'7* &%%&0)(&J'[7* )1,*
(-5-* $'* (-54&')(&J'* (-'* -3%)1* 3$('-+-0,)17* (-5-* (&$%%$*
)1&13&2-*#-%*/)(,-*Z]@C*>6$%)#K*7*jCB7*8)'*@'3-'&-*7*>$")1[*K*$+*
1&13$5)* ]$%1)X$3* RK2%-1.%0$%K* Z85&36* x* =$#6$r7* ;)%0-7*
l+-%&2)[L* 8$0\'* $+* 3&#-* K* $13)2&-* 2$* +)* +$1&J'7* 1$* #.$2$* )#+&()%*
.')7*2-1*-*3%$1*/$($1*)+*2,)L*
w)* 1$* 6)'* %$)+&Q)2-* $/)+.)(&-'$1* (+,'&()1* #&+-3-* s*
#%&'(&#)+5$'3$*$'*(+,'&()1*#%&/)2)1*$'*@5U%&()*;)3&')*K*!.%-#)*
s*#-%*#)%3$*2$*5U2&(-1*&'2$#$'2&$'3$1*#)%)*#%-4)%*+)*$O&()(&)*K*
1$0.%&2)2* $'* $+* #&$* 2&)4U3&(-* K* $'* \+($%)1* #-%* $13)1&1* /$'-1)7*
Y.$5)2.%)1* K* 6$%&2)1* #-13-#$%)3-%&)1L* 8$* 6)'* %$#-%3)2-*
4.$'-1* %$1.+3)2-1* $'* $13-1* ()1-1L* :-%* $X$5#+-7* .'* $13.2&-* 6)*
(-'13)3)2-*5$X-%$1*%$1.+3)2-1*(-'*A$%5)(K'*S-.'2*C)%$*Y.$*
!
(-'* #-/&2-')* K-2)2)* $'* $+* 3%)3)5&$'3-* 2$* FGd* #)(&$'3$1* (-'*
a
\+($%)1*2$+*#&$*2&)4U3&(-*$'*B3)+&) **
?(.+.1* 3)54&U'* #)%3&(&#)* )(3.)+5$'3$* $'* +)* #+)'&O&()(&J'* K*
$X$(.(&J'* 2$* '.5$%-1-1* $13.2&-1* (+,'&(-1* K* $/)+.)(&-'$1* #-13`*
)#%-4)(&J'* 2$* .1-* $'* #)(&$'3$1* 6.5)'-1* $'* !13)2-1* 9'&2-17*
<U"&(-*K*!.%-#)L*
*
C-'(+.1&J'**
!+* .1-* 2$* 1-+.(&-'$1* 1.#$%-"&2)2)1* (-5-* #%-2.(3-1* #)%)* $+*
(.&2)2-*2$*+)*6$%&2)*$1*.'*(-'($#3-*2$*/)'0.)%2&)L*;)*#%&5$%)*
1-+.(&J'* 1.#$%-"&2)2)* $13)4+$* K* 2&1#-'&4+$* $'* $+* 5$%()2-7*
A$%5)(K'*S-.'2*C)%$*Z!.%-#)[*K*?(.+.1*<&(%-(K'HG*Z<U"&(-[7*
6)* 2$5-13%)2-* 1$%* .'* )0$'3$* )'3&5&(%-4&)'-* $O&()Q* $'*
$"#$%&5$'3-1*&'*/&3%-L*!+*$O$(3-*6&2%)3)'3$*K*+)*3-"&(&2)2*5,'&5)*
-41$%/)2)* (-'* $+* .1-* 2$* $13)* 1-+.(&J'* 1.#$%-"&2)2)* 6)($* Y.$*
1$)*.')*4.$')*-#(&J'*#)%)*$+*(.&2)2-*2$*6$%&2)1L*8&'*$54)%0-7*
2$4$'* %$)+&Q)%1$* '.$/-1* $'1)K-1* (-'3%-+)2-1* #)%)* ()%)(3$%&Q)%*
(-5#+$3)5$'3$* +-1* $O$(3-1* )'3&5&(%-4&)'-17* )'3&&'O+)5)3-%&-17*
K* #-1&3&/-1* $'* +)* (.%)(&J'* 2$* 6$%&2)1L* =-* -413)'3$7* +-1*
%$1.+3)2-1* #%$+&5&')%$1* 1.0&$%$'* Y.$* $13)* 3$('-+-0,)* '-*
)'3&4&J3&()*#)%$($*-O%$($%*.'*)5#+&-*K*'.$/-*#)%)2&05)*#)%)*+)*
a
#%$/$'(&J'* K* $+* 3%)3)5&$'3-* 2$* 6$%&2)1* )0.2)1* K* (%J'&()1L * ;)*
)#+&()(&J'* #-3$'(&)+* 2$* $13)* 3$('-+-0,)* %$Y.&$%$* 5M1*
&'/$13&0)(&J'7* K* $'* +)* )(3.)+&2)2* 1$* $13M'* 2$1)%%-++)'2-*
O-%5.+)(&-'$1*$1#$(,O&()1*#)%)*2&/$%1)1*&'2&()(&-'$1L!**
*
f&4+&-0%)O,)**
IL** :)%u* R7* R.'0* wC7* j&5* CL* !OO$(3&/$'$11* -O* $+$(3%-+KQ$2* r)3$%* )1* )* 1)'&3&Q$%*
O-%*3%$)3&'0*2&OO$%$'3*1.%O)($1L*p*l--2*:%-3L*FGGFgHaZd[qIFPHsIFdGL**
FL** E.3)+)* S@7* S$4$%* ApL* =$r* 2&1&'O$(3&-'* )'2* 13$%&+&Q)3&-'* 5$36-21L* !5$%0*
B'O$(3*A&1L*FGGIgPZF[qNTdsNaNL**
NL** >)')u)*=7*>)')u)*=7*l.X&1)r)*>7*$3*)+L*>6$*.1$*-O*$+$(3%-+KQ$2*1-+.3&-'1*O-%*
36$* (+$)'&'0* )'2* 2&1&'O$(3&'0* -O* 2&)+KQ$%1L* @%3&O* ?%0)'1L* FGGGgFTZIF[qbFIs
bFdL**
TL** =$+1-'*AL*=$r$%*3$(6'-+-0&$1*O-%*$'2-1(-#*2&1&'O$(3&-'q*$+$(3%-+KQ$2*)(&2*
r)3$%*)'2*2&1#-1)4+$`(-5#-'$'3*$'2-1(-#$*1K13$51L*W)13%-&'3$13*!'2-1(*
C+&'*=*@5L*FGGGgIGqNIbsNFdL**
aL** A)++)*:)-+)*;7*f%-((-*!7*8$'$1&*@7*$3*)+L*91$*-O*A$%5)(K'7*)*'$r*)'3&1$#3&(*
)0$'3* O-%* 36$* +-()+* 3%$)35$'3* -O* 2&)4$3&(* O--3* .+($%1L* p-.%')+* -O* S-.'2*
R$)+&'0L*FGGagFqFGIL**
HL** 8$u&K)* 87* ?65-%&* j7* R)%&&* jL* >%$)35$'3* -O* &'O$(3&-.1* 1u&'* 2$O$(31* -%* .+($%1*
r&36* $+$(3%-+KQ$2* 13%-'0* )(&2* )Y.$-.1* 1-+.3&-'L* @%3&O* ?%0)'1L*
IbbPgFIZI[qNFsNdL**
PL** ?6'-* R7* R&0)16&2)3$* <7* w-u-1.u)* >L* <$2&)13&')+* &%%&0)3&-'* r&36*
1.#$%-"&2&Q$2* r)3$%* )O3$%* -#$'`6$)%3* 1.%0$%Kq* 36$* 1)O$3K* )'2* #&3O)++1* -O*
()%2&-/)1(.+)%*1.%0&()+*)##+&()3&-'L*8.%0*>-2)KL*FGGGgNGZII[qIGaasIGaHL**
dL** B'-.$* w7* !'2-* 87* j-'2-* j7* $3* )+L* >%&)+* -O* $+$(3%-+KQ$2* 13%-'0* )(&2* )Y.$-.1*
1-+.3&-'*+)/)0$*&'*36$*3%$)35$'3*-O*#$%&3-'&3&1*)'2*&'3%)#$%&3-'$)+*)41($11L*
@%3&O*?%0)'1L*IbbPgFIZI[qFdsNIL**
bL** 8)u)16&3)*<7*Br)1)r)*@7*=)u)5.%)*wL*@'3&5&(%-4&)+*$OO$(31*)'2*$OO&()(K*-'*
6)4&3.)++K*6)'2`r)16&'0*-O*13%-'0*)(&2&(*$+$(3%-+KQ$2*r)3$%€)*(-5#)%&3&/$*
13.2K* -O* )+(-6-+&(* )'3&1$#3&(1* )'2* 1-)#* )'2* 3)#* r)3$%L* j)'1$'16-0)u.*
t)116&L*FGGFgPHZa[qNPNsNPPL**
IGL* <)%3&'$Q`<.'&/$* @7* <$'$2$Q`8u$%3(6+K* @7* >-&4$%* <7* $3* )+L* 8.#$%`-"&2&Q$2*
r)3$%*Z<&(%-(K'*HG[*O-%*5$16*6$%'&-#+)13K*&'*0%-11+K*(-'3)5&')3$2*O&$+21q*
)'* $"#$%&5$'3)+* 13.2KL* 8!* IHNL* :%$1$'3$2* )3* 36$* @5$%&()'* C-++$0$* -O*
8.%0$-'1*bI13*@''.)+*C+&'&()+*C-'0%$11*&'*8)'*l%)'(&1(-7*C)+&O-%'&)7*?(3-4$%*
IHsFG7*FGGaL**
IIL* ;)'2)`8-+&17*W-'QM+$Q`!1#&'-1)*A7*W.Q5)'*f7*$3*)+L*<&(%-(K'*)*'-/$+*1.#$%`
-"&2&Q$2* r)3$%* r&36* '$.3%)+* #R* )'2* 2&1&'O$(3)'3* )(3&/&3KL* p* R-1#* B'O$(3L*
ZFGGagHIZT[qFbIsFbbL**
IFL* l$2$%)+* E$0&13$%L* >$'3)3&/$* l&')+* <-'-0%)#6L* IP* p.'$* IbbT7* /-+L*
abqIIH7#LNITTTL**
INL* w)6)0&*=7*j-'-*<7*j&3)6)%)*<7*$3*)+L*!OO$(3*-O*$+$(3%-+KQ$2*r)3$%*-'*r-.'2*
6$)+&'0L*@%3&O*?%0)'1L*FGGGgFTZIF[bdTsbdPL*
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
b*
H0+-$-2!-&!8&'+-$(!$,$#F$-2!)2#!
$=0$!(0%&'27+-$-$!&(*$D.&!
*
*
9'*$13.2&-*2$*(J5-*.'*3%)3)5&$'3-*(-54&')2-*#.$2$*-#3&5&Q)%*+)*
(&()3%&Q)(&J'*2$*+)1*6$%&2)1*
<21!A@!I2.,2(B!;>B!JAH:!
!!
!*
•*R$%&2)1*2$*+)*#)%$2*)42-5&')+*#-%*2$6&1($'(&)*(-'*5)++)*2$*+)*
#)%$2*)42-5&')+*$"#.$13)*Za*#)(&$'3$1[*
•*:)(&$'3$1* (-'* )#J1&3-1* * B'3$0%)* ZB'3$0%)* ;&O$1(&$'($1*
C-%#-%)3&-'7* :+)&'14-%-* 7* =p[* )#+&()2-1* $'* 1.1* 6$%&2)1* Z* F*
#)(&$'3$1[L*
R&'+-$(! %2(*2%&'$*2'+$(@* 9')* 6$%&2)* 2$* $13)* ()3$0-%,)* O.$*
.')*6$%&2)*$'*+)*&'0+$*$'*.')*5.X$%*2$*HI*)_-1*2$*$2)2*Y.$*1$*
1-5$3&J* )* (&%.0,)* 2$* %$/)1(.+)%&Q)(&J'* (-%-')%&)L* ;)* #)(&$'3$*
#%$1$'3)4)* .')* +,'$)* &'/)1&/)* K* 1)'0%)2-* $'* +)* &'0+$* K7* $'*
(-'1$(.$'(&)7* O.$* &'3$%/$'&2)* #)%)* 3%)3)%* $+* #%-4+$5)L* 8$* 6&Q-*
1U#3&()*$'*.'*($'3%-*2$*$'O$%5$%,)*K*O.$*3%)1+)2)2)*)+*6-1#&3)+*
2$+*).3-%L*;)*l&0.%)*I@*5.$13%)*1.*6$%&2)*$'*$+*&'0%$1-*Z#+&$0.$*
2$* +)* &'0+$* 2$%$(6)7* #)%$2* )42-5&')+* &'O$%&-%* K* +)* #&$%')*
2$%$(6)[L* B'&(&J* 3$%)#&)* ]@C* 3%)2&(&-')+* ZjCB[* K* #-13$%&-%5$'3$*
1$*()54&J*)+*1&13$5)*]@C*B'13&++L*;)*6$%&2)*5$X-%J*Zl&0.%)*If[*K*
1$*6Q-*.'*&'X$%3-*2$*#&$+*Zl&0.%)*IC[L*8$*.3&+&QJ*3$%)#&)*2$*(&$%%$*
)1&13&2-* #-%* /)(,-* #)%)* %$O-%Q)%* $+* &'X$%3-* 2$* #&$+* 2$* $1#$1-%*
#)%(&)+L* !'* $+* #-13-#$%)3-%&-7* +)* #)(&$'3$* (&()3%&QJ* +)* 5)K-%*
#)%3$* 2$* 1.* 6$%&2)* )* $"($#(&J'* 2$* .')* Q-')* $'* $+* ($'3%-L* 8$*
%$)+&Q)%-'* ()54&-1* 2$* )#J1&3-* (-'* A$%5)(K'* 2-1* /$($1* )+* 2,)L*
E$1.+3)2-1*2$+*$13.2&-**
!+*).3-%*(-5$'QJ*)*.3&+&Q)%*A$%5)(K'*$'*X.'&-*2$*FGGa*#)%)*$+* ;)*6$%&2)*O.$*&%%&0)2)*2&%$(3)5$'3$*(-'*A$%5)(K'*K*+.$0-7*2-1*
/$($1*)+*2,)7*1$*)#+&()4)*$'*+)*6$%&2)*.')*0)1)*6.5$2$(&2)*(-'*
3%)3)5&$'3-* 2$* FH* #)(&$'3$1* (-'* NG* 2&13&'3-1* 3&#-1* 2$* 6$%&2)17*
A$%5)(K'L* !13)* #)(&$'3$* $/-+.(&-'J* 6)13)* +)* (&()3%&Q)(&J'*
Y.$*1$*2&/&2$'*$'*+)1*1&0.&$'3$1*()3$0-%,)1q*
(-5#+$3)*2$*+)*6$%&2)*Zl&0.%)*IA[L*
•*R$%&2)1* #-13-#$%)3-%&)1* Zb* #)(&$'3$1[q* )#U'2&($* #$%O-%)2-g*
R&'+-$(! *'$01S*+)$(@* A$%5)(K'* #)%$($* 3$'$%* .'* #)#$+* $'* $+*
6$%&2)* )42-5&')+* )4&$%3)* 3%)1* (&%.0,)* #-%* #$%O-%)(&J'* 2$+*
#%-($1-*(-'3&'.-*2$*(.%)(&J'*2$*6$%&2)1L*9')*5.X$%*2$*PP*)_-1*
(-+-'g* 6$%&2)* )42-5&')+* )4&$%3)* 3%)1* $+* (&$%%$* 2$* .')*
2$* $2)2* (-'* 2&)4$3$1* #%$1$'3)4)* .')* 6$%&2)* 3%).5M3&()* $'* +)*
K$K.'-13-5,)g* 6$%&2)* #-%* &'X$%3-1* 2$* #&$+g* 6$%&2)* $'* +)* +,'$)*
#&$%')*2$%$(6)*Zl&0.%)*F@[L*;)*$1()%)*1-4%$*+)*6$%&2)*1$*$"3&%#J*
2$*&'(&1&J'*3%)1*)5#.3)(&J'*#-%*2$4)X-*2$*+)*%-2&++)g*6$%&2)*$'*
(-5#+$3)5$'3$7* K* +)* 6$%&2)* 1$* 3%)3J* 2&)%&)5$'3$* (-'* $+*
+)*#)%$2*)42-5&')+*#-13$%&-%*)*+)*)#+&()(&J'*1.13&3.3-1*2$*#&$+*
2$14%&2)2-%* $'Q&5M3&(-* @((.QK5$* ZR$)+36#-&'3* 7* ;32L7* l-%3*
2$* 2-1* ()#)1* Z@#+&0%)O7* ?%0)'-0$'$1&1* B'(L7* C)'3-'7*
S-%367* >$")1[L* A$1#.U1* 2$* F* 1$5)')17* +)* #)(&$'3$*
<)11)(6.1$331[g* 6$%&2)* $'* Q-')* 2-')'3$* 2$* /$')* 1)O$')g* K*
$"#$%&5$'3)4)*.'*#-(-*2$*Y.$5)QJ'7*K*+)*Q-')*)+%$2$2-%*2$*+)*
6$%&2)*$'*+)*&'0+$L*
6$%&2)* $13)4)* %-X)L* !+* (.&2)2-* 2$* +)* 6$%&2)* 1$* 1.13&3.KJ* #-%*
•*R$%&2)1* >%).5M3&()1* ZN* #)(&$'3$1* [q* 5-%2$2.%)* 2$* #$%%-g*
()54&-1* 2$* )#J1&3-* (-'* A$%5)(K'L* ;)* l&0.%)* Ff* 5.$13%)* +)*
(-'3.1&-'$1* #-%* )4%)1&J'* 2$* +)* #&$%')g* K* +)($%)(&-'$1* 2$* +)*
6$%&2)*2$1#.U1*2$*.1)%*A$%5)(K'*2.%)'3$*F*1$5)')1L*!+*(&$%%$*
#&$%')*
)1&13&2-*#-%*/)(,-*1$*&'&(&J*#%$-#$%)3-%&)5$'3$*$'*#%$#)%)(&J'*
•*m+($%)1*2$*2$(\4&3-*ZF*#)(&$'3$1[**
#)%)* .'* &'X$%3-* 2$* #&$+L* ;)* l&0.%)* FC* 5.$13%)* +)* &5)0$'*
•*R$%&2)1*2$+*#&$*2&)4U3&(-*Za*#)(&$'3$1[*
-#$%)3&/)*2$+*&'X$%3-*2$*#&$+*2$*$1#$1-%*#)%(&)+L*;)*#)(&$'3$*O.$*
10*
!
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
+* ).3-%* 1$* &'3$%$1J* #-%* .')* '.$/)* )0.)* 1.#$%-"&2)2)*
I
2$1#.U1* 2$* +$$%* .'* )%3,(.+-* $'* l-%4$1* 5)0)Q&'$L *
<&(%-(K'* ^* >$(6'-+-0K7* )6-%)* 2&1#-'&4+$* $'* !13)2-1*
9'&2-1*4)X-*+)*5)%()*A$%5)(K'*S-.'2*C)%$*Z?(.+.1*B''-/)3&/$*
8(&$'($1*7*:$3)+.5)*7*C)+&O-%'&)[7*$1*.')*1-+.(&J'*1.#$%-"&2)2)*
#)%)*6$%&2)1Y.$*'-*#%$(&1)*$'X.)0.$*K*'-*$1*3J"&()*'&*&%%&3)'3$L*
!+* ).3-%* #.4+&(J* $+* #%&5$%* )%3,(.+-* $'* !!L99L* 1-4%$* $+* 8&13$5)*
]@C*B'13&++*ZjCB*7*8)'*@'3-'&-7*>$")1[7*.'*1&13$5)*Y.$*(-54&')*$+*
3%)3)5&$'3-* 2$* 6$%&2)1* (-'* #%$1&J'* '$0)3&/)* (-'* +)* )#+&()(&J'*
(-'3%-+)2)* &'3$%5&3$'3$* 2$* 1-+.(&-'$1* K* 1.1#$'1&-'$1* 3J#&()1*
F
$'*$+*+$(6-*2$*+)*6$%&2)7 *K*6)4,)*$13)2-*4.1()'2-*.')*1-+.(&J'*
&2$)+*#)%)*.1)%*(-'*$+*1&13$5)L*:-%*+-*3)'3-7*1$*++$/J*)*()4-*.'*
$13.2&-*#)%)*2$3$%5&')%*+-1*%$1.+3)2-1*(+,'&(-1*2$*+)*.3&+&Q)(&J'*
2$*A$%5)(K'*'-*1J+-*(-'*$+*8&13$5)*]@C*B'13&++7*1&'-*3)54&U'*$'*
$+* 3%)3)5&$'3-* 2$* .')* /)%&$2)2* 2$* #)(&$'3$1* $'* .')* #%M(3&()*
)/)'Q)2)*2$*(.&2)2-*2$*6$%&2)1L*!'*$13$*)%3,(.+-*1$*)')+&Q)%M'*
+-1* %$1.+3)2-1* 2$* $13$* $13.2&-* K* 1$* 2&1(.3&%M* +)* &%%&0)(&J'* 2$*
6$%&2)1L*
*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
*
l&0.%)1*I@sAq*R$%&2)*2$+*#)(&$'3$*$'*+)*#%$1$'3)(&J'*Z@[7*3%)1*3$%)#&)*(-'*]@C*B'13&++*Zf[7*3%)1*+)*)#+&()(&J'**
2$*.'*&'X$%3-*2$*$1#$1-%*#)%(&)+*ZC[7*K*+)*6$%&2)*.')*/$Q*(&()3%&Q)2)*ZA[L**
*
2)2)*2$*)+3)*$+*2,)*2$*1.*&'3$%/$'(&J'*2$*&'X$%3-*2$*#&$+*.1)'2-*
+)*>$%)#&)*]@C*#)%)*%$O-%Q)%*$+*&'X$%3-L*;)*O&0.%)*FA*5.$13%)*+)*
6$%&2)*(.%)2)*$'*.')*/&1&3)*#-13-#$%)3-%&)*L**
T.)&'$(! -&! -&)KD+*2@* A$%5)(K'* #)%$($* 3$'$%* .'*#)#$+*(-5-*
$+*)0$'3$*3J#&(-*#)%)*+)*&%%&0)(&J'*2$*6$%&2)1*K*#)%)*6.5$2$($%*
+-1*)#J1&3-1*$'*#)(&$'3$1*(-'*\+($%)1*2$*2$(\4&3-L*A$4$*3$'$%1$*
$'*(.$'3)*#)%)*$+*3%)3)5&$'3-*2$*\+($%)1*2$*2$(\4&3-*Y.$*1$)'*
2$5)1&)2-*0%)'2$1*#)%)*.'*)0$'3$*$'Q&5M3&(-7*#$%-*2$5)1&)2-*
#$Y.$_)1*#)%)*+)*>$%)#&)*]@CL**
T.)&'$(! -&.! %+&! -+$D6*+)2@*9'*/)%J'*2$*ab*)_-1*2$*$2)2*(-'*
.')* 6$%&2)* 2$* #&$* 2&)4U3&(-* O.$* 3%)3)2-* (-'* $+* 8&13$5)* ]@C*
B'13&++*.3&+&Q)'2-*A$%5)(K'*(-5-*1-+.(&J'*2$*&%%&0)(&J'L*@2$5M17*
$+* #)(&$'3$* O.$* 3%)3)2-* (-'* -",0$'-* 6&#$%4M%&(-7*
2$14%&2)5&$'3-*Y.&%\%0&(-7*K*+)*3$%)#&)*(-'*1.13&3.3-1*2$*#&$+*2$*
2-1* ()#)1L* ;)* l&0.%)* N@* 5.$13%)* +)* 6$%&2)* 2$* $13$* #)(&$'3$*
)'3$1* 2$+* 3%)3)5&$'3-* L* ;)* l&0.%)* Nf* 5.$13%)* +)* 6$%&2)* (-'* $+*
)#J1&3-*]@C*B'13&++*)#+&()2-*Z$'*$13$*5-5$'3-7*%$(&4,)*2$*O-%5)*
&'3$%5&3$'3$* &%%&0)(&J'* 2&%$(3)* (-'* A$%5)(K'* (-'* $+* 1&13$5)*
]@C* B'13&++[7* K* +)* l&0.%)* NC* 5.$13%)* +)* 6$%&2)* (-'3%),2)*
(-5#+$3)5$'3$*(.4&$%3)*(-'*3$X&2-*2$*0%)'.+)(&J'*1)'-L**
;$..$!&7%0&(*$!&#!.$!%$'&-!$D-21+#$.@*!+*1&13$5)*]@C*B'13&++*
1$* .3&+&QJ* (-'* A$%5)(K'* (-5-* 1-+.(&J'* 2$* &%%&0)(&J'* $'* .')*
1$%&$* 2$* #)(&$'3$1* Y.$* #%$1$'3)4)'* 2$6&1($'(&)* 2$* 6$%&2)1*
)42-5&')+$1* (-'* 5)++)* @++-A$%5* Z;&O$C$++* C-%#-%)3&-'7*
f%)'(64.%07* =$r* p$%1$K[* $"#.$13)* $* &5#+)'3$* Y.&%\%0&(-*
:$%5)(-+* Z>&11.$* 8(&$'($* ;)4-%)3-%&$17* :;C7* @+2$%16-3* 7*
R)5#16&%$7*E$&'-*9'&2-[*L*!13)1*6$%&2)1*1$*(.4%&$%-'*(-'*3$X&2-*
2$*0%)'.+)(&J'*1)+.2)4+$*K*#.2&$%-'*%$(&4&%*&'X$1%3-1*2$*#&$+7*+)*
(-'2.X-*)*+)*(-5#+$3)*(&()3%&Q)(&J'L**
G$)+&#*&(! )2#! $%5(+*2(! U#*&='$! &#! (0(! 8&'+-$(@*!+*)#J1&3-*2$*
2-4+$* ()#)* B'3$0%)* f&+)K$%* <)3%&"* )(3\)* (-5-* .')* 5)3%&Q*
2U%5&()*#)%)*)K.2)%*)*O-%5)%*+)*()#)*2U%5&()*2$*+)*#&$+L*:.$2$*
++$0)%* )* 1$%* &'$O&()Q* 1&* 1$* &'O$(3)L* !'* F* #)(&$'3$17* $+* ).3-%*
)5#)#J*$+*)#J1&3-*B'3$0%)*(-'*A$%5)(K'*$'*$+*Y.&%JO)'-*)'3$1*
2$* 1.* )#+&()(&J'* )+* #)(&$'3$L* !5#)#)%* $+* )#J1&3-* B'3$0%)* (-'*
!
A$%5)(K'* #.$2$* 2&15&'.&%* +)* &'(&2$'(&)* 2$* &'O$((&-'$1* $'* $+*
#$%,-2-*#-13-#$%)3-%&-L*
*
*
l&0.%)1*F@sFAq*R$%&2)*$'*+)*#&$%')*$'*+)*#%$1$'3)(&J'*Z@[7*)*
+)1*F*1$5)')1*2$*.1)%*A$%5)(K'*Zf[7*3%)1*.'*&'X$%3-*2$*#&$+*ZC[7*
K*.')*/$Q*3-3)+5$'3$*(&()3%&Q)2)*ZA[L**
*
!+*(-'($#3-*2$*&%%&0)(&J'*2$*+)*6$%&2)**
!+*-4X$3&/-*2$*+)*&%%&0)(&J'*2$*6$%&2)1*$1*$+&5&')%*+-1*%$1&2.-1*
K* +)1* 4)(3$%&)1* 2$* +)* 6$%&2)* )+* 3&$5#-* Y.$* 1$* 5&'&5&Q)'* +-1*
2)_-1*)+*3$X&2-*'-%5)+*)+%$2$2-%*2$*+)*6$%&2)L*!'*+-1*()54&-1*2$*
)#J1&3-7*1$*#.$2$*3$'$%*+)*3$'3)(&J'*2$*Y.&3)%*$+*)#J1&3-*/&$X-*K*
)#+&()%*.'*'.$/-*)#J1&3-7*1&'*$'()%0)%1$*2$*+)*#%-#&)*6$%&2)L*;)*
&%%&0)(&J'*2$*+)*6$%&2)*#.$2$*)K.2)%*)*5$X-%)%*+)*(&()3%&Q)(&J'L**
*
*
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
II*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
;)* #%$1&J'* 2$* )#+&()(&J'* 2$* +)* &%%&0)(&J'* 2$* +)* 6$%&2)* #)%$($*
X.0)%* .'* O)(3-%* &5#-%3)'3$* )* +)* 6-%)* 2$* #%-5-/$%* +)*
(&()3%&Q)(&J'*2$*+)*6$%&2)L*9')*#%$1&J'*2$*)#+&()(&J'*2$*aÌG*#1&*
$1*.'*%)'0-*)($#3)2-*#)%)*$+&5&')%*2$1$(6-1*K*4)(3$%&)1*2$*.')*
6$%&2)* K* %$2.(&%* )+* 5,'&5-* $+* 2)_-* )* +-1* 3$X&2-1* '-%5)+$1*
N
(&%(.'2)'3$1L **
!1* (-5\'* -41$%/)%* $+* /$%3&2-* 2&%$(3-* $'* +)* 6$%&2)* 2$+*
(-'3$'&2-*2$*.')*4-3$++)*-*$+*.1-*2$*.')*#$%)*2$*0-5)*-*.')*
X$%&'0)* 2$* #$%)* #)%)* $+* %&$0-* 2$* .')* 6$%&2)* $'* +-1* ()54&-1* 2$*
)#J1&3-L*:%M(3&()5$'3$*'-*6)K*#%$1&J'*ZGÌ*#1&*[*)#+&()2)*$'*+)*
6$%&2)*(.)'2-*1$*.3&+&Q)*$+*/$%3&2-*2&%$(3-*2$12$*+)*4-3$++)*-*.')*
#$%)*2$*0-5)*-*X$%&'0)*2$*#$%)L*:-%*-3%-*+)2-*7*.')*X$%&'0)*2$*
U54-+-* 2$* Na* ((* (-'* .')* )0.X)* 2$* ()+&4%$* Ib* #%-#-%(&-')* .')*
#%$1&J'* 2$* .')1* d7T* #1&L* @+* (-5#)%)%* +-1* 2)3-1* 2$* &'O$((&J'*
0%)/$7*$'2.%$(&5&$'3-*K*%$(.$'3-1*4)(3$%&)'-1*(-'*.')*X$%&'0)*
2$* #$%)* 2$* 4)X)* #%$1&J'* O%$'3$* )* +-1* 2$* +)* #%$1&J'* 5M1* )+3)*
)+()'Q)2)*(-'*.')*X$%&'0)*2$*Na*((*K*.')*)0.X)*2$*()+&4%$*Ib7*+-1*
%$1.+3)2-1* 5.$13%)'* Y.$* 1.#-'$* .')* /$'3)X)* (+,'&()* .3&+&Q)%* $+*
1&13$5)*2$*#%$1&J'*1.#$%&-%*ZX$%&'0)*2$*Na*((*K*)0.X)*2$*()+&4%$*
T
Ib[ L*@+0.'-1*$13.2&-1*1.0&$%$'*Y.$*.')*1-+.(&J'*)'3&1U#3&()*$1*
5M1*$O&()Q*Y.$*1J+-*1.$%-*1)+&'-*)*$O$(3-1*2$*+&5#&)%*+)*6$%&2)*K*
a**
#%-5'-(/$%*+)*(&()3%&Q)(&J'L
*
l&0.%)1*N@sNCq*R$%&2)*2$+*#&$*
2&)4U3&(-*)'3$1*2$+*
3%)3)5&$'3-*Z@[7*(-'*.'*
)#J1&3-*]@C*B'13&++*$'*
#-1&(&J'*%$(&4&$'2-*
&%%&0)(&-'$1*&'3$%5&3$'3$1*
(-'*A$%5)(K'*Zf[7*K*
(-'3%),2)*K*(.4&$%3)*#-%*
3$X&2-*2$*0%)'.+)(&J'*1)'-*
ZC[L*
*
A&1(.1&J'**
=-* 6)* 6)4&2-* ()1-1* %$#-%3)2-1* 2$* 3-"&(&2)2* -* $O$(3-1*
1$(.'2)%&-1*(-'*A$%5)(K'L*:)%$($*Y.$*A$%5)(K'*1J+-*)3)()*)*
+-1* -%0)'&15-1* .'&($+.+)%$1* 1&'* )O$(3)%* )* +-1* -%0)'&15-1*
5.+3&($+.+)%$1L**
!'*$13)*1$%&$*2$*#)(&$'3$17*A$%5)(K'*#)%$($*1$%*.')*1-+.(&J'*
$O&()Q*#)%)*+)*6&2%)3)(&J'*K*$+*2$14%&2)5&$'3-*2$*6$%&2)1L*!'*$+*
#)1)2-7*1$*6)*2$5-13%)2-*Y.$*+)1*)0.)1*1.#$%-"&2)2)1*#-1$$'*
H
#%-#&$2)2$1* )'3&1U#3&()1L * !'* +-1* #)(&$'3$1* $13.2&)2-1* $'* $13)*
1$%&$7* A$%5)(K'* 3)54&U'* #)%$($* 1$%* .'* )'3&1U#3&(-* $O&()Q* #)%)*
6$%&2)1L**
A$%5)(K'* 1$* #.$2$* .3&+&Q)%* #)%)* 3%)3)%* .')* )5#+&)* /)%&$2)2*
2$* 6$%&2)17* 2$12$* 1&5#+$1* )* $"3%$5)2)5$'3$* (-5#+$X)1L* 8$*
#.$2$* .3&+&Q)%* (-5-* 1-+.(&J'* 2$* &%%&0)(&J'* 2$* 6$%&2)1* $'* +-1*
()54&-1*2$*)#J1&3-1*1&5#+$17*K*Y.$*#.$2$*1$%/&%*(-5-*1-+.(&J'*
#)%)*6.5$2$($%*+)*0)1)*.3&+&Q)2)*#)%)*/$'2)%*+)*6$%&2)*L**
A$%5)(K'*(-5#+$5$'3)*.')*)5#+&)*/)%&$2)2*2$*#%-2.(3-1*K*
5U3-2-1* )/)'Q)2-1* 2$* (.%)(&J'* 2$* 6$%&2)1L* :-%* $X$5#+-* 7* 1$*
#.$2$* .3&+&Q)%* (-5-* &%%&0)'3$* $'* ()54&-1* 2$* )#J1&3-1* 2$* +)*
3$%)#&)* ]@C* 3%)2&(&-')+7* K* (-5-* 1-+.(&J'* 2$* &%%&0)(&J'* (-'* $+*
1&13$5)*]@C*B'13&++L*>)54&U'*1$*#.$2$*.3&+&Q)%*#)%)*+)*&%%&0)(&J'*
2$*6$%&2)1*)*#%$1&J'7*4&$'*(-'*.'*1&13$5)*1&5#+$*Z.')*X$%&'0)*2$*
Na* ((* K* .')* )0.X)* 2$* ()+&4%$* Ib[7* 4&$'* (-'* #%-2.(3-1* 2$*
&%%&0)(&J'* 2$* 6$%&2)1* 5M1* O-%5)+$17* (-5-* $+* 1&13$5)* ]$%1)X$3*
RK2%-1.%0$%K*Z85&36*x*=$#6$r7*;)%0-*7*l+-%&2)[*-*$+*1&13$5)*2$*
+)/)2-7*+&5#&$Q)*K*2$14%&2)5&$'3-*2$*6$%&2)1*)*(6-%%-*Zp$3?"*`
=A7*A$E-K)+7*:-r$++7*>$''$11$$[L**
*
*
*
!+*.1-*2$*A$%5)(K'*#)%$($*3)54&U5*1$0.%-*(-'*#%-2.(3-1*2$*
&'0$'&$%,)* 3&1.+)%* K* 1.13&3.3-1* 2U%5&(-1L* ?3%-1* $13.2&-1* (+,'&(-1*
)K.2)%M'* )* (-'O&%5)%* +)* $O&()(&)* K* +)* (-5#)3&4&+&2)2* 2$*
A$%5)(K'*$'*$+*()5#-*2$+*(.&2)2-*)/)'Q)2-*2$*6$%&2)1L!**
*
!13$* $13.2&-* O.$* )#-K)2-* #-%* .')* 4$()* 2$* &'/$13&0)(&J'* 1&'*
%$13%&((&-'$1*2$*?(.+.1*B''-/)3&/$*8(&$'($1L*
*
*
*
f&4+&-0%)O,)*
IL* !0)'*<!L*R-+K*S)3$%L*l-%4$1L*l$4%.)%K*Fd7*FGGaL**
FL* S-+/-1*>L*S-.'2*&'13&++)3&-'*€*36$*'$"3*13$#*&'*'$0)3&/$*#%$11.%$*r-.'2*
36$%)#KL*;$11-'1*+$)%'$2*O%-5*&'&3&)+*$"#$%&$'($1L*?13-5K*S-.'2*<)')0$L*
FGGTgaGZII[qaHsHHL**
NL* ;.$23u$`R-OO5)''*j@7*8(6)O$%*A8L*:.+1$2*+)/)0$*&'*r-.'2*(+$)'1&'0L*:6K1*
>6$%L*FGGGgdGZN[qFbFsNGGL**
TL* 83$/$'1-'* >E7* >6)(u$%* pW7* E-2$6$)/$%* W>7* $3* )+L* C+$)'1&'0* 36$* 3%).5)3&(*
r-.'2*4K*6&06*#%$11.%$*1K%&'0$*&%%&0)3&-'L*p@C!:L*IbPHgaZI[qIPsFIL**
aL* ;&'2O-%1* pL* @* (-5#)%&1-'* -O* )'* )'3&5&(%-4&)+* r-.'2* (+$)'1$%* 3-* '-%5)+*
1)+&'$* &'* %$2.(3&-'* -O* 4&-4.%2$'* )'2* &31* $OO$(3* -'* r-.'2* 6$)+&'0L* ?13-5K*
S-.'2*<)')0$L*FGGTgaGZd[qFdsTIL**
HL* >)')u)*R7*R&%)u)3)*w7*j)u.*<7*$3*)+L*@'3&5&(%-4&)+*)(3&/&3K*-O*1.#$%-"&2&Q$2*
r)3$%L*p*R-1#*B'O$(3L*IbbHgNTZI[qTNsTbL**
*
*
!
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
IF*
<'$*$1+&#*2!-&!K.)&'$(!-&.!%+&!
-+$D6*+)2!)2#!$=0$!(0%&'27+-$-$!!
*
9')*/&1&J'*2$*+-1*)/)'($1*$'*$13$*3%)3)5&$'3-*)3J"&(-*2$*#R*'$.3%-**
L0)$!>$..$!G$2.$B!;>!
!
;*
*)* &'O$((&J'* $1* .'-* 2$* +-1* O)(3-%$1* 5M1* &5#-%3)'3$1* #)%)*
2$3$%5&')%* $+* %&$10-* 2$* )5#.3)(&J'* $'* #)(&$'3$1* (-'*
IÌI
2&)4$3$1L *8&*1$*)#+&()*.'*3%)3)5&$'3-*$13)'2)%&Q)2-*(-'*
.'*$Y.&#-*2$*)3$'(&J'*5.+3&2&1(&#+&')%*2$+*#&$7*$1*#-1&4+$*$/&3)%*
.')* )5#.3)(&J'* 5)K-%* $'* )#%-"&5)2)5$'3$* $+* dG`bGe* 2$* +-1*
#)(&$'3$1*(-'*&1Y.$5&)*2$*%&$10-*#)%)*+)1*$"3%$5&2)2$1*K*$'*$+*
PÌG7IFÌa
ba* e* 2$* +-1* #)(&$'3$1* (-'* &'O$((&J'L
* !+* 3%)3)5&$'3-*
Y.&%\%0&(-* $1* .')* 6$%%)5&$'3)* \3&+* #)%)* $+* 3%)3)5&$'3-* 2$* +)*
PÌG7IF7IN7IaÌP
&'O$((&J'*$'*#&$1*2&)4U3&(-1L
**
*
8&*1$*)#+&()*.'*3%)3)5&$'3-*
$13)'2)%&Q)2-*(-'*.'*$Y.&#-*2$*
)3$'(&J'*5.+3&2&1(&#+&')%*2$+*#&$7*$1*
#-1&4+$*$/&3)%*.')*)5#.3)(&J'*5)K-%*
$'*)#%-"&5)2)5$'3$*$+*dG`bGe*2$*
+-1*#)(&$'3$1*(-'*&1Y.$5&)*2$*%&$10-*
#)%)*+)1*$"3%$5&2)2$1*K*$'*$+*ba*e*2$*
+-1*#)(&$'3$1*(-'*&'O$((&J'LPsIG7*IFsIa*
*
X.$0)'*.'*#)#$+*&5#-%3)'3$L*!'*$13$*)%3,(.+-*1$*$13.2&)%M*$+*.1-*
2$*A$%5)(K'*S-.'2*C)%$*$'*$+*3%)3)5&$'3-*2$*+)1*\+($%)1*2$+*
#&$*2&)4U3&(-L*
*
?L?H<MWLU:U:!
@W9@*
9;>E@:9E@*
G'2)&(2!!
&.&)*'2N041+)2!'&-27!!
-&!V!)S1$'$(!
;-1*&-'$1*2$*-",0$'-*K*(+-%-*1-'*)3%),2-1*)+*M'-2-*K*1$*-"&2)'7*
$1*2$(&%7*1$*$+&5&')'*$+$(3%-'$1*
N*5$54%)')1*#$%5$)4+$1*
.'&2&%$((&-')+$1*
>&'1$)3#!X!
%R!#&0*'2!
Y!OZZ!%%1!W!
;-1*&-'$1*2$*1-2&-*$*6&2%J0$'-*1-'*)3%),2-1*)+*(M3-2-*K*1$*
%$2.($'7*$1*2$(&%7*1$*)0%$0)'*$+$(3%-'$1*
*
l&0.%)*Iq*:%-($1-*2$*#%-2.((&J'*2$*A$%5)(K'L*
*
!X$5#+-1*2$*A$%5)(K'*$'*)((&J'**
;)* l&0.%)* I* 5.$13%)* $+* #%-($1-* 2$* #%-2.((&J'* 2$* A$%5)(K'L*
!13)* 1-+.(&J'* 1.#$%-"&2)2)* 1$* .3&+&Q)* 3)'3-* $'* +)* (&%.0,)* 2$*
.%0$'(&)* (-5-* $+$(3&/)* (.)'2-* $+* 2$14%&2)5&$'3-* Y.&%\%0&(-* K*
O,1&(-* 1$* %$)+&Q)* (-'* &%%&0)(&J'* #.+1)'3$7* 2$14%&2)5&$'3-* #-%*
.+3%)1-'&2-1* K* 3$%)#&)* (&$%%$* )1&13&2)* #-%* /)(,-* Z]@C* >6$%)#K7*
jCB*7*8)'*@'3-'&-7*>$")1[L*8$*.3&+&Q)*(.)'2-*+)*&5#%$1&J'*(+,'&()*
1.0&$%$* +)* #%$1$'(&)* 2$* &'O$((&J'* K* #.$2$* .3&+&Q)%1$* (-'* .'*
&'X$%3-*2$*#&$+*K*3$X&2-*2$*4&-&'0$'&$%,)*
*
*
:.$2$'*.1)%1$*)'3&1U#3&(-1*#)%)*#%$/$'&%*K*3%)3)%*+)*&'O$((&J'*
K* #%$1$%/)%* $+* #%-($1-* 2$* (&()3%&Q)(&J'L* 8-'* #%$O$%&4+$1* )* +-1*
)'3&4&J3&(-1* 3J#&(-1* (-'* %$1#$(3-* )+* 2$1)%%-++-* 2$* %$1&13$'(&)*
Id
4)(3$%&)')L * @+0.'-1* $"#$%3-1* )%0.5$'3)'* (-'3%)* $+* .1-* 2$*
)0$'3$1*)'3&1U#3&(-1*$'*$+*3%)3)5&$'3-*2$*+)1*6$%&2)17*K*+)*%)QJ'*
#%&'(&#)+*3%)1*2$*$13-1*)%0.5$'3-1*$1*+)*(&3-3-"&(&2)2*(-'3%)*+)1*
(U+.+)1*2U%5&()1*K*$#&2U%5&()1*2$+*6.U1#$2L*R)K*#-()*$/&2$'(&)*
*
Id
2$* .1-* 2$* )0$'3$1* )'3&1U#3&(-1* +-()+$1* $'* #&$1* &'O$(3)2-1L * @*
;)* O&0.%)* F* 5.$13%)* .'* #)(&$'3$* Y.$* #%$1$'3J* 0)'0%$')* K*
#$1)%* 2$* +)* $1()1)* $/&2$'(&)7* +-1* )'3&1U#3&(-1* 1$* .3&+&Q)'* $'* +)*
'$(%-1&1*#+)'3)%*K*%$Y.&%&J*(&%.0,)*2$*.%0$'(&)*#)%)*3%)3)%*3)'3-*
F7Id`FG
#%M(3&()* (+,'&()* #)%)* +)* #&$+* K* 6$%&2)1* &'O$(3)2)1L
* !"&13$*
+)* 0)'0%$')* (-5-* $+* 1,'2%-5$* (-5#)%3&5$'3)+* #+)'3)%L* 8$*
#%$-(.#)(&J'*1-4%$*$+*$O$(3-*2$*+-1*)'3&1U#3&(-1*$'*+)1*\+($%)1*
)#+&(J*A$%5)(K'*$'*+)*6$%&2)*2&)%&)5$'3$*2.%)'3$*bG*2,)1*6)13)*
2$+* #&$* 2&)4U3&(-L* @Y.,* $1* 2-'2$* +)1* 1-+.(&-'$1* 1.#$%-"&2)2)17*
Y.$* (&()3%&QJL* !+* 8&13$5)* ]@C* B'13&++* 3-2)/,)* '-* $13M* 2&1#-'&4+$*
(-5-* A$%5)(K'* S-.'2* C)%$* ZO-%5.+)2)* (-'* <&(%-(K'^*
$'* B3)+&)7* #-%* +-* A$%5)(K'* 1$* &'K$(3)* 2&)%&)5$'3$* 1-4%$* +)*
>$(6'-+-0K7* ?(.+.1* B''-/)3&/$* 8(&$'($17* :$3)+.5)7* C)+&O-%'&)[*
13*
!
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
$1#.5)*(-'*+)*>$%)#&)*]@CL*;-1*5U2&(-1*$'*B3)+&)*3)54&U'*$13M'*
.3&+&Q)'2-*A$%5)(K'*)'3$1*2$*&'X$%3-1*2$*#&$+*$'*)5#.3)(&-'$1*
)4&$%3)17*(-5-*1$*5.$13%)*$'*+)*l&0.%)*NL*
*
A)3-1*2$*A$%5)(K'*
!'3%$*'-/&$54%$*2$*FGGT*K*5)%Q-*2$*FGGa7*FId*#)(&$'3$1*(-'*
2&)4$3$1*O.$%-'*&'(+.&2-1*$'*.'*$13.2&-*)+$)3-%&Q)2-*$'*.'*1-+-*
($'3%-* &3)+&)'-* Y.$* $/)+.J* +)* $O&()(&)* 2$* A$%5)(K'L* 8$*
$'%-+)%-'* #)(&$'3$1* (-'* \+($%)1* 2$* 0%)2-* BB* K* BBB* .3&+&Q)'2-* +)*
C+)1&O&()(&J'*2$*+)*9'&/$%1&2)2*2$*>$")1*2$*\+($%)1*2$+*#&$7*K*IIG*
2$* +-1* #)(&$'3$1* &'(+.&2-1* O.$%-'* )1&0')2-1* )+$)3-%&)5$'3$* )+*
0%.#-* 2$* A$%5)(K'* K* IGd* )+* 0%.#-* 2$* (-'3%-+L* ;-1* F* 0%.#-1*
O.$%-'*$5#)%$X)2-1*#-%*$2)27*2.%)(&J'*2$*+)*2&)4$3$1*K*0%)2-*
2$*.+($%)(&J'L**
>-2-1*+-1*#)(&$'3$1*(-'*$'O$%5$2)2*/)1(.+)%*#$%&OU%&()*Z!]:[*
O.$%-'* %$5&3&2-1* #)%)* %$/)1(.+)%&Q)(&J'* 5$2&)'3$* 3U('&()1*
H7FI`FT
$'2-/)1(.+)%$1* -* (&%.0,)* 2$* 2$%&/)(&J'L
* !+* 3%)3)5&$'3-*
Y.&%\%0&(-* 2$* +)* &'O$((&J'* J1$)* Z$"-13$(3-5,)* -* )5#.3)(&-'$1*
5$'-%$1[* 1$* %$)+&QJ* $'* #)(&$'3$1* (-'* -13$-5&$+&3&1* K* 1$* 3-5J*
.')*5.$13%)*5&(%-4&-+J0&()*()2)*5$1*2$12$*$+*5-5$'3-*2$*+)*
&'(+.1&J'* K* +)* )+$)3-%&Q)(&J'* 6)13)* $+* (&$%%$7* (-'* -4X$3-* 2$*
$/)+.)%* $+* '\5$%-* K* +)* ()+&2)2* 2$* +)1* ($#)1* 4)(3$%&)')1L* !+*
3%)3)5&$'3-*+-()+*1$*++$/J*)*()4-*2&)%&)5$'3$*.1)'2-*.')*0)1)*
$5#)#)2)* (-'* A$%5)(K'* Z$'* $+* 0%.#-* 2$* A$%5)(K'[* -*
#-/&2-')*K-2)2)*Z$'*$+*0%.#-*2$*(-'3%-+[*L*;)*(&%.0,)*$+$(3&/)*1$*
++$/J* )* ()4-* 2$1#.U1* 2$* +)* 5$X-%,)* (+,'&()* 2$* +)* &'O$((&J'* K* +)*
%$/)1(.+)%&Q)(&J'L* ;)1* 2&O$%$'(&)1* $'3%$* +-1* 0%.#-1* $'* O)/-%* 2$*
A$%5)(K'*O.$%-'*$/&2$'3$1*$'*(.)'3-*)*%$2.((&J'*2$+*'\5$%-*
2$* ($#)1* 4)(3$%&)')17* $O$(3-1* )2/$%1-1* +-()+$17* 2$6&1($'(&)*
Y.&%\%0&()* 7* 3)1)1* 2$* )5#.3)(&J'* K* 3&$5#-* 2$* (&()3%&Q)(&J'L* !+*
$13.2&-*K)*6)*1&2-*#%$1$'3)2-*#)%)*1.*#.4+&()(&J'L*
*
C-'(+.1&-'**
;)* &'O$((&J'* $1* .'* O)(3-%* #%-'J13&(-* '$0)3&/-* Y.$* $"#+&()* $+*
)+3-* %&$10-* 2$* )5#.3)(&J'* $'* #)(&$'3$1* (-'* 2&)4$3$1* K* \+($%)1*
2$+* #&$L* !+* 3%)3)5&$'3-* )0%$1&/-* Z3%)3)5&$'3-* )'3&4&J3&(-*
(-54&')2-*(-'*(&%.0,)[*'-1*#$%5&3$*++$0)%*)*.'*)+3-*#-%($'3)X$*
2$* %$(.#$%)(&J'* 2$* +)* $"3%$5&2)2L* !+* 3%)3)5&$'3-* 2$* +)*
&'O$((&J'* %$Y.&$%$* .'* 2$14%&2)5&$'3-* )0%$1&/-* +-()+* 2$* +-1*
3$X&2-1* 4+)'2-1* '-* /&)4+$1* K* $+* 3%)3)5&$'3-* 2$* +)* -13$-5&$+&3&1L*
=-* 6)K* $/&2$'(&)* 1J+&2)* Y.$* 5.$13%$* +)* $O&()(&)* 2$* )0$'3$1*
)'3&1U#3&(-1* +-()+$1* $'* $+* 3%)3)5&$'3-* 2$* +)* &'O$((&J'* 2$+* #&$*
2&)4U3&(-L*@*#$1)%*2$*$13)*O)+3)*2$*#%.$4)17*+-1*5U2&(-1*.3&+&Q)'*
)0$'3$1*)'3&1U#3&(-1*(-5-*3%)3)5&$'3-*(-5#+$5$'3)%&-*$'*+-1*
#&$1* &'O$(3)2-1L* ;-1* %$1.+3)2-1* 2$* $13$* $13.2&-7* #-%* 3)'3-7*
#)%$($'*5-13%)%*%$1.+3)2-1*5M1*O)/-%)4+$1*#)%)*A$%5)(K'*Y.$*
#)%)* +)* #-/&2-')* K-2)2)L* 8&'* $54)%0-* 7* ).'Y.$* +-1* %$1.+3)2-1*
1-'* $13)2,13&()5$'3$* 5.K* 1&0'&O&()3&/-17* +)* O.$%Q)* 2$* +)*
$/&2$'(&)* 2$* +)* 1.#$%&-%&2)2* 2$* A$%5)(K'* 1-4%$* +)* #-/&2-')*
K-2)2)*2$#$'2$*2$+*2&1$_-*2$+*$13.2&-L*;-1*%$1.+3)2-1*2$*$13$*
$13.2&-* X.13&O&()'* +)* &'/$13&0)(&J'* )2&(&-')+* $'* $+* .1-* 2$*
A$%5)(K'* $'* $+* 3%)3)5&$'3-* 2$* \+($%)1* 2&)4U3&()1L* !1*
&5#-%3)'3$*)1$0.%)%1$*2$*Y.$*1$*$"(+.K)'*+)1*#-1&4+$1*O.$'3$1*
2$* 1$10-* $'* +-1* $13.2&-1* O.3.%-17* #-%* $X$5#+-* 5$2&)'3$* +)*
)1&0')(&J'* )+* )Q)%* 2$* +-1* #)(&$'3$1* )+* 3%)3)5&$'3-* K* +)*
$/)+.)(&J'*($0)2)*2$*+-1*%$1.+3)2-1L!
*
!
*
l&0.%)*F*q*;)*O-3-*1.#$%&-%*5.$13%)*$+*#&$*2$*.'*#)(&$'3$*(-'*
0)'0%$')*K*'$(%-1&1*#+)'3)%7*5&$'3%)1*Y.$*+)*O-3-*&'O$%&-%*
5.$13%)*+)*6$%&2)*.')*/$Q*(&()3%&Q)2)L*
*
*
f&4+&-0%)O,)**
IL** @2+$%* !B7* f-Ku-* !p7* @6%-'&* pR7* $3* )+L* ;-r$%* $"3%$5&3K* )5#.3)3&-'* &'*
2&)4$3$1q* 36$* &'2$#$'2$'3* $OO$(31* -O* #$%&#6$%)+* /)1(.+)%* 2&1$)1$7* 1$'1-%K*
'$.%-#)36K7*)'2*O--3*.+($%1L*A&)4$3$1*C)%$L*IbbbgFFZP[qIGFbsIGNaL**
FL** @5$%&()'* A&)4$3$1* @11-(&)3&-'L* :%$1$'3$2* )3* 36$* C-'1$'1.1* A$/$+-#5$'3*
C-'O$%$'($*-'*A&)4$3&(*l--2*S-.'2*C)%$*&'*f-13-'7*<)11)(6.1$3317*@#%&+*
Psd7*IbbbL*A&)4$3$1*C)%$L*IbbbgFFZd[qINaTsINHGL**
NL** f-&u-* !p7* ;&#1uK* f@L* B'O$(3&-'* )'2* 2&)4$3$1* 5$++&3.1L* B'q* R)%%&1* <B* Z$2[q*
A&$)4$3$1* &'* @5$%&()7* 8$(-'2* !2&3&-'L* A&)4$3$1* 2)3)* (-5#&+$2* IbbaL*
f$36$12)7*<Aq*=)3&-')+*B'13&3.3$1*-O*R$)+36L*=BR*#.4+&()3&-'*=-q*baÌTHd7*
Ibba7*##TdasTbbL**
TL** C6)'0* ff7* A)%+&'0* EC* BBB7* :)3K* :8j7* $3* )+L* !"#$2&3&-.1* 5)')0$5$'3* -O*
&1(6$5&(*&'/)1&/$*O--3*&'O$(3&-'1L*C)%2&-/)1(*8.%0L*IbbHgTZH[qPbFsPbaL**
aL** C6)'3$+).* !7* >)'.2X)X)* >7* @+3$'6-O$%* l7* $3* )+L* @'3&4&-3&(* 3%$)35$'3* O-%*
.'(-5#+&()3$2* '$.%-#)36&(* O-%$O--3* .+($%1* &'* 2&)4$3$1q* )* (-'3%-++$2* 3%&)+L*
A&)4$3*<$2L*IbbHgINZF[qIaHsIabL**
HL** !'$%-36* <7* $3* )+L* C+&'&()+* (6)%)(3$%&13&(* )'2* -.3(-5$* &'* FFN* 2&)4$3&(*
#)3&$'31*r&36*2$$#*O--3*&'O$(3&-'1L*l--3*@'u+$*B'3L*IbbPgIdZII[qPIHsPFFL**
PL** W&44-'1* WSL* >6$* 2&)4$3&(* O--3q* )5#.3)3&-'1* )'2* 2%)&')0$* -O* &'O$(3&-'L* p*
])1(*8.%0L*IbdPgHZa[qPbIsPbNL**
dL** W%)K1-'*<;7*W&44-'1*WS7*f)+-06*j7*$3*)+L*:%-4&'0*3-*4-'$*&'*&'O$(3$2*#$2)+*
.+($%1q*)*(+&'&()+*1&0'*-O*.'2$%+K&'0*-13$-5K$+&3&1*&'*2&)4$3&(*#)3&$'31L*p@<@L*
IbbagFPNZb[qPFIsPFNL**
bL** R-+13$&'* :7* 8-%$'1-'* 8L* ;&54* 1)+/)0$* $"#$%&$'($* &'* )* 5.+3&2&1(&#+&')%K*
2&)4$3&(*O--3*.'&3L*A&)4$3$1*C)%$L*IbbbgFFZ8.##+*F[L**
IGL**;&#1uK*f@L*B'O$(3&-.1*#%-4+$51*-O*36$*O--3*&'*2&)4$3&(*#)3&$'31L*B'q*f-ru$%*
pR7* :O$&O$%* <@* Z$21[L* ;$/&'* )'2* ?‚=$)+‚1* >6$* A&)4$3&(* l--3L* 8&"36* !2&3&-'L*
<-14K7*FGGIL**
IIL**E)51$K* 8A7* =$r3-'* j7* f+-.06* A7* $3* )+L* B'(&2$'($7* -.3(-5$17* )'2* (-13* -O*
O--3*.+($%1*&'*#)3&$'31*r&36*2&)4$3$1L*A&)4$3$1*C)%$L*IbbbgFFZN[qNdFsNdPL**
IFL**@%513%-'0* AW7* l%Ku4$%0* EWL* C+)11&OK&'0* 2&)4$3&(* O--3* 1.%0$%Kq* 3-r)%2* )*
%)3&-')+*2$O&'&3&-'L*A&)4$3*<$2L*FGGNgFGZT[qNFbsNNIL**
INL**R-+13$&'* :7* !++&310))%2* =7* ?+1$'* ff7* !++&310))%2* ]L* A$(%$)1&'0* &'(&2$'($* -O*
5)X-%*)5#.3)3&-'1*&'*#$-#+$*r&36*2&)4$3$1L*A&)4$3-+-0&)L*FGGGgTNZP[qdTTs
dTPL**
ITL**;)%11-'* p7* @#$+Y/&13* p7* @0)%26* CA7* 83$'13%-'* @L* A$(%$)1&'0* &'(&2$'($* -O*
5)X-%* )5#.3)3&-'1* &'* 2&)4$3&(* #)3&$'31q* )* (-'1$Y.$'($* -O* )*
5.+3&2&1(&#+&')%K* O--3* ()%$* 3$)5* )##%)-(6v* A&)4$3* <$2L* IbbagIFZb[qPPGs
PPHL**
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
IT*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
*
l&0.%)*Nq*!X$5#+-*2$*.1-*2$*A$%5)(K'*$'*.')*)5#.3)(&J'*)4&$%3)*ZO-3-*2$*+)*&QY.&$%2)[*K**
)'3$1*2$*+)*)#+&()(&J'*2$*.'*&'X$%3-*2$*#&$+7*(-5-*1$*5.$13%)*$'*+)*O-3-*2$*+)*2$%$(6)L*
*
*
IaL**E-1$'4+.5*fB7*:-5#-1$++&*lf7*W&.%&'&*p<7*$3*)+L*<)"&5&Q&'0*O--3*1)+/)0$*4K*)*
(-54&'$2*)##%-)(6*3-*O--3*&1(6$5&)*)'2*'$.%-#)36&(*.+($%)3&-'*&'*#)3&$'31*
r&36*2&)4$3$1L*@*a`K$)%*$"#$%&$'($L*A&)4$3$1*C)%$L*IbbTgIPZb[qbdNsbdPL**
IHL**C)#.3-*W<7*C)/)')06*:E7*9+4%$(63*p87*$3*)+L*@11$115$'3*)'2*5)')0$5$'3*
-O*O--3*2&1$)1$*&'*#)3&$'31*r&36*2&)4$3$1L*=*!'0+*p*<$2L*IbbTgNNIZIN[qdaTs
dHGL**
IPL**C)/)')06* :E7* f.1$* pf7* l%Ku4$%0* EW7* $3* )+L* l-%* 36$* @5$%&()'* A&)4$3$1*
@11-(&)3&-'q* 2&)4$3&(* O--3* r-.'2* ()%$L* :%$1$'3$2* )3* 36$* C$'1.1*
A$/$+-#5$'3* C-'O$%$'($* 6$+2* &'* f-13-'7* <)11)(6.1$3317* @#%&+* Psd7* IbbbL*
A&)4$3$1*C)%$L*IbbbgFFZd[qINaTsINHGL**
IdL**A%-1-.* @7* l)+)4$++)* @7* j&%1'$%* 8L* @'3&1$#3&(1* -'* r-.'21q* )'* )%$)* -O*
(-'3%-/$%1KL*S?9=A8L*FGGNgIaZa[qITbsIHHL**
IbL**f$%013%-5* =7* f$''$3* <@7* C)%+1-'* C!7* $3* )+L* C+&'&()+* #%)(3&($* 0.&+2$+&'$*
'.54$%*Iaq*3%$)35$'3*-O*#%$11.%$*.+($%1L*E-(u/&++$*<Aq*98*A$#)%35$'3*-O*
R$)+36* )'2* R.5)'* 8$%/&($1L* @0$'(K* O-%* R$)+36* C)%$* :-+&(K* )'2* E$1$)%(6L*
@RC:E*:.4+&()3&-'L*IbbTgHasGHaFL**
FGL**B'3$%')3&-')+* C-'1$'1.1* -'* 36$* 2&)4$3&(* O--3L* @513$%2)5q* B'3$%')3&-')+*
S-%u&'0*W%-.#*-'*36$*A&)4$3&(*l--37*IbbbL**
FIL**!25-'21*<7*l-%13$%*@]<L*E$2.(3&-'*-O*5)X-%*)5#.3)3&-'1*&'*36$*2&)4$3&(*
13%)3$0K* 3-* y3)u$* (-'3%-+z* r&36* (-'1$%/)3&/$* ()%$* )1* r$++* )1*
%$/)1(.+)%&Q)3&-'L*]@8@*FGGIgadZ1.##+[qHsITL**
FFL**l)0+&)* !7* A)++)* :)-+)* ;7* $3* )+L* :$%&#6$%)+* )'0&-#+)13K* )1* 36$* O&%13* (6-&($*
%$/)1(.+)%&Q)3&-'*#%-($2.%$*&'*2&)4$3&(*#)3&$'31*r&36*(%&3&()+*+&54*&1(6$5&)q*
#%-1#$(3&/$* 13.2K* -O* bbN* (-'1$(.3&/$* #)3&$'31* 6-1#&3)+&Q$2* )'2* O-++-r$2*
4$3r$$'*Ibbb*)'2*FGGNL*!.%*p*])1(*!'2-/)1(*8.%0L*FGGagFbZH[qHFGsHFPL**
FNL**l)0+&)*!7*l)/)+$1*l7* @+2$06&*@7*$3* )+L*C6)'0$*&'*5)X-%* )5#.3)3&-'* %)3$*&'*)*
($'3$%* 2$2&()3$2* 3-* 2&)4$3&(* O--3* ()%$* 2.%&'0* 36$* IbdG1q* #%-0'-13&(*
2$3$%5&')3'31* O-%* 5)X-%* )5#.3)3&-'L* p* A&)4$3$1* C-5#+&()3&-'1L*
IbbdgIFZF[qbHsIGFL**
FTL**l)0+&)* !7* <)'3$%-* <7* C)5&'&3&* <7* $3* )+L* !"3$'1&/$* .1$* -O* #$%&#6$%)+*
)'0&-#+)13K7* #)%3&(.+)%+K* &'O%)#-#+&3$)+7* &'* 36$* 3%$)35$'3* -O* &1(6$5&(*
2&)4$3&(* O--3* .+($%1q* (+&'&()+* %$1.+31* -O* )* 5.+3&($'3%&(* 13.2K* -O* FFI*
(-'1$(.3&/$*1.4X$(31L*p*B'3$%'*<$2L*FGGFgFaFZN[qFFasFNFL**
*
*
*
!
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
Ia*
M&-0)+5#!-&!.$(!)21%.+)$)+2#&(!
+#/&))+2($(!D$)*&'+$#$(!-&!.$(!8&'+-$(!
%2'!N0&1$-0'$!!
*
9')*/&1&J'*2$+*.1-*2$*?(.+.1*<&(%-(K'HG*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*$'*
<U"&(-**
A'+&.!;+'$#-$!A.*$1+'$#2B!;>!
!
;*
)1* Y.$5)2.%)1* 1-'* .'* #%-4+$5)* &5#-%3)'3$* )1-(&)2-* )*
)+3)* 5-%4&+&2)2* $'* <U"&(-L* !'* FGGN* 1$* '-3&O&()%-'* FGLNNG*
I
()1-1*2$*Y.$5)2.%)1*7*+)*5)K-%,)*$'*'&_-1L *@*#$1)%*2$*+)1*
5$X-%)1* $'* $+* 3%)3)5&$'3-* 5.+3&2&1(&#+&')%&-7* +)* &'O$((&J'* 1&0.$*
1&$'2-* +)* ().1)* #%&'(&#)+* 2$* 5.$%3$* $'3%$* +-1* #)(&$'3$1* Y.$*
$13M'*6-1#&3)+&Q)2-1L**
;)1*&'O$((&-'$1*2$*+)1*6$%&2)1*#-%*Y.$5)2.%)1*%$#%$1$'3)'*$+*
N`Pe*2$*3-2)1*+)1*&'O$((&-'$1*$'*#)(&$'3$1*(-'*Y.$5)2.%)1*$'*
F
!13)2-1* 9'&2-1L * 8$* #%$1$'3)'* (-'* 5M1* O%$(.$'(&)* $'* '&_-17*
1$0.&2-1* #-%* #)(&$'3$1* 2$* $2)2* )/)'Q)2)L* ;)* &'(&2$'(&)* 2$* +)1*
&'O$((&-'$1* $'* 6$%&2)1* #-%* Y.$5)2.%)1* #.$2$* 1$%* {* IGe7* (-'*
.')* 3)1)* 2$* a7HcILGGG* #)(&$'3$1`2,)* $'* (&$%3)1* .'&2)2$1*
N
$1#$(&)+&Q)2)1* $'* 2$* Y.$5)2-1* $'* !13)2-1* 9'&2-1L * 8&'*
$54)%0-* 7* $13)1* 3)1)1* 1-'* 5.(6-* 5M1* )+3)1* $'* -3%-1* #),1$17*
(-5-* <U"&(-7* 2$4&2-* )* (-'2&(&-'$1* 2$* 6)(&')5&$'3-* 7* 5$'-1*
4)%%$%)1* 2$* (-'3%-+* 2$* &'O$((&-'$1* 7* K* 5$'-%* )(($1-* )+*
2$14%&2)5&$'3-* &'5$2&)3-* 2$* +)* 6$%&2)* -* 3$%)#&)1*
)'3&5&(%-4&)')1*Z$'*(-5#)%)(&J'*(-'*!13)2-1*9'&2-1[L
*
!3&-+-0,)*2$*+)1*Y.$5)2.%)1*K*-3%-1*6$(6-1**
!+* %&$10-* 2$* &'O$((&J'* 2$* +)* 6$%&2)* #-%* Y.$5)2.%)* $13M*
2&%$(3)5$'3$*(-%%$+)(&-')2-*(-'*+)*$"3$'1&J'*2$*+)*Y.$5)2.%)*
K* 0.)%2)* %$+)(&J'* (-'* $+* 2$3$%&-%-* 2$* +)* %$1&13$'(&)* %$1.+3)'3$*
2$*+)*#U%2&2)*2$*+)*&'3$0%&2)2*5$(M'&()*2$*+)*#&$+*K*+)*1.#%$1&J'*
&'5.'$* 0$'$%)+&Q)2)L* ;)1* &'O$((&-'$1* $'* +)1* 6$%&2)1* #-%*
Y.$5)2.%)1*#.$2$'*(+)1&O&()%1$*(-5-*($+.+&3&1*2$*+)*6$%&2)*Z$1*
2$(&%7* #&$+* 1&'* Y.$5)%* $'* $+* 5)%0$'* 2$* +)* Y.$5)2.%)[* -* (-5-*
.')* &'O$((&J'* &'/)1&/)* 2$* +)* 6$%&2)* Z* $1* 2$(&%7* +)* &'/)1&J'*
5&(%-4&)')* 2$* 3$X&2-* /&)4+$* 2$4)X-* 2$* +)* $1()%)* 2$* +)1* 6$%&2)*
#-%*Y.$5)2.%)[L*;)1*&'O$((&-'$1*4)(3$%&)')1*2$*+)1*6$%&2)1*#-%*
Y.$5)2.%)* 1-'* ().1)2)1* #-%* 83)#6K+-(-((.1* ).%$.17*
:1$.2-5-')1* )$%.0&'-1)7* !'3$%-4)(3$%* (+-)()$7* j+$41&$++)*
#'$.5-'&)$7*!'3$%-(-((.1*O)$()+&1*K*@(&'$3-4)(3$%*4).5)''&&L**
!
;-1* )/)'($1* $'* +)1* 3$%)#&)1* 2$* Y.$5)2.%)1* +-()+$17*
&'(+.K$'2-* $+* .1-* #%.2$'3$* 2$* )'3&5&(%-4&)'-17* 6)'* %$2.(&2-*
1&'* 2.2)* +)1* (-5#+&()(&-'$1* &'O$((&-1)1* 4)(3$%&)')1* 2$* +)1*
Y.$5)2.%)1L* ;)5$'3)4+$5$'3$7* $+* '\5$%-* 2$* &'O$((&-'$1*
-#-%3.'&13)1* $'* +)1* 6$%&2)1* #-%* Y.$5)2.%)1* 6)* ).5$'3)2-*
1&0'&O&()3&/)5$'3$L*@1,7*+)1*&'O$((&-'$1*#-%*4)(3$%&)1*%$1&13$'3$1*
)* +-1* )'3&4&J3&(-1* Z#-%* $X$5#+-7* 8L* ).%$.1* %$1&13$'3$1* )* +)*
5$3&(&+&')[* K* 6-'0-1* #)3J0$'-1* Z#-%* $X$5#+-7* 2$* +)1* $1#$(&$1*
@1#$%0&++.17* C)'2&2)* K* <.(-%[* 6)'* &2-* ).5$'3)'2-*
(-'13)'3$5$'3$*$'*+-1*\+3&5-1*)_-1L*!13$*3&#-*2$*&'O$((&-'$1*1$*
-41$%/)* 1-4%$* 3-2-* $'* +-1* #)(&$'3$1* Y.$* 1.O%$'* Y.$5)2.%)1*
5)K-%$1* Z{* TG* e* 2$* +)* 1.#$%O&(&$* (-%#-%)+* 3-3)+* n8C>o[* Y.$*
%$(&4$'* 5\+3&#+$1* 2-1&1* #$%&-#$%)3-%&)1* * 2$* )'3&4&J3&(-1* 2$*
)5#+&-*$1#$(3%-L**
!'*0$'$%)+7*+)1*3)1)1*2$*5-%3)+&2)2*#-%*1$#1&1*2$*6$%&2)1*#-%*
Y.$5)2.%)* 1$* 5)'3&$'$'* $+$/)2)1L* =-* -413)'3$7*
&'2$#$'2&$'3$5$'3$* 2$+* $1#$1-%* 2$* +)* 6$%&2)7* +)* #%$1$'(&)* 2$*
&'O$((&J'* #-2%,)* 3)54&U'* %$3)%2)%* 1$/$%)5$'3$* $+* #%-($1-* 2$*
(&()3%&Q)(&J'* 2$* +)* 6$%&2)7* ).5$'3)%* +)1* 3)1)1* 2$* #U%2&2)* 2$+*
&'X$%3-7*2$3$%&-%)%*+-1*%$1.+3)2-1*(-15U3&(-17*K*$+$/)%*+-1*(-13$1*
T7a
6-1#&3)+)%&-1L * :-%* +-* 3)'3-* 7* +)* 0$13&J'* 2$* +)* 6$%&2)* 2$4$*
($'3%)%1$* $'* $/&3)%* +)* &'O$((&J'* K* #%$/$'&%* +)* #%-0%$1&J'* 2$* +)*
+$1&J'*2$12$*$+*#%&5$%*2,)L*
*
W$13&J'*2$*+)1*Y.$5)2.%)1**
;)* 0$13&J'* 2$* +)1* 6$%&2)1* #-%* Y.$5)2.%)1* 0%)/$1* $1*
5.+3&2&1(&#+&')%L* ],)1* 2$* )&%$* #$%5$)4+$17* %$13).%)(&J'* 2$+*
/-+.5$'* K* $+&5&')(&J'* 3$5#%)')* 2$+* 3$X&2-* '$(%J3&(-7* 1$0.&2-*
2$+*(&$%%$*2$*+)*6$%&2)7*1-'*+-1*-4X$3&/-1*(+)/$L*9'*3%)3)5&$'3-*
)'3&5&(%-4&)'-* 3J#&(-* $O&()Q* K* +)* &'1#$((&J'* 2&)%&)* 2$* +)* 6$%&2)*
1-'* '$($1)%&-1* #)%)* 2$3$(3)%* +)* &'O$((&J'7* Y.$* #.$2$* ().1)%* +)*
(-'/$%1&J'*2$*+)1*Y.$5)2.%)1*2$*$1#$1-%*#)%(&)+*$'*+$1&-'$1*2$*
$1#$1-%*3-3)+*L**
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
16*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
*
!1* '-3)4+$* Y.$* $+* 3%)3)5&$'3-* 3J#&(-* )'3&&'O$((&-1-* 2$* +)1*
6$%&2)1* '-* 6)* ()54&)2-* 1&0'&O&()3&/)5$'3$* $'* +-1* \+3&5-1* aG*
)_-1L* ;)* )3$'(&J'* $13M'2)%* #.$2$* /)%&)%* 2$* .')* &'13&3.(&J'* )*
-3%)7* #$%-* #-%* +-* 0$'$%)+* (-5&$'Q)* (-'* +)* +&5#&$Q)* 2$* +)1*
6$%&2)1* (-'* 1.$%-* 1)+&'-* K* .'* 2$3$%0$'3$* Y.&%\%0&(-* Z#-%*
$X$5#+-*7*0+.(-')3-*2$*(+-%6$"&2&')[7*1$0.&2-*#-%*+)*)#+&()(&J'*
2$* (%$5)1* #)%)* Y.$5)2.%)1* 2$* 1.+O)2&)Q&')* 2$* #+)3)* -* 2$*
)($3)3-* 2$* 5)O$'&2)* Z;)* 1-+.(&J'* 2$* A)u&'* K* 4$3)2&'$* 1-'*
)0$'3$1* )+3$%')3&/-1* Y.$* K)* $13M'* $'* 2$1.1-[* ;)1* Y.$5)2.%)1*
1$*3%)3)'*+.$0-*$'*O-%5)*)4&$%3)*-*($%%)2)L*C-'*$+*.1-*2$*$13$*
$'O-Y.$7* +)1* 3)1)1* 2$* &'O$((&J'* 1$* 6)'* 5)'3$'&2-* $'* .'* %)'0-*
2$* N`Pe* $'* +-1* #)(&$'3$1* 3%)3)2-1* $'* +-1* !13)2-1* 9'&2-17* #$%-*
F
+)1*3)1)1*2$*&'O$((&J'*1-'*5M1*)+3)1*$'*#),1$1*5M1*#-4%$1L *
;-1* #%&'(&#)+$1* &'(-'/$'&$'3$1* 2$* 3-2-1* +-1* )'3&1U#3&(-17* 1&'*
$54)%0-7* 6)'* 1&2-* $+* $13%$(6-* $1#$(3%-* )'3&5&(%-4&)'-* K* 1.*
(&3-3-"&(&2)2* (-'-(&2)* #)%)* $+* M%$)* 2$* +)* Y.$5)2.%)7* +-1*
&'X$%3-1*2$*#&$+*7*K*+-1*1.13&3.3-1*2U%5&(-1L*;)*()+&2)2*-#)()*2$*
4$3)2&'$* &5#&2$* +)* 2$3$((&J'* 3$5#%)')* 2$* +)* &'O$((&J'*
1.4K)($'3$* $'* $+* +$(6-* 2$* +)* 6$%&2)L* ;)* 1.+O)2&)Q&')* 2$* #+)3)* K*
()2$"J5$%-* K-2)2-* %$Y.&$%$'* +)%0-1* 3&$5#-1* 2$* $"#-1&(&J'*
#)%)* 5)3)%* .')* )5#+&)* 0)5)* 2$* 4)(3$%&)1* K* /&%.1L* @2$5M1* 7*
$13)1* 1-+.(&-'$1* '-* 1$* #.$2$'* .3&+&Q)%* $'* (&$%3)1* #)%3$1* 2$+*
(.$%#-7* (-5-* )+%$2$2-%* 2$* +-1* -X-17* K* +-1* #)(&$'3$1* )* /$($1*
3&$'$'* %$)((&-'$1* '$0)3&/)1* )* $13-1* #%-2.(3-1* 2$4&2-* )* 1.*
3-"&(&2)2L* @2$5M17* +-1* #%-2.(3-1* )* 4)1$* 2$* #+)3)* %$Y.&$%$'*
2-1&1*$")(3)1*K*.'*(-'3%-+*$13%&(3-*#-%*#)%3$*2$*#$%1-')+*5U2&(-*
(.)+&O&()2-* #)%)* 5&'&5&Q)%* $+* #-3$'(&)+* 2$* 5.3)(&-'$1* K*
%$1&13$'(&)* 4)(3$%&)')L* 8$* 6)'* .3&+&Q)2-* -3%-1* 2&/$%1-1*
)'3&4&J3&(-1* 3J#&(-1* K* )#J1&3-1* Y.$* (-'3&$'$'* #+)3)7* #$%-* 1-'*
()%-1* K* '-* $13M'* )5#+&)5$'3$* 2&1#-'&4+$1* $'* +-1* #),1$1* 5M1*
#-4%$1L* ;)* )#)%&(&J'* 2$* 4)(3$%&)1* %$1&13$'3$1* )* 5\+3&#+$1*
OM%5)(-1* K* +)1* &'O$((&-'$1* #-%* 6-'0-1* 1-'* -3%-* #%-4+$5)*
&5#-%3)'3$*)*3$'$%*$'*(.$'3)*1&*$+*)'3&5&(%-4&)'-*3J#&(-*O)++)L**
C-5-* )+3$%')3&/)7* 1$* 6)* .3&+&Q)2-* .')* 1-+.(&J'* 1.#$%-"&2)2)*
#)%)* +)* 2$1&'O$((&J'* 2$* 6$%&2)1* #-%* Y.$5)2.%)1* K* #)%)* +)*
H
#%$/$'(&J'* 2$* +)* 1$#1&1* #-%* :1$.2-5-')1* $'* %)3)1L * ;)*
4&4+&-0%)O,)* 3)54&U'* 2$1(%&4$* +)* $O&()(&)* 2$* +)1* 1-+.(&-'$1*
1.#$%-"&2)2)1* #)%)* $+* 3%)3)5&$'3-* 2$* \+($%)1* -* 2$O$(3-1*
P
(.3M'$-1* &'O$((&-1-1* $'* 6.5)'-1L * @* O&')+$1* 2$* FGGN7* .')*
'.$/)* 1-+.(&J'* 1.#$%-"&2)2)* Z?(.+.1* <&(%-(K'HG•[* 1$*
&'3%-2.X-*$'*<U"&(-*(-5-*#%-2.(3-*#)%)*$+*(.&2)2-*2$*6$%&2)1L*
!1*.')*1-+.(&J'*$13)4+$7*(-'*#R*'$.3%-7*4)(3$%&(&2)*7*O.'0&(&2)*7*
d
/&%.(&2)* K* $1#-%&(&2)L * 8$* 6)* 2$5-13%)2-* Y.$* $13)* 1-+.(&J'* '-*
$%)* &%%&3)'3$* '&* 1$'1&4&+&Q)'3$* 2$* )(.$%2-* (-'* +)1* '-%5)1*
&'3$%')(&-')+$1* #)%)* #%-2.(3-1* 2$* (.&2)2-* 2$* 6$%&2)1* Z?(.+.1*
B''-/)3&/$*8(&$'($1g*83&++5$)2-r7*B'(L7*8.0)%*;)'27*>$")17*FGGT*7*
2)3-1*'-*#.4+&()2-1[*L*?(.+.1*<&(%-(K'HG*'-*)+3$%J*$+*#%-($1-*
b
'-%5)+* 2$* (.%)(&J'L * ;-1* $13.2&-1* (+,'&(-1* (-'* ?(.+.1*
<&(%-(K'HG* 3)54&U'* 5.$13%)'* .'* %$1.+3)2-* O)/-%)4+$* $'* +)1*
\+($%)1* 2$* +)1* #&$%')1* 2&)4U3&()1* K* \+($%)1* #-%* $13)1&1* /$'-1)*
(%J'&()*Z/U)1$*$+*$13.2&-*2$+*A%L*A)++)*:)-+)*$'*+)*#M0&')*IT*2$*
IG
$13$*1.#+$5$'3-[L *A$4&2-*)*Y.$*+)1*1-+.(&-'$1*)*4)1$*2$*#+)3)*
'-*6)'*$13)2-*2&1#-'&4+$1*$'*<U"&(-*2$12$*$+*)_-*FGGT*K*)*Y.$*
'-* 1$* 6)'* %$#-%3)2-* $O$(3-1* 1$(.'2)%&-1* (-'* ?(.+.1*
<&(%-(K'HG7* $13$* \+3&5-* 1$* 6)* (-'/$%3&2-* $'* $+* 3%)3)5&$'3-*
)'3&5&(%-4&)'-*3J#&(-*$13M'2)%*#)%)*Y.$5)2.%)1*#)%(&)+$1*K*2$*
$1#$1-%* 3-3)+* $'* #)(&$'3$1* #$2&M3%&(-1* $'* +)* .'&2)2* 2$*
Y.$5)2-1*2$+*R-1#&3)+*C&/&+*2$*W.)2)+)X)%)*$'*<U"&(-L*
*
!
*
l&0.%)1*I@sIAL*9')*'&_)*2$*F*)_-1*(-'*Y.$5)2.%)1**
2$*$1#$1-%*#)%(&)+L*
*
C)1-1*(+,'&(-1*
!'* 3-3)+7* $'3%)%-'* $'* $+* $13.2&-* HT* '&_-1* &'0%$1)2-1* $'* $+*
R-1#&3)+*C&/&+*2$*W.)2)+)X)%)7*$'*<U"&(-7*$'3%$*5)%Q-*2$*FGGT*
5)%Q-* 2$* FGGa* (-'* .'* 2&)0'J13&(-* 2$* +$1&-'$1* 3U%5&()1*
1.#$%O&(&)+$1*2$*$1#$1-%*#)%(&)+7*#%-O.'2)1*2$*$1#$1-%*#)%(&)+*K*
2$* $1#$1-%* 3-3)+* $'* +)* #&$+L* 8$* %$)+&QJ* .'* )'M+&1&1* %$3%-1#$(3&/-*
2$* ()1-1* $5#)%$X)2-1* Y.$* #%$1$'3)4)'* Y.$5)2.%)1* 1&5&+)%$1*
$'*$1)*&'13&3.(&J'*2.%)'3$*$+*)_-*FGGN*#)%)*$+*0%.#-*2$*(-'3%-+L*
!+* -4X$3&/-* 2$+* #%$1$'3$* $13.2&-* O.$* $/)+.)%* $+* .1-* 2$* ?(.+.1*
<&(%-(K'HG*$'*Y.$5)2.%)1*$'*(.)'3-*)*1.*)((&J'*$'*$+*(-'3%-+*
2$* &'O$((&-'$17* )(3&/&2)2* 2$* (&()3%&Q)(&J'7* 2.%)(&J'* 2$* +)*
$13)'(&)*6-1#&3)+)%&7*.1-*2$*)'3&4&J3&(-17*K*$/)+.)(&J'*O&')+*2$*+)*
(&()3%&QL**
*
!'* 3-2-1* +-1* ()1-17* 1$* ++$/J* )* ()4-* .'* 2$14%&2)5&$'3-*
Y.&%\%0&(-*Kc-*2$*)+3)*#%$1&J'*(-'*$+*1&13$5)*p$3?"•*ZA$*E-K)+7*
:-r$++7* >$''$11$$[* 4)X-* )'$13$1&)* 0$'$%)+* $'* +)* &'(+.1&J'L* ;)1*
Y.$5)2.%)1* 2$* $1#$1-%* #)%(&)+* 1$* 2$X)%-'* )4&$%3)1* 1&'* 0$+$1* -*
)#J1&3-1L*;)1*Y.$5)2.%)1*2$*$1#$1-%*(-5#+$3-*(-'*)4.'2)'3$*
$".2)2-*1$*2$14%&2)%-'*K* (.4%&$%-'*(-'*/$'2)X$1L*>)54&U'* 1$*
.3&+&Q)%-'*&'X$%3-1*2$*#&$+*$'*()1-*'$($1)%&-L*;)1*5.$13%)1*#)%)*
(.+3&/-1* 5&(%-4&)'-1* 1$* 3-5)%-'* )'3$1* 2$* +)* $1(&1&J'* K* $'*
2&13&'3-1* #.'3-1* $'* +)1* #%&5$%)1* F* 1$5)')1L* A$1#.U1* 2$+*
2$14%&2)5&$'3-* &'&(&)+7* +)1* 6$%&2)1* #-%* Y.$5)2.%)1* 1$*
6.5$2$(&$%-'*(-'*?(.+.1*<&(%-(K'HG*N*/$($1*)+*2,)*.1)'2-*.'*
#.+/$%&Q)2-%L* ;-1* %$1.+3)2-1* O&')+$1* 2$* $13)* $/)+.)(&J'* (+,'&()*
$13M'* )6-%)* 4)X-* %$/&1&J'* #)%)* 1.* #.4+&()(&J'* L* @* (-'3&'.)(&J'*
1$*#%$1$'3)'*+-1*2$3)++$1*2$*F*2$*+-1*HT*()1-1L*
*
*
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
*
IP*
!"#$%&$'(&)*(+,'&()*(-'*.')*'.$/)*)0.)*1.#$%-"&2)2)*$13)4+$*$'*$+*3%)3)5&$'3-*2$*6$%&2)1*
C)1-*I**
9')*'&_)*2$*F*)_-1*2$*$2)2*1$*#%$1$'3J*(-'*Y.$5)2.%)1*2$*
$1#$1-%* #)%(&)+* $'* .'* NN* e* 2$* +)* 8C>* 3%)1* (-'3)(3-* (-'* )0.)*
6&%/&$'2-* Zl&0.%)* I@* [* L* 8$* 1-5$3&J* )* 2$14%&2)5&$'3-* (-'* $+*
1&13$5)* p$3?"* K* 7* (-5-* $'* $+* %$13-* 2$* +-1* ()1-1* 7* +)* +$1&J'* 1$*
6.5$2$(&J*(-'*?(.+.1*<&(%-(K'HG*N*/$($1*()2)*2,)*.1)'2-*.'*
#.+/$%&Q)2-%L* ;)* '&_)* 3-+$%J* +)* +&5#&$Q)* 2&)%&)* 2$* +)* +$1&J'* 1&'*
5.(6-*2-+-%L*!'*$+*2,)*N7*$+*(-+-%*%-X-*4%&++)'3$*3,#&(-*2$*+)*Q-')*
Y.$5)2)* $13)4)* #%$1$'3$* Zl&0.%)* If[L* :-13$%&-%5$'3$*
)#)%$(&$%-'*$1()%)1*)1U#3&()1*$'*+)1*1$5)')1*I*K*F*K*'-*O.$%-'*
%$3&%)2)1* Zl&0.%)* IC[L* ;)* %$$#&3$+&Q)(&J'* 2$* +)1* 6$%&2)1* -(.%%&J*
0$'$%)+5$'3$* $'* +)1* 1$5)')1* N`T* Zl&0.%)* IA[* L* !'* $+*
1$0.&5&$'3-7*+)1*()%)(3$%,13&()1*2$*+)*'.$/)*#&$+*$%)'*1&5&+)%$1*)*
+)1*2$*+)*#&$+*)*1)+/-7*).'Y.$*2$*.'*(-+-%*2&13&'3-L*
*
*
l&0.%)1*F@sFAL*9')*'&_)*2$*IF*)_-1*(-'*Y.$5)2.%)1**
2$*$1#$1-%*#)%(&)+*K*3-3)+L*
*
C)1-*F**
9')* '&_)* 2$* IF* )_-1* 2$* $2)2* (-'* Y.$5)2.%)1* 2$* $1#$1-%*
#)%(&)+*K*3-3)+*$'*.'*TN7a*e*2$*+)*8C>*#)%(&)+*2$1#.U1*2$*Y.$*1.1*
%-#)1* 1$* &'($'2&)%)'* #-%* .')* 2$1()%0)* $+U(3%&()* Zl&0.%)* F@[L* !+*
3$X&2-* 2$* 0%)'.+)(&J'* (-'* O-%5)(&J'* )1U#3&()* 2$* (&()3%&($1*
)#)%$(&J*$'*3-2)1*+)1*+$1&-'$1*$'*$+*2,)*a*Zl&0.%)*Ff[L*!'*$+*2,)*
FI7* 6)4,)* $#&3$+&Q)(&J'* (-5#+$3)* $'* $+* (.$++-7* +)1* )"&+)1* Zl&0.%)*
FC[7*K*+)*#&$%')*1&'*(&()3%&($1*2$O-%5)'3$1*'&*.1-*2$*&'X$%3-1*2$*
#&$+* $'* +)* #&$%')L* @* 2$13)()%* +-1* $"($+$'3$1* %$1.+3)2-1*
(-15U3&(-1*2$1#.U1*2$*I*)_-*2$*3%)3)5&$'3-*Zl&0.%)*FA[L*
*
C-5$'3)%&-1*K*#$%1#$(3&/)1*
@(3.)+5$'3$7* $"&13$* .')* )5#+&)* /)%&)(&J'* $'* $+* 3%)3)5&$'3-*
3J#&(-* 2$* +-1* #)(&$'3$1* (-'* Y.$5)2.%)1L* !+* -4X$3&/-* 1&0.$*
1&$'2-* #)%)* &2$'3&O&()%* +)1* 5$2&2)1* 5M1* $O&()($1* K* %$'3)4+$1*
#)%)* #%$/$'&%* 4%-3$1* 2$* &'O$((&J'* Y.$* #.$2)'* )O$(3)%* )* -3%-1*
#)(&$'3$1*$'*+)*.'&2)2L**
;)* 1.+O)2&)Q&')* $1* $+* )'3&&'O$((&-1-* 3J#&(-* 5M1* .3&+&Q)2-* $'*
#)(&$'3$1*(-'*Y.$5)2.%)1*$'*3-2-*$+*5.'2-7*K)*Y.$*$1*\3&+*$'*
+)* #%$/$'(&J'* 2$* &'O$((&-'$1* $'* Y.$5)2.%)1* 2$* 1$0.'2-* -*
3$%($%* 0%)2-L* >&$'$* )(3&/&2)2* 4)(3$%&(&2)* (-'3%)* 5.(6)1*
4)(3$%&)1* W%)5`#-1&3&/)1* K* W%)5`'$0)3&/)1* K* .')* )(3&/&2)2*
)'3&O\'0&()*1.)/$L*:-%*2$10%)(&)7*'-*1$*$'(.$'3%)*2&1#-'&4+$*$'*
<U"&(-*L**
C-5-*1$*#%$2&X-*)*#)%3&%*2$*)'3$%&-%$1*$13.2&-1*$'*)'&5)+$1*K*
$"#$%&$'(&)1* (+,'&()17* $+* .1-* 2$* ?(.+.1* <&(%-(K'HG* O.$* $O&()Q* K*
1$0.%-* #)%)* +)* #%$/$'(&J'* 2$* &'O$((&-'$1* 2$* Y.$5)2.%)1* 2$*
$1#$1-%*#)%(&)+*K*3-3)+*$'*#)(&$'3$1*#$2&M3%&(-1L*!+*3%)3)5&$'3-*
(-'* ?(.+.1* <&(%-(K'HG* %$2.($* +)* ()%0)* 5&(%-4&)')* $'* $+* bG* e*
2$*+-1*#)(&$'3$1*(-'*+$1&-'$1*3U%5&()1*2$*$1#$1-%*#)%(&)+*K*3-3)+L*
;-1* '&_-1* 3)54&U'* %$#-%3)%-'* 5$'-1* 2-+-%* 2.%)'3$* +-1*
#%-($2&5&$'3-1*2$*+&5#&$Q)L*;)*)#+&()(&J'*O.$*OM(&+*K*$(-'J5&()L*
@2$5M17*+)*2.%)(&J'*2$*+)*$13)'(&)*6-1#&3)+)%&)*2$*+-1*#)(&$'3$1*
3%)3)2-1* (-'* ?(.+.1* <&(%-(K'HG* 1$* %$2.X-* $'* .'* aG* e* (-'*
%$1#$(3-*)+*0%.#-*2$*(-'3%-+L*>$'&$'2-*$'*(.$'3)*Y.$*$+*(-13$*
6-1#&3)+)%&-* 2&)%&-* $'* $13)1* &'13)+)(&-'$1* $1* 2$* .'-1* ILdGG*
h* 98@* #-%* #)(&$'3$7* $+* 3%)3)5&$'3-* (-'* ?(.+.1* <&(%-(K'HG*
)6-%%J* )* +)* &'13&3.(&J'* .'* #%-5$2&-* 2$* FT7HHG* h* 98@* #-%*
#)(&$'3$L*;-1*%$1.+3)2-1*2$*$13$*$13.2&-*3)54&U'*1.0&$%$'*Y.$*
+)1*Y.$5)2.%)1*3%)3)2)1*(-'*?(.+.1*<&(%-(K'HG*(&()3%&Q)'*(-'*
5$X-%$1* %$1.+3)2-1* (-15U3&(-1* K* 5$'-1* Y.$+)(&J'* $'* %$+)(&J'*
(-'* $+* 3%)3)5&$'3-* 2$* Y.$5)2.%)1* $13M'2)%* )'3$%&-%L* @.'Y.$*
$13-1* %$1.+3)2-1* 1-'* )+$'3)2-%$17* 2$4$'* 1$%* $/)+.)2-1*
)2$(.)2)5$'3$*$'*$'1)K-1*(+,'&(-1*5.+3&(U'3%&(-1*#%-1#$(3&/-1L*
:)%3$*&'3$0%)+*2$*+)*$/)+.)(&J'*2$*?(.+.1*<&(%-(K'HG*2$4$*1$%*
$+* &5#)(3-* Y.$* 3&$'$* 1.* .1-* 1-4%$* +)1* 3)1)1* $"&13$'3$1* 2$*
&'O$((&J'* K* (-5#+&()(&-'$1* &'O$((&-1)17* +-1* %$1.+3)2-1* 2$* +-1*
#)(&$'3$1*7*+-1*(-13$1*K*+)*1)3&1O)((&J'*2$+*#)(&$'3$L*8&'*$54)%0-7*
$1* )+$'3)2-%* 1)4$%* Y.$* $+* )0.)7* ).'Y.$* 1$)* $'* $13)* O-%5)*
)/)'Q)2)7* 1&0.$* 1&$'2-* $+* 5$X-%* 5U3-2-* #)%)* +&5#&)%* .')*
6$%&2)L!**
*
f&4+&-0%)O,)*
IL** A&%$((&J'*W$'$%)+*2$*!#&2$5&-+-0,)L*8&13$5)*9'&(-*2$*B'O-%5)(&J'*#)%)*+)*
]&0&+)'(&)* !#&2$5&-+J0&()L* B'O-%5)(&J'* #%$+&5&')%* FGGNL* <U"&(-L*
rrrL20$#&L1)+.2L0-4L5"L**
FL** l-0+&)*E:7*<-.16$K*E7*<$)2-r1*;7*$3*)+L*!/-+/&'0*3%$)35$'3*&'*)*2$()2$*-O*
#$2&)3%&(*4.%'*()%$L*p*:$2&)3%*8.%0L*FGGTgNbZH[qbaPsbHGL**
NL** S$4$%* p<7* 86$%&2)'* E;7* :)13$%')(u* <87* >-5#u&'1* EWL* =-1-(-5&)+*
&'O$(3&-'1* &'* #$2&)3%&(* #)3&$'31* r&36* 4.%'1L* @5* p* B'O$(3* C-'3%-+L*
IbbPgFaZN[qIbasFGIL**
TL** 9')+* 87* !%1-Q* W7* A$5&%u)'* l7* $3* )+L* @')+K1&1* -O* 1u&'`0%)O3* +-11* 2.$* 3-*
&'O$(3&-'q*&'O$(3&-'`%$+)3$2*0%)O3*+-11L*@''*:+)13*8.%0L*FGGagaaZI[qIGFsIGHL**
aL** A)'3Q$%* !7* f%)K$* l<L* E$(-'13%.(3&/$* 1.%0$%K* .1&'0* )'* )%3&O&(&)+* 2$%5&1*
ZB'3$0%)[q*%$1.+31*r&36*Nb*0%)O31L*f%*p*:+)13*8.%0L*FGGIgaTZd[qHabsHHTL**
HL** =)u)$*R7*B')4)*RL*!OO$(3&/$'$11*-O*$+$(3%-+KQ$2*-"&2&Q$2*r)3$%*&%%&0)3&-'*&'*
)*4.%'`r-.'2*&'O$(3&-'*5-2$+L*p*>%).5)L*FGGGgTbZN[qaIIsaITL**
PL** 8$u&K)* 87* ?65-%&* j7* R)%&&* jL* >%$)35$'3* -O* &'O$(3&-.1* 1u&'* 2$O$(31* -%* .+($%1*
r&36*$+$(3%-+KQ$2*13%-'0*)(&2*)Y.$-.1*1-+.3&-'L*@%3&O*?%0)'1L*IbbPgFIZI[qNFsNdL*
dL** ;)'2)`8-+&1* C7* W-'Q)+$Q`!1#&'-1)* A7* W.Q5)'`8-%&)'-* f7* $3* )+L* <&(%-(K'q* )*
'-/$+*1.#$%`-"&2&Q$2*r)3$%*r&36*'$.3%)+*#R*)'2*2&1&'O$(3)'3*)(3&/&3KL*p*R-1#*
B'O$(3L*FGGagHIZT[qFbIsFbbL**
bL** <$1(63$%*CL*8)O$3K*)'2*!OO&()(K*-O*>%$)35$'3*O-%*C.3)'$-.1*S-.'2*83.2KL*
C-5#)%)3&/$*f&-1(&$'($17*B'(L*83.2K*=.54$%q*dFIF`GT7*FGGaL**
IGL* A)++)*:)-+)*;7*f%-((-*!7*8$'$1&*@7*=&'u-/&(*87*<$%&(/-*<7*A$*]&2-*AL*91$*-O*
A$%5)(K'7* )* '$r* )'3&1$#3&(* )0$'3* O-%* 36$* +-()+* 3%$)35$'3* -O* 2&)4$3&(* O--3*
.+($%1L*p*S-.'2*R$)+&'0L*FGGagFqFGIL**
IIL* <)%3,'$Q*2$*p$1\1*lL*@*#%-1#$(3&/$7*%)'2-5&Q$27*1&'0+$*4+&'2$2*13.2K*r&36*
'$.3%)+* #R`1.#$%* -"K2&Q$2* r)3$%* &'* 2&)4$3&(* #)3&$'31* r&36* &'O$(3$2* O$$3*
.+($%1L*:%$1$'3)2-*$'*FGGaL*A)3-1*1&'*#.4+&()%*
*
*
!
"#$%&'7*89:;!<!=>?*@*;@*!ABCBD=*A!*!=!E?*A!*FGGH*
Id*
IV
V Congreso
Co
de la Sociedad Española de Heridas
5 al 7 de Febrero de 2015 - Madrid
A
VALORACIÓN DE UNA SOLUCIÓN ELECTROLIZADA
(MICRODACYN®) PARA LA LIMPIEZA DE HERIDAS
+'=3#++6>E?;',=#'$'($6>F?;#3'+ 16$ +6>G?;1%=%+,
+++>H?;+#+16#'>I?;+''+#,+/%>J?;++-#-31##',>K?
;?<;C<;D<;E< 0
*!%;1 ##<6;@<##0 *6;A<0,0% 1*+#6;B<;&*,&+<
INTRODUCCIÓN
,,'#1'%,,1)+'4(%,,++'##%)+.+#
#-+'#,,15#'+1+',(';%+%'')'#'+','=
'#($%-;#')'#'+',',#,%-+'#+1)'
,),+.3,#'4 %'>?;,%-.6,)'+#1#,
%1,-+',,-$%$1%<%1-+(#',5$+(',>%,7#6
@>>E?=
'+-%-';,1'+$1#(%,-,%#$%,$','#('
1$%'%,%-#%(%=
+'5%® ,1%,'#1(%%'#'+;'%)
%1-+'51%$)#'
,)-+'%.$+'%'=
,.3'%)+,%$-+'+%;'$).#'%'-+',
)+'1-',,%-+',5)1,+1,'%$1',,=
%-',-(4',,'+#-"'%''+$'=
8,&,*
%$%&+D>+0%&+3+ % '%
#,&%
1#;+(&* <%?C$ %0,&+9;*.%4:0% 1,7#6@>>C<7
OBJETIVO
3#1+#+'5%A'$'%-%.,).'
=
)+##$)65,%(%+,3+,.'#'
DISEÑO Y METODOLOGÍA
,-1'',+3'%#=
%#1,(%FD)%-,;,$+FDEH
%+'FDEI=
+-+',%#1,(%<
4'$,1#%'5$%%'
5'+ >EL&',?
+,%+,-+1$.,;+,
*1+2+,'*1$1+,
+.)(%3'#1%-+;)+3%'+$(%5
+$'%,%.$%-'%'+$'
1$%-''-'+'#,#,'%,
'+%-"-"'%'3#>1+-"'+%1#(%?=
+,%41'>%.5'#'+?=
,-'#)#)+#,'%#=
'%,3+,,<,'6'+;)'+;'#'+;, '$'
++-(%#)#)+#,'%#=
)#+,'+#+1%,$)))+'1-'1+%-I
$%1-',=
+1%1+(%<HL'+,>%1,%'$)#'%,?
%-#%,)+'#'%+#(%%.,).;,1,(
+'5%A
+'#=
'+-1+'%)(,-',)1$)'#1+-%',.%-'+','+;
)%%'#%3#41'#+=
$++ %*&* $ %,&,&&+)0##&+( %,+)0%
&#&*&+ %,*+$%,%+,+,0 &
$3#LD@$#='$
RESULTADOS
3%'1%1%#$)6%#EDDO#,+,
-+-,;3#1'-+3,#,$%1(%'1,%
+++,$%,'$'-+-1,;+,-',+%;-"'
%+(.'',#';%##'5'+,#+=
#$%(%,-,+++,+1'#+,'
%(%;3'+%'#)+','+%+(%.,1#+5)'+
-%-';,$%15%'#.$)'-+6(%=
1+%-#1,'+'5%A;%'%)+'
'$)#'%,%,%,#6(%#)#)+#,'%#
%%%1%'#',)%--+-',=
“++&#0 &%++0(*&2 '%#*%#(*&+&
,* 4 '%6+-$0#%&#(*&# * '%3$ * '%
*&#+,&+9;
,7#6@>>><7
CONCLUSIONES
,,'#1'%,#-+'#6,,)+,%-%'$'1%4#%-
')(%)+##$)65,%(%+,3+,
.'#' =
+'5%A,1%,'#1(%$)#',)-+';+)
(%5$)#'$+%,1+;)'+#'*1)1,+
1.#6')+'%-+'#+5)+3%+1%$)#'%2$+'
%'%,#)#5#,$1',,;#'*1#''%3+-%1%
%.,).'#(%=
%.,).'
1-1+# %%3,.(%<1#0*#&+,:% &
1 *&3%=%&$(* '%&%&,*&+%-+(-&+7
Dermacyn® Effective in Treatment of Chronic Wounds with
Extensive Bioburden while Reducing Local Pain Levels
Debra J. Peterson, CCRN, MSN, ACNP-BC, Karre Hermann, MSN, APNP-BC, Jeffrey A. Niezgoda MD, FACEP, FACHM
The Center for Comprehensive Wound Care and Hyperbaric Oxygen Therapy, Aurora St. Luke's Medical, Milwaukee, WI
Hyperbaric & Wound Care Associates, Milwaukee, WI
INTRODUCTION:
Treatment of chronic and acute wounds requires
comprehensive local wound care, which clearly
must include bioburden control and pain
management. Due to ease of use and relative cost
efficiency, local antiseptic agents are widely used
to assist with prevention of infection while
maintaining a moist wound environment to
promote healing. Super-Oxidized Water (SOW)
has shown to be an effective antiseptic agent via a
mechanism of denaturing cellular membrane
proteins which results in the destruction of
single-cell organisms while blocking the
inflammatory process. Data suggests that SOW
can reduce critical bioburden levels without
affecting the host as human cell walls are not
disrupted due to minimal cellular wall exposure.¹
This is a 57-year-old male with a 40 year history of painful bilateral lower extremity
ulcerations that failed to heal despite topical enzymatic, cadexomer, and
antimicrobial care. Also attempted were hyperbaric oxygen therapy, split thickness
skin grafting, as well as vein stripping and compression therapy. Patient had
multiple courses of systemic antibiotic therapy for MRSA, while pain management
included scheduled doses of Oxycontin and Percocets for breakthrough pain.
Dermacyn was initiated 6 months ago as a wound soak for 45 minutes and then the
wounds were covered with a silver product. Pain levels were measured at each
appointment.
Figure 1 - Pre-Treatment
R Medial
Pain = 8
DISCUSSION:
Historically SOW has had a short shelf life and
was therefore under utilized. Recently, a stable,
pH-neutral SOW was developed which has
eliminated this storage problem. Dermacyn® is a
SOW approved for the treatment of pressure
ulcers, diabetic foot ulcers, stasis ulcers,
post-surgical wounds, and burns. We present a
series of 4 patients with recalcitrant wounds that
failed to heal despite aggressive local wound care
that included serial sharp debridement and local
antimicrobial
control.
All
wounds
were
subsequently treated with Dermacyn® soaks 30-45
minutes prior to resuming local wound care efforts.
CASE #3
CASE #1
Figure 3 - Pre-Treatment
L Medial
Pain = 8
This is a 47-year-old male with a 7 year history of non-healing wounds secondary to venous
insufficiency. Wounds failed to close despite compression therapy, Ultrasound Assisted Wound
(UAW) therapy, cadexomer iodine and topical wound care as well as grafting. Pain was
significantly reduced while wounds showed contracture while on Dermacyn®.
Figure 7 - Pre-Dermacyn
L Anterior
Pain = 8
Figure 8 - 6 Weeks Post Dermacyn
L Anterior
Pain = 1
L Lateral
Pain = 8
L Lateral
Pain = 1
Figure 2 - Current Appearance
R Medial
Pain = 0 (no meds)
Figure 4 - Current Appearance
L Medial
Pain = 0 (no meds)
CASE #2
This is a 79-year-old male seen on consult with a one year history of venous ulceration on the left medial ankle. Treatment prior to Dermacyn® included compression,
vein stripping, ablation of deep vein, as well as enzymatic, cadexomer iodine and
Negative Pressure Wound Therapy, all of which failed. Punch biopsy was performed
to rule out malignancy.
CONCLUSION:
All patients showed contracture
with progression to closure soon
after the initiation of SOW.
Additionally,
these
patients
reported a significant reduction in
pain levels with the addition of
Dermacyn® therapy as measured
using a numerical pain scale. We
conclude that SOW is an effective
antiseptic agent that assists with
bioburden control and pain
management while promoting
wound healing.
CASE #4
This is a 37-year-old female with a non-healing surgical abdominal wound. Wound was present for
18 months prior to consultation with healing compromised due to obesity and colonization with
Pseudomonas. The wound failed to heal despite NPWT, local wound care, antibiotics and UAW
therapy. Pain was also a problem prior to therapy, but patient was pain free with Dermacyn®. The
wound progressed to closure in 2 months.
REFERENCES:
Bryant R. (2005).
Super-oxidized water
kills bacteria; demonstrates potential for
healing. Dermatology
Pain = 4
Pain = 0
Pain = 8
Figure 12 - 2 Months Post Initiation
Pain = 0
Times.
Efficacy and Compatibility of Combination Therapy with Super-Oxidized Solution*
and a Skin Substitute§ for Lower Extremity Wounds
Regulski M, Floros R, Petranto R, Migliori V, Alster H, Pfeiffer D
Ocean County Foot & Ankle Surgical Associates. NJ. USA
PURPOSE
New technologically advanced wound care products, like skin substitutes and
a super-oxidized solution, SOS*, have been shown to promote healing rates.
Unfortunately, the evaluation of combined therapies is rarely undertaken.
OBJECTIVE
Evaluate the incidence of 100% closure (epithelialized) of non-infected, graft
ready wounds treated with SOS and a skin substitute (SkS) § during the initial
12 weeks of the treatment period and additional 12 weeks of follow-up.
METHODS
Twenty-two patients with lower extremity wounds of at least 1 month were
randomized to receive SOS or saline solution. SOS or saline solution (30 mL)
was applied bid for three days before grafting the SkS and once everyday
thereafter. A dressing saturated with either SOS or saline was placed in the
wound bed and covered with a 2-layer compression system. The SkS was
changed every week and assessments were conducted on Day 0, Day 3 and
weekly thereafter for up to 12 weeks.
Patient Demographics
Control Group (N=9)
Mean ± SD (Median)
Study Group (N=9)
Mean ± SD (Median)
Age (in years)
70.22 ± 13.86 (72.00)
64.89 ± 18.81 (66.00)
Gender (M/F)
7/2
1/8
Wound Type
Control Group (N=9)
Frequency
Study Group (N=9)
Frequency
Post – traumatic
5
5
Post – surgical
1
3
Venous Ulcer
3
1
Baseline
Wound Measurements
Control Group (N=9)
Mean ± SD (Median)
Study Group (N=9)
Mean ± SD (Median)
Length (cm)
1.55 ± 0.91 (1.34)
2.22 ± 1.34 (1.83)
Width (cm)
2.26 ± 1.04 (2.11)
1.94 ± 0.81 (1.69)
2
Area (cm )
2.53 ± 1.37 (2.08)
3.39 ± 3.11 (1.62)
Depth (cm)
2.89 ± 0.60 (3.00)
3.33 ± 0.71 (3.00)
Volume (cm3)
0.71 ± 0.34 (0.62)
1.14 ± 1.21 (0.51)
RESULTS
Eighteen out of 22 patients were fully evaluable, 9 in each group (SOS or
Saline). The median ulcer volumes were similar for the study group (0.51 cm3)
and the control group (0.62 cm3). Despite of this the median number of weeks
to complete epithelialization was shorter for the study group (6 weeks) than the
control group (7 weeks).
Before
After 4 weeks
Before
After 4 weeks
CONCLUSION
SOS might induce a faster epithelialization than saline solution independently
of the use of the OWM. Both technologies appear to be compatible.
* Microcyn® Technology, Oculus IS, Petaluma, USA.
§
OASIS® Wound Matrix, HealthPoint, Texas, USA.
The Heart Surgery Forum #2009-1162
13 (4), 2010 [Epub August 2010]
doi: 10.1532/HSF98.20091162
Online address: http://cardenjennings.metapress.com
Dermacyn® Irrigation in Reducing Infection of a Median
Sternotomy Wound
Abdul Ramzisham Rahman Mohd, MS, Mohd Khairulasri Ghani, MD,
Raflis Ruzairee Awang, MBChB, Joanna Ooi Su Min, MMed, Mohd Zamrin Dimon, MS
Heart and Lung Centre, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
Dr. Ramzisham
ABSTRACT
Background: Sternal wound infection is an infrequent yet
potentially devastating complication following sternotomy.
Among the standard practices used as preventive measures are
the use of prophylactic antibiotics and povidone-iodine as an
irrigation agent. A new antiseptic agent, Dermacyn® superoxidized water (Oculus Innovative Sciences), has recently
been used as a wound-irrigation agent before the closure of
sternotomy wounds.
Methods: This prospective, randomized clinical trial
was conducted to compare the effectiveness of Dermacyn
and povidone-iodine in reducing sternotomy wound infection in patients undergoing coronary artery bypass graft surgery. Upon chest closure and after insertion of sternal wires,
wounds were soaked for 15 minutes with either Dermacyn
or povidone-iodine. Subcutaneous tissue and skin were then
closed routinely. Patients were followed up, and any wound
infection was analyzed.
Results: Of the 178 patients, 88 patients were in the Dermacyn group, and 90 were in the povidone-iodine group. The
mean (±SD) age of the patients was 61.1 ± 7.6 years. The incidence of sternotomy wound infection was 19 cases (10.7%).
Five (5.7%) of these cases were from the Dermacyn group, and
14 (15.6%) were from the povidone-iodine group (P = .033).
No Dermacyn-related complication was identified.
Conclusion: We found Dermacyn to be safe and more
effective as a wound-irrigation agent than povidone-iodine
for preventing sternotomy wound infection.
INTRODUCTION
Patients undergoing coronary artery bypass grafting
(CABG) surgery are exposed to possible sternal wound
Received October 13, 2009; received in revised form November 8, 2009; accepted
November 24, 2009.
Correspondence: Associate Professor Dr. Mohd Ramzisham Abdul Rahman,
Senior Lecturer/Consultant Cardiothoracic Surgeon, Heart and Lung Centre,
Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre, Jalan
Yaacob Latif, 56000 Cheras, Kuala Lumpur, Malaysia; +603-91456201/2;
fax: +603-91737831 (e-mail: ramzisham@hotmail.com).
E228
infection despite the procedure being categorized as clean
surgery. Infections range from superficial infection to deeper
infection of soft tissue, sternal osteomyelitis, and mediastinitis. The incidence of such infections ranges from 0.9% to
20% of cases [Loop 1990; Ulicny 1991], and the incidence of
mediastinitis reported in most studies is 1% to 2% [El Oakley
1996; Bitkover 1998]. Although deep sternal wound infections, including mediastinitis, are infrequent complications,
such infections are associated with significant morbidity and
mortality (between 9.8% and 14% [Loop 1990; Ulicny 1991;
El Oakley 1996]), prolonged hospitalization, and an increased
financial burden on the health care system [Vegas 1993].
Therefore, it is vital to prevent infection of the sternotomy
wound following surgery. Among the standard practices for
prevention are the prophylactic use of antibiotics and placement of the pericardial drains to facilitate drainage of blood
and serous fluid. These practices have been shown to lower
the rate of deep sternal infection [Blanchard 1995]. Agents
that irrigate the dermal wound have also been used to facilitate removal of debris before wound closure. One common
practice is the use of saline and antiseptics such as povidoneiodine as wound-irrigation agents.
Dermacyn® (Oculus Innovative Sciences, Petaluma, CA,
USA), a superoxidized aqueous solution, is a new antiseptic agent cleared by the US Food and Drug Administration
(FDA) that has recently been used in our center as an irrigation agent during closure of sternotomy wounds. The initial
experience has been good with no adverse effects. Dermacyn
is produced by means of a proprietary electrolysis process that
uses a sophisticated, unique multichamber system. The solution is manufactured from purified water and sodium chloride. The electrolysis process separates and captures the ions
to produce a sterile, pH-neutral solution consisting of a stable
controlled formula of reactive oxygen and chlorine species
[Oculus Innovative Sciences 2006]. The active compounds in
Dermacyn are 99.9% water, hypochlorous acid, and sodium
hypochlorite, and the inactive compounds are sodium carbonate, sodium hydroxide, hydrogen peroxide, chlorine dioxide, and ozone.
Dermacyn wound-irrigation agent is applied to chemically
debride, flush, and cleanse the wound surface. The reactive
oxygen species assist in promoting the body’s own healing
process by reducing the microbial load and via the agent’s
Dermacyn Irrigation in Reducing Infection—Ramzisham et al
moistening properties [Bongiovanni 2006]. Several studies
have found Dermacyn to be safe and to exhibit a wide antimicrobial spectrum [Landa-Solis 2005]. Paola et al [2006]
proved the effectiveness of Dermacyn over povidone-iodine
and Dermacyn’s safety in treating the infected diabetic foot.
A study of another series by Ohno et al [2000] showed that
superoxidized water had no adverse effect on hemodynamics and was safe when used as a mediastinal irrigation solution during open heart surgery. Dermacyn has also been subjected to a series of biocompatibility tests. These tests were
performed in accordance with the requirements set forth by
International Standards Organization and FDA guidelines.
The product has also been tested in animal models to satisfy FDA requirements and to ensure its safety and efficacy
[Oculus Innovative Sciences 2006]. Several studies, however,
have identified various factors that contribute to wound infection that always need to be considered [Zacharias 1996].
We therefore conducted this study to compare the effectiveness of Dermacyn irrigation and povidone-iodine with
respect to reducing the incidence of sternotomy wound infection following CABG. We also evaluated our study population
to identify the potential risk factors for sternotomy wound
infection following CABG.
MATERIALS AND METHODS
This prospective randomized clinical trial took place
between June 2007 and December 2008. All patients scheduled for elective CABG were included in this trial. Exclusion
criteria included emergency cases, patients who underwent
other surgical procedures in addition to CABG, patients
allergic to Dermacyn, and those who had infective or other
skin lesions over anterior chest wall area. Informed consent
was obtained, and patients were consecutively randomized
into 2 groups. Group A patients used Dermacyn as a woundirrigation agent, and group B patients used povidone-iodine.
All patients received intravenous prophylaxis with 1.2 g Augmentin (amoxicillin and clavulanate) at induction. Before
the surgery, the skin was cleaned with 10% povidone-iodine
solution and covered with polyurethane drapes. CABG was
performed through a standard median sternotomy by 3 cardiothoracic surgeons. Upon closure, bone wax and diathermy
were used sparingly for hemostasis. Two drains were normally
left in the mediastinal cavity. The sternum was closed primarily with no. 6 steel wires in a figure-of-eight manner. In both
groups, the wounds were then soaked for 15 minutes after
insertion of the sternal wires. The subcutaneous tissue was
closed in 2 layers with polyglactin 1-0 suture, and the skin was
closed subcuticularly with Vicryl 3-0 suture.
Diagnosis and Follow-up
The sternotomy wounds were inspected on postoperative
day 2 and daily until discharge. Patients were then followed up
at 2, 4, and 6 weeks postoperatively to assess for the presence
of wound infection and Dermacyn side effects. The primary
outcome was the presence of sternotomy wound infection,
which was defined according to the Centers for Disease Control and Prevention in their National Nosocomial Infections
© 2010 Forum Multimedia Publishing, LLC
Table 1. Clinical Characteristics of the 178 Patients Involved
in the Trial*
Age, y
61.1 ± 7.6
Male-female ratio
3.24:1
COPD, n
66 (37.1%)
Diabetes mellitus, n
79 (44.4%)
ESRF, n
32 (18.0%)
2
Obesity (BMI >30 kg/m ), n
20 (11.2%)
Smoking, n
66 (37.1%)
On-pump/off-pump surgery, n
153 (86%)/25 (14%)
Bypass time, min
99.0 ± 7.4
IMA harvested, n
171 (96.1%)
*Data are presented as the mean ± SD where indicated. COPD indicates
chronic obstructive pulmonary disease; ESRF, end-stage renal failure; BMI,
body mass index; IMA, internal mammary artery.
System [Horan 1992]. Wound infections were graded according to Horan et al [1992] as superficial (involving the skin and
subcutaneous tissue of the incision), deep (involving fascia,
muscle layers, and sternum), or deep organ space. The nature
of discharge from the wounds was documented, and samples
of the discharge were sent for culture and sensitivity analyses. The risk factors for wound infections were identified and
analyzed.
Ethical Considerations
This trial involved no financial gain and was approved by
the research and ethics committee of the Universiti Kebangsaan Malaysia Medical Centre (code no. FF-236-2007).
Statistical Analysis
Data were stored and analyzed with SPSS software (version 12.0; SPSS, Chicago, IL, USA). Continuous and categorical variables were analyzed with the independent Student
t test and the chi-square test, respectively. With the use of
95% confidence intervals, a P value <.05 was considered statistically significant.
RESULTS
We recruited 190 patients for this trial, 95 patients in each
group. Twelve patients, however, dropped out owing to postoperative mortality (4 cases, 2 deaths due to poor left ventricular function of <20% and 2 deaths due to cerebrovascular
accident) and chest reopened for bleeding (8 cases), leaving
178 patients remaining in the study. Eighty-eight patients
were in group A, and 90 were in group B. The mean (±SD)
age of the patients was 61.1 ± 7.6 years. The male-female
ratio was 3:1. Diabetes mellitus and chronic obstructive pulmonary disease (COPD) were the most common comorbidities (44.4% and 37.1%, respectively). End-stage renal failure
(ESRF) and obesity were documented in 18% and 11.2% of
cases, respectively. On-pump CABG surgery was performed
in 86% of the patients with a mean cardiopulmonary bypass
E229
Table 2. Comparison of Comorbidities and Intraoperative
Details for the 2 Randomized Groups*
Group A
Group B
P
Age, y
62.61 ± 7.7
59.54 ± 7.2
.085
COPD, n
35 (39.8%)
31 (34.4%)
.462
ESRF, n
39 (44.3%)
40 (44.4%)
.986
8 (9.1%)
24 (26.7%)
.002
Obesity (BMI >30 kg/m2), n
7 (8.0 %)
13 (14.4%)
.170
Smoking, n
35 (39.8%)
31 (34.4%)
.462
73 (83%)
80 (88.9%)
.255
Bypass time, min
98.14 ± 9.8
99.83 ± 9.9
.076
IMA harvested, n
84 (95.5%)
87 (96.7%)
.677
On-pump surgery, n
chronic obstructive pulmonary disease; ESRF, end-stage renal failure; BMI,
body mass index; IMA, internal mammary artery.
time of 99 ± 7.4 minutes. A single internal mammary artery
(IMA) was harvested in 171 patients (96.1%). Table 1 summarizes the patients’ clinical characteristics. The 2 groups
were well matched with respect to demographic, comorbidity,
and intraoperative variables. The only exception was ESRF,
which was more prevalent in group B (26.7%) than in group
A (9.1%). Table 2 summarizes the comparison of comorbidities and intraoperative details of the 2 groups.
Sternal wound infections occurred in 19 patients (10.7%).
Group B had a significantly higher incidence of infections
(14 patients, 15.6%) than group A (5 patients, 5.7%)
(P = .033, Table 3). All 5 patients who developed sternotomy
wound infections in group A had superficial infections. Of
the 14 patients in group B who developed infections, 10 had
superficial infections, and the remaining 4 patients had deep
sternal wound infections that led to sternal dehiscence requiring surgical debridement and repair (Table 4).
Bacteriology
Swabs for microbiology analyses were obtained from
infected wounds. Of the 19 patients with infections,
11 patients had significant microbial growth. Six patients had
Staphylococcus aureus infection, and Acinobacter sp was cultured
in 2 patients. Pseudomonas aeroginosa, Staphylococcus epidermidis,
and coagulase-negative Staphylococcus were isolated from
1 patient each.
Risk Factors
Risk factors were divided into preoperative, intraoperative,
and postoperative factors. A univariate analysis of all preoperative variables revealed that COPD, diabetes mellitus, ESRF,
obesity (body mass index >30 kg/m2), and smoking were associated with an increased risk of sternal wound infection at a
P level of <.05. In this study, however, age was not significantly
associated with sternal wound infection. Intraoperatively, we
studied 3 variables: the CABG technique, the use of an IMA,
and bypass time. Bypass time was significantly associated with
E230
Table 3. Incidence of Sternal Wound Infection in the 2 Groups*
Sternal Wound
Infected
Not Infected
Total
Group A, n
5 (5.7%)
83 (94.3%)
88
Group B, n
14 (15.6%)
76 (84.4%)
90
*P = .033.
Table 4. Type of Infection
Type of Infection
Superficial
Deep
Total
Group A, n
5 (100%)
0 (0%)
5
Group B, n
10 (71.4%)
4 (28.6%)
14
the risk of infection (P < .001). Patients who had an IMA harvested, however, were not associated with an increased risk
of infection. The duration of mechanical ventilation and the
length of intensive care unit (ICU) stay, which were studied
as postoperative risk factors of sternotomy wound infection in
this trial, were significantly associated with an increased risk
of wound infection (Table 5).
DISCUSSION
It is imperative to reduce the risk of sternotomy wound
infection, and many standard practices have been described,
including meticulous scrubbing, skin preparation, use of disposable prefabricated drapes, use of prophylactic antibiotics, and placement of the pericardial drains to facilitate the
drainage of blood and serous fluid. The standard practice
of irrigating the wound before closure with either normal
saline or povidone-iodine has long been used in most centers. The efficacy of Dermacyn for antiseptic wound irrigation during closure of the sternotomy wound following open
heart surgery has yet to be proven, however. As an antiseptic solution, it exerts a wide range of antimicrobial activities
[Landa-Solis 2005; Oculus Innovative Sciences 2006]. It can
also be applied when chemically debriding and cleansing
wound surfaces. The mechanism of action in eradicating various microorganisms is well documented [Landa-Solis 2005].
The active agents in Dermacyn consist of both chlorine and
reactive oxygen ions. It is believed that the bactericidal action
exhibited by Dermacyn is due to the combined effect of these
species. The reactive oxygen species is also beneficial in the
wound-healing process. Both ions are often referred to as free
radicals. A number of different types of free radicals are also
produced naturally by the body. Many free radicals provide
significant health benefits, whereas free radicals produced by
radiation can be destructive in nature. Conversely, Dermacyn
ions and free radicals are biological and are not produced by
radiation. Dermacyn technology has been tested in accordance with FDA requirements to ensure that such free radicals do not cause any harm.
Dermacyn Irrigation in Reducing Infection—Ramzisham et al
Table 5. Univariate Analysis of Preoperative Risk Factors for
Sternal Infection*
Infected (n = 19)
Not Infected (n = 159)
P
Age, y
63.0 ± 7.5
60.8 ± 7.6
.257
COPD, n
11 (57.9%)
55 (34.6%)
.047
13 (68.7%)
66 (41.5%)
.026
ESRF, n
11 (57.9%)
21 (13.2%)
.000
Obesity, n
16 (84.2%)
4 (5.2%)
.000
Smoking, n
11 (57.9%)
55 (34.6%)
.047
108.05 ± 11.5
96.4 ± 7.9
.000
IMA harvest, n
17 (89.5%)
154 (96.9%)
.118
Ventilation duration, h
10.84 ± 6.1
4.21 ± 0.7
.000
Length of ICU stay, d
2.63 ± 0.76
2.06 ± 0.23
.000
Bypass time, min
Infected
ESRF
chronic obstructive pulmonary disease; ESRF, end-stage renal failure; IMA,
internal mammary artery; ICU, intensive care unit.
In this study, the 5 patients from the Dermacyn group
with infected wounds had only superficial infections, and they
required only a course of antibiotics and wound dressings
to treat the infection and to promote wound healing. Four
patients from the povidone-iodine group with wound infection, however, had associated deep wound infection and sternal dehiscence. These patients required surgical debridement
and sternal rewiring. The remaining 10 patients had superficial infections and were successfully treated with antibiotics and wound dressings. Obviously, these findings indicate
that the Dermacyn group not only had a lower infection rate
but also had less severe infections than the povidone-iodine
group.
Many studies have demonstrated that the development
of sternotomy wound infection following CABG is multifactorial. Most authors have classified the risk factors into
3 groups: preoperative factors pertaining to the patient, such
as advanced age and comorbidities; intraoperative factors,
such as a prolonged duration of operation and the need for
reoperation; and postoperative factors, such as the use of an
intra-aortic balloon pump, massive blood transfusion, and
prolonged mechanical ventilation [Oschner 1972].
In the present study, we assessed 11 variables as potential risk factors for sternotomy wound infection. A univariate analysis was performed to determine the associations
between these risk factors and wound infection (Table 5). In
contrast to the results of other studies, we found that age was
not significantly associated with sternotomy wound infection (P = .257). This result was probably because most of our
patients were younger than 65 years, whereas several studies
have shown that older patients are at high risk of developing wound infection. Our analysis revealed that patients who
had diabetes mellitus and were obese were more likely to
develop sternotomy wound infection, a result that is concordant with other studies [Moulton 1996]. Cigarette smoking
and COPD were also identified as significant risk factors for
© 2010 Forum Multimedia Publishing, LLC
Table 6. Infected Cases among ESRF and non-ESRF Patients*
Non-ESRF
Total
Group A, n
3 (60%)
2 (40%)
5
Group B, n
8 (57.1%)
6 (42.9%)
14
*Odds ratio, 1.1.
sternal wound infection following CABG. More than 60%
of our patients with infection were smokers and had COPD.
The latter is frequently associated with an increased risk of
postoperative mediastinitis, probably because of frequent
coughing, which may contribute to wound dehiscence and
thereby facilitate bacterial migration into the mediastinum.
Patients with COPD also experience respiratory infections
more frequently and prolonged weaning from mechanical
ventilation [Grossi 1991]. The details of the pathophysiology
causing the infection in these patients are beyond the scope
of this report.
In this trial, we were unable to match the 2 groups with
respect to the number of ESRF patients. ESRF was more
prevalent in group B. The overall incidence of sternal
wound infection in ESRF patients was statistically significant
(P < .001). Further analysis, however, revealed that 3 (60%)
of the 5 patients in group A and 8 (57.1%) of the 14 patients
in group B who developed infection had ESRF. The calculated odds ratio between these 2 groups was 1.1, implying that
sternotomy wound infection is equally likely to occur in the
2 groups, regardless of the type of irrigation used (Table 6).
We observed that 14 patients (82.4%) who developed wound
infection had bypass times >110 minutes. This finding was
supported by the statistical analysis, which showed bypass time
to be significantly associated with the risk of sternal infection.
This finding is similar to findings from most other studies,
which showed a higher incidence of sepsis with longer bypass
times [Loop 1990]. Many studies have linked the use of IMA
grafts to a higher incidence of sternal infections [Hirotani
2002]. Of the 19 patients who developed sternotomy wound
infection in the present study, 17 (89.5%) had a single IMA
harvested. This incidence showed that this variable did not
make a significant contribution to the risk of sternal infection.
Decreased sternal perfusion has been hypothesized as a cause
for an increased incidence of sternal infections following use
of an IMA [Carrier 1992]. Sofer et al [1999] showed that after
bilateral IMA dissection, sternal perfusion was reduced by a
mean of 24% ± 6%. Four weeks postoperatively, sternal blood
flow was still reduced by a mean of 2% ± 2%. This low sternal
perfusion may lead to tissue necrosis, and hence to an impaired
wound-healing process. We tried to avoid bilateral IMA use
unless it was absolutely necessary. Our results also confirmed
that prolonged mechanical ventilation and a longer ICU stay
were significantly associated with wound infection. All of our
patients were ventilated and observed postoperatively in the
cardiac beds in the general ICU rather than in a dedicated
cardiac ICU. The risk of infection is generally greater in the
E231
general ICU. These patients not only are exposed to endogenous infection (ie, normal commensals) but also are prone to
contract infections from exogenous sources, such as the staff,
other patients, and visitors.
This trial had certain limitations. The number of participants in this study was relatively small because our center is
not the main center for cardiothoracic surgery in this region;
thus, the logistics allowed for only a limited number of operations. In addition, the variables for risk factors for sternotomy
wound infections were limited to 11. Although all patients
underwent their operations with the same cardiothoracic surgical teams, we were not able to appoint a dedicated surgeon
for closure of sternotomy wounds. Some nonobjective factors
that might also have influenced this study include the number
of staff and medical students entering and exiting the theater
during surgery. This trial, however, suggests that the use of
Dermacyn as a wound-irrigation agent at closure of sternotomy following CABG reduced the incidence of wound infection, compared with povidone-iodine. There were no adverse
side effects associated with the use of Dermacyn. Therefore,
it can be used without hesitancy in view of its effectiveness
and safety as a wound-irrigation agent.
REFERENCES
Bitkover CY, Gårdlund B. 1998. Mediastinitis after cardiovascular operations: a case-control study of risk factors. Ann Thorac Surg 65:36-40.
Blanchard A, Hurni M, Ruchat P, Stumpe F, Fischer A, Sadeghi H. 1995.
Incidence of deep and superficial sternal infection after open heart surgery. A ten years retrospective study from 1981 to 1991. Eur J Cardiothorac Surg 9:153-7.
Bongiovanni CM. 2006. Superoxidized water improves wound care outcomes in diabetic patients. Diabet Microvasc Complications Today May/
June:11-4.
Carrier M, Grégoire J, Tronc F, Cartier R, Leclerc Y, Pelletier LC. 1992.
Effect of internal mammary artery dissection on sternal vascularization.
Ann Thorac Surg 53:115-9.
El Oakley RM, Wright JE. 1996. Postoperative mediastinitis: classification and management. Ann Thorac Surg 61:1030-6.
Grossi EA, Esposito R, Harris LJ, et al. 1991. Sternal wound infections and
E232
use of internal mammary artery grafts. J Thorac Cardiovasc Surg 102:342-6.
Hirotani T, Shirota S, Cho Y, Takeuchi S. 2002. Feasibility and suitability
of the routine use of bilateral internal thoracic arteries. Ann Thorac Surg
73:511-5.
Horan FC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. 1992. CDC
definitions of nosocomial surgical site infections, 1992: a modification
of CDC definitions of surgical wound infections. Infect Control Hosp
Epidemiol 13:606-8.
Landa-Solis C, González-Espinosa D, Guzmán-Soriano B, et al. 2005.
Microcyn: a novel super-oxidized water with neutral pH and disinfectant
activity. J Hosp Infect 61:291-9.
Loop FD, Lytle BW, Cosgrove DM, et al. 1990. J. Maxwell Chamberlain
memorial paper. Sternal wound complications after isolated coronary
artery bypass grafting: early and late mortality, morbidity, and cost of
care. Ann Thorac Surg 49:179-87.
Moulton MJ, Creswell LL, Mackey ME, Cox JL, Rosenbloom M. 1996.
Obesity is not a risk factor for significant adverse outcomes after cardiac
surgery. Circulation 94(suppl):II87-92.
Oculus Innovative Sciences. 2006. Technical description of DERMACYN™. Microcyn™ Technology, Inc. Petaluma, Calif.: Oculus Innovative Sciences.
Ohno H, Higashidate M, Yokosuka T. 2000. Mediastinal irrigation with
superoxidized water in open-heart surgery: the safety and pitfalls of cardiovascular surgical application. Surg Today 30:1055-6.
Oschner JL, Mills NL, Woolverton WC. 1972. Disruption and infection
of median sternotomy incision. J Cardiovasc Surg 13:394-9.
Paola LD, Brocco E, Senesiet A, et al. 2006. Super-oxidized solution
(SOS) therapy for infected diabetic foot ulcers. Wounds 18:262-70.
Sofer D, Gurevitch J, Shapira I, et al. 1999. Sternal wound infections in
patients after coronary artery bypass grafting using bilateral skeletonized
internal mammary arteries. Ann Surg 229:585-90.
Ulicny KS Jr, Hiratzka LF. 1991. The risk factors of median sternotomy
infection: a current review. J Card Surg 6:338-51.
Vegas AA, Jodra VM, García ML. 1993. Nosocomial infection in surgery wards: a controlled study of increased duration of hospital stays and
directs cost of hospitalization. Eur J Epidemiol 9:504-10.
Zacharias A, Habib RH. 1996. Factors predisposing to median sternotomy complications. Deep vs superficial infection. Chest 110:1173-8.
Microcyn and HAIs
Saturday, January 22, 2011
Expanded article - A New Approach to the Problem of Antibiotic Resistance
A NEW APPROACH TO THE PROBLEM OF ANTIBIOTIC RESISTANCE AND HOSPITAL
ACQUIRED INFECTIONS
by Susanne Lewis
Hospital-acquired infections, (HAIs), have become far too prevalent across the nation. The statistics
are grim. Ten million patients will get an infection in a health care institution over the next five
years and half a million of them will die. Many people fear going to the hospital because that is
where the most virulent antibiotic-resistant microbes are encountered. A vast study conducted
several years ago found that about half of the patients in ICU wards around the world are battling
some kind of acquired infection. This study looked at data from 1,265 ICU units in 75 countries.
The longer the patients stayed in the ICU, the greater the risk of becoming infected—from a 32%
chance for patients staying one day or less to a 70% chance for patients staying more than seven
days. These patients were more than twice as likely to die than non-infected patients. This problem
accounts for about 40% of total ICU health care costs. There is a great need for new approaches to
be developed to cope with resistant superbugs. Appropriately, our age is described as being on the
cusp of the “post-antibiotic era.”
Microbes in the community are also becoming resistant. Superbugs are on everyone’s mind. MRSA,
multi-drug resistant staph aureus, has taken a terrible toll, and continues to proliferate, generating a
wide range of afflictions. At this point four million people have MRSA on the skin or in the nostrils,
and that is a very conservative estimate. New strains of resistant staph are continuing to show up,
especially in livestock. It has been dubbed “the perfect pathogen.” But it has competition for that
title. Pseudomonas Aeruginosa, C. Diff, actinobacter, e. coli and many others are developing super
strains. One woman, who was infected in a wound care clinic where she had been referred for postoperative care, became colonized by three different superbugs—MRSA, pseudomonas and
actinobacter. Five years later she still has an open wound in her abdomen where mesh to repair
hernia had been inserted. She is on maintenance doses of very strong antibiotics and running out of
options.
After 60 years of reliance on antibiotics, we are slowly descending into an iatrogenic nightmare that
has already reached epidemic proportions and seems to be heading in the direction of a pandemic of
global proportions. How has this happened? We all know about the over-use of antibiotics as a
causative factor. But that only accelerated the problem, it did not cause it. To understand the cause,
we need to understand the nature of antibiotics themselves.
Bacteria naturally produce their own antibiotics as a means of controlling competing bacteria for
nutritional resources. In other words, they engage in a kind of “chemical warfare” against each
other. Medical science simply learned to isolate the antibiotics directly from the microbes, and then
to synthetically produce them. But microbes that produce antibiotics themselves have the ability to
withstand them, at least potentially. This is one of their primary survival strategies, built into their
DNA. And antibiotic resistance can be transmitted from one species to another via plasmids. So, in
the long run, medical science can never win out against microbes with antibiotics because it is
trying to fight them on their own turf with their own weapon. And superbugs are here to call our
bluff.
In The Coming Plague, Laurie Garrett writes:
…the use of antibiotics in colonies of bacteria in which even 1% of the organisms were
genetically resistant could have tragic results. The antibiotics would kill off the 99% of the
bacteria that were susceptible, leaving a vast nutrient-filled Petri dish free of competitors
for the surviving resistant bacteria. Like weeds that suddenly invaded an untended open
field, the resistant bacteria rapidly multiplied and spread out.”
At this point, we struggle with infections nearly impossible to treat as a direct result of the use of
antibiotics—not just staph but pneumonia, strep, dysentery, even resistant strains of tuberculosis
and gonorrhea. The list is getting long.
The problem is further exacerbated by the widespread use of antiseptics, antibacterials and
disinfectants, such as BSK (benzalkonium chloride), CHG (chlorhexidine gluconate), povidone
iodine, dilute bleach, triclosan, and more. Unfortunately, microbes are able to develop resistance to
these chemicals in the same way they develop resistance to antibiotics. A recent study showed
microbes resistant to BSK could withstand concentrations of BSK up to 400 times greater than nonmutated strains. More importantly, these same microbes also developed resistance to ciprofloxacin,
even though they had never been exposed to the drug. The conclusion is that these chemicals
proliferate antibiotic resistance. In addition to this, some people are allergic to certain antibacterials,
such as CHG, the severest reaction documented being anaphylactic shock. Some health care
professionals are against the use of well known antiseptics in wound treatment because of the
proven cytotoxicity in dermal and epidermal cells.
Antibiotic toxicity is also becoming a serious issue. Antibiotics have been shown to be
chondrotoxic, damaging the body’s cartilage; neurotoxic, carcinogenic, toxic to the retina,
nephrotoxic, and more. In fact, antibiotics are the principle cause of drug-associated nephropathy.
The FDA was compelled to put out a black-box warning on Cipro as well as Gentamicin, for tendon
rupture, ototoxicity and renal damage. A black box warning is the strongest form of warning issued
by the FDA about a drug, the step taken just short of removing the drug from the market. A 2008
study conducted by the CDC revealed more than 140,000 incidences of bad reactions to antibiotics
which resulted in visits to the Emergency Room each year in the US. Far more reactions go
unreported, so there’s really no way of telling what the actual figure is.
It is not mere speculation that prolonged and repeated exposure to antibiotics induces cancer. A
2008 two-year study of three million people who were tracked for six years, concluded those who
had taken two to five prescriptions during that two year period had a 27% increase in cancers
compared to those who took none. Those who took six or more prescriptions had a 37% increase in
cancers. This study was published in the International Journal of Cancer. And a National Cancer
Institute study found that the number of breast cancers doubled among women who took more than
25 antibiotic prescriptions over 17 years—usually for recurrent urinary tract infections and acne.
This study was published in the Journal of American Medical Association.
Antibiotics tend to have a down-regulating effect on the immune system, some even interfering
with lymphocyte blastogensis. Macrobid (nitrofurantoin), often used for urinary tract infections, is
one of many implicated here. Destruction of intestinal microflora is also a contributing factor. A
repetitive cycle of illness and dependency on repeated use of antibiotics results. People repeatedly
treated with antibiotics have far more infections than those not treated this way, especially children
with recurring ear infections. Studies have clearly demonstrated that long-term use of antibiotics
does indeed suppress the immune system. This is in part due to the fact that antibiotics do not
reinforce the immune system but rather replace one of its functions—the destruction of bacteria.
This causes that arm of the immune system to weaken. Thus re-infection is easily succumbed to.
Combine this syndrome with the problem of virulent resistant strains of microbes and you have a
recipe for disaster.
A paradigm shift is greatly needed in order to devise new approaches to the problems of infectious
disease. One important idea is to shift emphasis from attacking the microbe at the expense of the
immune system, to attacking the microbe in a way that enhances the immune system. There are
many approaches. One is to use recombinant electrolyzed salt water which is laden with freefloating electrically charged oxygen ions with traces of hypochlorous acid--an antimicrobial
solution that mimics the way neutrophils work to eradicate infection through what is known as
oxidative burst. During oxidative burst, also known as respiratory burst, or phagocytosis, white
blood cells surround the pathogen and release hypochlorous acid and reactive oxygen to burst
through the cell wall of the pathogen, annihilating it, (lysis). This does not harm mammalian tissue,
because its cells are tightly bound together in a matrix that cannot be affected by oxidative burst.
Working in tandem with the immune system, this solution, dubbed nSOS, or pH neutral
superoxidized solution, is highly effective against a very broad spectrum of pathogens, including
abx resistant bacteria, viruses, fungi and spores. It is neither acidic nor alkaline, but has a neutral pH
of between 6.2 and 7.8, depending on the formula. It is an entirely new class of antiseptic.
In an article entitled, “The Science Behind Stable, Super-Oxidized Water,” Dr. Andres A. Gutierrez
describes what he calls “the dawn of a new solution.” Tests have documented in-vitro antimicrobial
activity of an astonishing thoroughness. Toxicology studies are cited that confirm nSOS is neither
genotoxic nor cytotoxic. Worldwide approvals have been coming steadily forth for about eight
years, in Europe, Canada, United States, Mexico, Russia, China, Middle Eastern countries, India,
and more. It has been used in such a wide variety of applications as to be bewildering—everything
from cleaning and treating cuts and scrapes to treating periodontal disease to mediastinal irrigation
after open heart surgery. It has also been used to treat peritonitis and abscesses of the abdominal
cavity, as well as bladder infections, urethritis, cystitis, ear infections, acne, and much much more.
The list of potential uses is long indeed. Much of this is being done in an off-label capacity, pending
clearance by regulatory agencies. But approvals are coming steadily through each year.
The use of nSOS as a treatment for infection as well as a preventative to keep infection from
occurring, is gradually being recognized by the medical community as a very promising alternative
to over-reliance on antibiotics. It is being used in wound care clinics, limb salvage clinics, diabetic
foot clinics, and burn clinics, with wonderful results. Much of the research to date has been with
diabetic foot ulcers. These wounds are particularly difficult to treat and often result in amputation,
which is known to significantly shorten the lifespan of many undergoing this procedure. Non
healing diabetic wounds are highly vulnerable to opportunistic infections, which are more and more
frequently turning out to be MDROs—multi drug resistant organisms, or superbugs. Treatment
with neutral superoxidized water has been highly effective with these kinds of wounds, reducing
bacterial load, enhancing local blood supply, promoting neovascularity and reducing inflammation.
Neutral superoxidized water is marketed in Europe, Russia and China as Dermacyn, in India as
Oxum, and in the United States and Mexico as Microcyn, Puracyn, Vetericyn, Periocyn and
MyClynse. It is the first neutral superoxidized water to be stable enough to make it practical for
widespread use, with a shelf life of approximately two years.
One study demonstrated that Microcyn was effective in treating chronic wounds with extensive
bioburden, and it discovered that local pain levels were substantially reduced when this treatment
was used. And there have been a number of clinical studies comparing povidone iodine and
Microcyn in wound care. They have been done in the United States, Italy, India and Mexico, to
name just four. Wounds range from diabetic foot ulcers, venous stasis ulcers, pressure sores,
surgical site infections and burns. Here is info on just one of those studies:
STUTTGART, Germany -- 218-patient study indicates Microcyn(TM) Technology superior
in microbial load reduction, healing time, surgical dehiscence and adverse side effects as
compared to povidone iodine (10%).
Oculus Innovative Sciences, Inc. announced that Dr. Luca Dalla Paola, a surgeon with the
diabetic foot unit of the Abano Terme Hospital in Italy, recently presented the results of a
218-patient controlled clinical study that assessed the safety and efficacy of Microcyn(TM)
Technology in treating diabetic foot ulcers as compared to povidone iodine (10%)
antiseptic, which is often used as the "standard care" in treatment of open wounds.
In the study, the Microcyn(TM) Technology proved superior to the iodine relative to the
reduction of the number of bacterial strains, local adverse effects, surgical dehiscence
(incidence of not healing after surgery due to infection or ischemia) and healing time. The
key endpoint of the study was microbial load reduction at both entry and at surgery (or
follow-up). The Microcyn(TM) Technology showed a significantly improved rate of
reduction of microbial load and healing time in open wounds as compared to the povidone
iodine group. 88.2% of ulcers in the Microcyn(TM) group had a negative microbiological
specimen versus 68.5% of ulcers in the povidone iodine group. The Microcyn(TM) group
showed no local adverse effects, while the povidone iodine group experienced 18 incidences
of such effects.
All studies indicated more complete wound healing, healthier appearance, absence of odor,
reduction of inflammation, and greater presence of granulation tissue. Microcyn’s well-established
“safe as saline” profile assures there will be no irritation or other adverse reactions when used.
There is a lot of misinformation circulating about neutral superoxidized solution, but research
clearly refutes these myths. First, nSOS is NOT dilute bleach in any way shape or form. Dakins
solution is dilute bleach, and amongst enlightened wound care clinicians, it went out with the
dinosaurs. Dakins solutions is damaging to mammalian tissue and is in well deserved disrepute
because of this. It was used in the Vietnam war, but that was before research proved that it destroys
fibroblasts, which are crucial to wound closure. When compared to dilute bleach, studies show that
nSOS is actually a much more powerful antimicrobial solution of oxidants that are actually able to
eliminate bleach resistant bacteria, without damaging fibroblasts in any way. Another myth
circulating about nSOS is that it is only another manifestation of so-called ionized water. Medical
grade nSOS is hardly the alkaline ionized water people drink thinking it will do everything from
making them younger to curing cancer. Stable nSOS is made through an intricate proprietary
method that requires considerable scientific sophistication to master. So far only one company has
been able to do it successfully, Oculus Innovative Sciences, located in Petaluma, California.
In-vitro studies have shown nSOS to eradicate viruses as well as bacteria--poliovirus-1, rhinovirus1A, herpes simplex viruses 1 & 2, influenza H1N1, West Nile virus, HIV, and many others. In
addition to all the drawbacks I have mentioned in this article, one of the major limitations to
antibiotic therapy is that antibiotics are helpless against viruses. Viruses have always been
superbugs.
In an article on bacterial complications from burn wounds by Dr. Ariel Miranda Altamirano,
Microcyn60, the nSOS product used in Mexico, was evaluated. He indicated that infection by
superbugs in burn wounds has been steadily increasing in recent years, retarding overall wound
healing, elevating the rate of graft loss and increasing mortality from sepsis. He concluded that:
As predicted from previous animal and clinical experience, the use of Oculus Microcyn60
was efficient and safe for the prevention of partial- and full-thickness burn infections in
pediatric patients. Treatment with Oculus Microcyn60 reduced the microbial load in 90% of
patients with partial- and full-thickness thermal injuries. Children also reported less pain
during cleaning procedures. Application was easy and inexpensive. In addition, the length
of hospital stay of patients treated with Oculus Microcyn60 was reduced by 50% relative to
the control. Considering that the daily hospital cost at this facility is approximately $1,800
US per patient, treatment with Oculus Microcyn60 saved the institution an average of
$24,660 US per patient. The results of this study also suggest that burns treated with Oculus
Microcyn60 heal with better cosmetic results and less chelation relative to the previous
standard burn treatment.
Dr. David E. Allie said that infection plays a significant role in many chronic limb wounds, leading
to amputation. In the United States the amputation rate has increased dramatically over the last two
decades, and there is an excessively high mortality rate in the higher risk patients. “Successful
rehabilitation after below-knee amputation is achieved in less than two-thirds of patients.”
Statistics for above knee amputations are even worse. This is why there has been an increasing
emphasis on limb salvage work. And nSOS is beginning to play a vital role in this area. In Dr.
Allie’s study, limb salvage rate was 100% with Microcyn, there was a marked decrease in antibiotic
use, both oral and IV, and far fewer hospitalizations were required.
It’s hard to imagine a solution that not only eliminates bioburden but reduces inflammation while
delivering a healing payload of oxygen to tissue, but this is actually the case. nSOS contains more
than five times the amount of oxygen as tap water, and elevated tissue oxygen levels have been
measured up to 72 hours after application. Just how this works in tandem with small amounts of
hypochlorous acid to promote such rapid and thorough healing is not fully understood yet. But an
increasing body of evidence indicates that it does possess a special kind of healing power. A group
of scientists in Japan speculated that reactive oxygen species, shown to be electron spin resonance
spectra present in nSOS, triggers would healing through fibroblast migration and proliferation.
Whatever the reason, it works beautifully, and has saved a great many lives around the world.
Dramatic stories abound. In one case, a seventeen year old developed necrotizing fasciitis, also
known as flesh eating bacteria, after having a wisdom tooth extracted. The infection rapidly spread
and he was in the ICU on a ventilator by the time his father, a surgeon who happened to be aware of
the uses of nSOS, had several gallons of Microcyn overnighted to the hospital, with instructions to
irrigate the wound around the clock. Within the next few days the young man made a remarkable
recovery from a terrible infection that even the strongest IV antibiotics could not contain. Another
case of necrotizing fasciitis happened recently in Florida. The patient had a leg wound that had
become infected with this microbe, and the progress of the infection could not be contained. The
doctor was on the verge of amputating when he was advised about nSOS. He had a shipment
overnighted to his hospital and began irrigations as soon as he could. The leg was saved and the
family was ecstatic.
At a well known specialty wound care clinic that focuses on life-threatening wounds only, Lake
Wound Care Clinic in Lakeview Oregon, Dr. Cheryl Bongiovanni uses nSOS extensively. Many
patients are referred to her with surgical site infections that are wildly insensitive to just about every
antibiotic in existence. She routinely saves lives and limbs by skillful use of nSOS. Her success rate
is phenomenal. She says that she no longer uses hyperbaric oxygen, or saline solution, and the use
of topical and systemic antibiotics has been greatly reduced in her clinic.
Microcyn, the only stabile nSOS, with a shelf life of two years, has been evaluated by the USP
<51> Antimicrobial Effectiveness Test and is now designated as a Category 1 product. The log
reduction numbers are spectacular. As an antiseptic, it highly versatile and unparalleled in its
effectiveness. Over just the past seven years, over two million people have been treated worldwide
without a single report of a serious adverse effect.
Health care professionals struggling with the enormous problem of HAIs are trying to establish
higher standards of hygiene, especially hand washing technique, hoping to curb the epidemic.
Though this is a good effort which will certainly help, it could never really solve the problem. It is
impractical to expect extremely busy nurses and aides to be 100% thorough in hand washing as they
struggle through another busy day. Somewhere along the line, they are all going to slip up. What
needs to be done in addition to focusing on strict sanitation standards is to bring nSOS into our
hospitals and clinics for a whole spectrum of treatment and techniques, thereby eliminating the
danger of a missed hand wash.
If appropriate protocol using nSOS were to be established in our health care institutions, the
outcome would be far reaching indeed. It has the capability of preventing HAIs when used as a skin
prep prior to surgery, an irrigant during surgery, and as an antiseptic for post-operative care. A
highly qualified reconstructive surgeon in Cabo San Lucas related that he has been using nSOS in
his practice for some time, finding it to be extremely effective. He uses it instead of saline solution
during his surgeries. In the future he believes that Microcyn60, the nSOS product in Mexico, will
become the only product used for treatment during surgeries.
nSOS can also be used as a nasal spray, which could greatly reduce the danger of patients bringing
staph into the hospital setting. And nSOS can eliminate catheter-associated urinary tract infections,
(CAUTIs), by rinsing the bladder on a daily basis. Ventilator associated pneumonia could be
prevented by routinely cleansing the both ventilator tubing, stoma and even the trachea.
Neutral super-oxidized water could be to the epidemic of HAIs what quinine was to malaria and the
Salk vaccine to polio. Unfortunately, history demonstrates that the obstacles of ignorance and
oversight bias often create barriers to the timely emergence of such crucial medical breakthroughs.
Back before Pasteur, circa 1785, when hundreds of women were dying from childbirth
infection, Alexander Gordon noticed that the cleaner things were in the birthing room the
less a women giving birth was susceptible to infection. Though he attempted to spread the
word about the need for cleanliness, he was scorned and ignored. Seventy years later Ignaz
Semmelweis, aware that scores of women were still dying from what was called childbirth
fever, took extensive empirical procedures to test the cleanliness element in birthing rooms,
especially having doctors wash their hands just before delivering a baby. Yet though
Semmelweis did his best, even using empirical evidence to prove cleanliness was essential,
he was rejected, ridiculed and ignored, thus thousands of women continued to die because
of such arrogant self-willed ignorance. (Pushing Ultimates, 2006)
Let’s hope this notorious syndrome does not prevent the timely recognition and acceptance of vital
Email ThisBlogThis!Share to TwitterShare to Facebook
Object 1
Friday, August 20, 2010
Microcyn and HAIs
Hospital-acquired infections, (HAIs) have become far too prevalent across the nation. The statistics
are grim. Ten million hospital patients will get an infection in a health care institution over the next
five years and half a million of them will die. Many fear going to the hospital because that is where
the most virulent microbes are encountered.
Along with MRSA, many significant infection-causing bacteria in the world are also becoming
resistant to the most commonly prescribed antimicrobial treatments. Antimicrobial resistance occurs
when bacteria change or adapt in a way that allows them to survive in the presence of antibiotics
designed to kill them. In some cases bacteria become so resistant that no available antibiotics are
effective against them. People infected with antibiotic-resistant organisms like MRSA are more
likely to have longer and more expensive hospital stays, and may be more likely to die as a result of
the infection. When the drug of choice for treating their infection doesn’t work, they require
treatment with second- or third-choice medicines that may be less effective, more toxic and more
expensive.
Antibiotic toxicity is just as serious a problem as resistance. Antibiotics have been shown to be
chondrotoxic, damaging the body’s cartilage; neurotoxic, carcinogenic, nephrotoxic, and more. In
fact, antibiotics are the principle cause of drug-associated nephropathy.
But there is a new weapon in the fight against resistant microbes. Microcyn technology is a safe-assaline anti-infective that quickly eradicates a broad range of pathogens, including antibioticresistant bacteria (including MRSA and VRE), viruses, fungi and spores. Dual-action in nature, in
addition to killing the infection, Microcyn also accelerates the wound-healing process by reducing
inflammation in the wound and increasing nutrient-rich blood and oxygen flow to the wound bed.
Twenty-five clinical studies have demonstrated Microcyn to be both safe and effective in killing
pathogens.
What makes Microcyn so remarkably effective is the way hypochlorous acid works in tandem with
reactive oxygen species. This is also the way the immune system’s neutrophils work, through
oxidative burst. This is something no microbe can stand up to, nor can they develop resistance to it.
Microcyn has been evaluated by the USP <51> Antimicrobial Effectiveness Test, now designated as
a Category 1 product. The log reduction rates are spectacular. As a hygiene product it is
unparalleled.
Microcyn has revolutionized wound care as we know it. A dramatic case of limb salvage when
dealing with necrotizing fasciitis came to my attention just this week. A well known Infectious
Disease specialist in Florida was fighting a losing battle against NF in a leg wound. Amputation was
inevitable. However, the doctor became aware of Microcyn and called the company, requesting an
emergency shipment. Microcyn irrigations were initiated and the leg was saved. The family was
ecstatic. This is just one of many such cases.
The medical applications for Microcyn are too numerous to list here. Over two million people have
been treated worldwide without a single report of a serious adverse effect.
FDA clearances are coming steadily through this year and next. We will most certainly be seeing
more remarkable medical breakthroughs involving Microcyn.
If appropriate protocol using Microcyn were to be established in our health care institutions, the
outcome would be far reaching indeed. It has the capability of preventing HAIs when used as a skin
prep prior to surgery, an irrigant during surgery, and as an antiseptic for post-operative care. It also
can be used as a nasal spray, ear drops, eye drops, and can eliminate catheter-associated urinary
tract infections, (CAUTIs), by rinsing the bladder on a daily basis.
Microcyn is to the epidemic of HAIs what quinine was to malaria and the Salk vaccine to polio.
There is a great deal more to be said about this, but a picture is worth a thousand words:
http://www.youtube.com/watch?v=sAiWWNCfYH4
http://www.youtube.com/watch?v=O2saruj3qvQv
http://www.youtube.com/watch?v=3b0gp2C8R5E
Email ThisBlogThis!Share to TwitterShare to Facebook
Object 2
Home
Subscribe to: Posts (Atom)
Irrigación con Solución Superoxidada (SSO)
en el tratamiento del conducto radicular
Miguel Angel Flores-Martínez1
1Universidad Michoacana de San Nicolás de Hidalgo, U.M.S.N.H. Morelia Michoacán,
México.
Palabras clave: agua superoxidada, radicales libres, estrés oxidativo, oxidación del ADN,
agua electrolizada, tratamiento del conducto radicular.
Introducción
Las infecciones del conducto radicular son una enfermedad infecciosa de etiología
bacteriana y constituyen una de las mayores causas de pérdida de piezas dentales en el
mundo. Las modalidades terapéuticas actuales incluyen el raspado y alisado radicular de
las superficies de los dientes para eliminar la placa bacteriana y los cálculos, así como el
uso de soluciones antisépticas para combatir el proceso infeccioso causado por un amplio
espectro de microorganismos orales. Sin embargo, estos antisépticos tienen una elevada
toxicidad y por lo tanto no pueden ser utilizados durante periodos prolongados. Además,
algunos de los antisépticos de uso común tienen efectos secundarios adversos tales como
modificar el sabor o manchar los dientes. Entre los numerosos antisépticos alternativos
propuestos hasta ahora se incluyen las soluciones superoxidadas (SSO), que podrían ser
una buena opción. Horiba et al. (1998) mostraron que una SSO de pH neutro era eficaz
contra cepas bacterianas obtenidas de conductos radiculares infectados. Una segunda
publicación sobre este campo mostró que el agua electrolizada ácida podría ser un
tratamiento aceptable para el enjuague de impresiones con hidrocoloides (Nakagawa et
al, 2002). Lamentablemente no se publicó más información.
La SSO ensayada aquí (Microcyn™, Oculus Innovative Sciences, EE.UU.) ha
demostrado que ejerce una actividad microbicida amplia, que incluye bacterias, virus,
hongos y esporas (Landa et al, 2005). El amplio espectro no puede explicarse únicamente
en base a las especies de cloro, ya que su concentración es muy baja (contenido de cloro
total <80 ppm). También ha superado ensayos de biocompatibilidad según los requisitos
de la Food and Drug Administration para productos de cuidado de heridas en EE.UU..
Estos ensayos incluyeron pruebas de citotoxicidad, sensibilización, irritación y
reactividad intracutánea, e incluso pruebas de genotoxicidad. Tras su aprobación en
México, esta SSO ha sido utilizada de forma amplia y segura en todo tipo de heridas
abiertas y lesiones mucosas en los últimos 24 meses. El único efecto secundario
reportado hasta el momento ha sido una sensación de ardor en los pacientes
hipersensibles, particularmente en aquellos con úlceras venosas. Nuestra experiencia en
odontología comenzó con el éxito en el tratamiento de la enfermedad periodontal con la
irrigación de esta SSO con un escarificador ultrasónico (Flores MA, 2005). Dado que esta
novedosa solución superoxidada no era ni sensibilizante ni irritante en la enfermedad
periodontal y su contenido de cloro estaba era como máximo de 80 ppm, ofrecía un mejor
enfoque para tratar las infecciones del conducto radicular. Por lo tanto, este estudio se
realizó para evaluar la eficacia de la SSO frente a irrigación con hipoclorito sódico al
2,5% en la prevención de reacciones agudas después del tratamiento del canal radicular.
En conjunto estos resultados favorecen la terapia con SSO en comparación con la
solución diluida de hipoclorito sódico como solución de irrigación en el tratamiento del
conducto radicular. Un estudio prospectivo, controlado, multicéntrico, debe llevarse a
cabo para confirmar plenamente estas observaciones iniciales.
Pacientes y métodos
Pacientes
Todos los pacientes consecutivos atendidos en la Universidad Michoacana de San Nicolás
de Hidalgo en Morelia, México, entre octubre de 2003 abril de 2005 y con diagnóstico de
infección del conducto radicular se incluyeron en el grupo de SSO. La infección aguda
del conducto radicular se define como una imagen de rayos X que muestra una lesión
periapical, además de pruebas clínicas negativas de vitalidad pulpar y positivas de
percusión. En el grupo de control se realizó un análisis retrospectivo de pares de casos
que presentaron infecciones similares del conducto radicular entre 2002 y 2003 en la
misma institución.
Solución superoxidada (SSO)
Se investigó la actividad antimicrobiana de una solución de pH neutro, con una cantidad
controlada de especies reactivas de cloro y oxígeno (Microcyn™, Oculus Innovative
Sciences, EE.UU.) en pacientes mexicanos con infecciones agudas del conducto
radicular. Esta novedosa solución superoxidada (SSO) para el cuidado de heridas, ofrece
un enfoque radicalmente mejorado en el tratamiento del conducto radicular. Esta SSO de
pH neutro sin enjuague fue certificada inicialmente como antiséptico para tratar heridas
en México en 2004. En primer lugar se realizaron ensayos en animales para mostrar que
la SSO no induce irritación o sensibilización en la piel y mucosas (Gutiérrez, 2006). Los
componentes activos de esta solución son 99,98% de agua superoxidada y <0,02% de
diversas especies reactivas de cloro y oxígeno, incluyendo ácido hipocloroso, hipoclorito
sódico, cloruro sódico, ozono y dióxido de cloro. Es de destacar que el contenido total de
cloro libre disponible es bajo y oscila entre 50 y 80 ppm. Esta SSO tiene actividad
bactericida, virucida, fungicida y esporicida y está lista para su uso sin dilución adicional
o mezcla (Landa et al, 2006). Además, no requiere una manipulación o desecho especial
y tiene una vida útil superior a 12 meses.
Manipulación dental con SSO
Durante el proceso, los conductos están aislados para evitar la contaminación. Se abre la
cavidad se perfora la raíz. Es necesario localizar un conducto apropiado para garantizar
una manipulación eficiente. La irrigación con SSO comienza con el proceso de
perforación, en lugar de usar solución salina o agua. La instrumentación se lleva a cabo
de acuerdo con la técnica de corona invertida utilizando instrumentos rotatorios de NiTi.
La instrumentación se realiza de acuerdo con la extensión del conducto, según lo
determinado por rayos X. La irrigación del conducto se realiza con SSO después de usar
cada instrumento. Se realiza una irrigación final con SSO en la cavidad de la raíz durante
un máximo de 15 minutos (tiempo de contacto); la inyección de SSO con una aguja
hipodérmica para infiltrar el tejido blando que rodea la raíz es otra alternativa para
descontaminar completamente el conducto. Este último se seca con papel dental y la
oclusión se realiza por condensación lateral con hidróxido de calcio y resina epoxi. El
tratamiento ambulatorio se compone de enjuague bucal con SSO durante 30 días, 3 veces
al día durante 2 minutos (15 ml que se cambian cada 30 segundos). Después de 30 días,
se recomienda enjuague bucal una vez al día por un tiempo indefinido. Ninguno de los
pacientes tratados con la terapia de SSO recibió antibióticos o analgésicos.
Manipulación dental con hipoclorito sódico al 2,5% (HS 2,5%)
Se realizó el procedimiento típico de terapia con hipoclorito sódico para el tratamiento
del conducto radicular (Walton y Torabinejad, 2002). Se prestó especial atención para
evitar la infiltración de la solución a la región periapical durante la manipulación. Todos
los pacientes de este grupo recibieron ampicilina (500 mg tres veces al día) o cefalexina
(500 mg dos veces al día) durante 7 días, así como medicación antiinflamatoria
(naproxeno 500 mg dos veces al día) según era necesario.
Resultados
Se completó un estudio en 238 pacientes con tratamiento de conducto radicular con HS
2,5% (129 pacientes) o SSO (109 pacientes). Las características demográficas fueron
similares en ambos grupos (Figuras 1 y 2). La media de edad fue de 42,5 años (rango 1768) y 40 años (rango 13-67) para los grupos de control y de SSO, respectivamente. La
relación varones:mujeres fue similar para los grupos de control y SSO (44:56 frente a
39:61, respectivamente).
Sólo 2 pacientes tuvieron una reacción local aguda después del tratamiento del conducto
radicular con SSO, por 16 pacientes en el grupo de HS 2,5%. Sin embargo, los resultados
son más significativos teniendo en cuenta el número total de dientes afectados en el grupo
de SSO (2) en comparación con los del grupo de HS 2,5% (23). Sólo se registraron
pérdidas dentales en el grupo de hipoclorito, por ninguna en el grupo de SSO. Esto podría
ser debido a que el re-tratamiento con SSO fue viable y exitoso. Por lo tanto, incluso en
los dos casos con reacciones agudas, fue posible preservar los dientes.
El dolor se resolvió en 24 horas en la mayoría de los casos. Los pacientes también
pudieron masticar en un plazo de 24 horas, cuando generalmente se tarda 72 horas con el
uso de otros antisépticos.
Diez pacientes de los 109 experimentaron una ligera sensación de ardor en la lengua al
realizar enjuagues con SSO. En estos casos, la sensación de ardor se produjo sólo en los
dos primeros días de aplicación y sólo fue necesario indicar a los pacientes que
escupieran la solución de enjuague sin más. El ardor se disipó sin ningún otro efecto
secundario. No se observó ninguna contraindicación para el uso de SSO.
Figura 1.- Irrigación con SSO en el tratamiento del conducto radicular
Pacientes
Varones
Mujeres
Número de tratamientos
Ptes. con 1 tratamiento
Ptes. con 2 tratamientos
Dientes con reacción aguda
Ptes. con reacción aguda
Figura 2.- Irrigación con hipoclorito sódico
2,5% en el tratamiento del conducto radicular
Pacientes
Varones
Mujeres
Número de tratamientos
Ptes. con 1 tratamiento
Dientes con reacción aguda
Ptes con reacción aguda
Discusión
La infección debida a un canal que no está totalmente limpio o lleno es una complicación
que puede ocurrir en un 10 a un 30% de los casos sometidos a tratamiento del conducto
radicular. Esto puede ser debido a la complejidad del sistema de conductos rediculares,
por ejemplo algunos canales pueden ser muy estrechos o curvos. La infección también
puede ser debida a un canal que no está en absoluto limpio o lleno, si los rayos X no
mostraban todos los canales de un diente. Además, ciertas bacterias pueden no responder
al tratamiento del conducto radicular, por lo que el tratamiento puede fallar (Walton &
Torabinejad, 2002). Dado que la SSO ejerce una actividad antimicrobiana amplia sin
sensibilizar o irritar la piel y las mucosas (Gutiérrez AA, 2006), se supuso que podría ser
útil para la prevención de las reacciones agudas tras el tratamiento del conducto radicular.
El control de infecciones en el conducto radicular se ha basado tradicionalmente en la
irrigación con hipoclorito o clorhexidina. En ambos casos, la aplicación se ve limitada
por los efectos secundarios limitantes. La solución de hipoclorito sódico al 2,5%, por
ejemplo, es muy irritante para el conducto radicular y no puede entrar en contacto con el
tejido blando circundante debido al potencial de necrosis. La irrigación con SSO, en
cambio, tiene la ventaja de no ser irritante o sensibilizante para la piel y las mucosas. Por
ejemplo, la SSO se ha utilizado de forma segura en el tratamiento de heridas diversas (por
ejemplo, estasis venosa, quemaduras, úlceras de pie diabético, etc), así como en la
cavidad peritoneal (Dalla Paola, 2005; Miranda, 2005; Barrera et.al., 2006). En
comparación con la clorhexidina, la SSO tiene mejor sabor, no mancha los dientes y se
puede utilizar por lo menos durante 30 días como enjuague bucal tras el procedimiento.
Los pacientes tratados en este estudio con SSO no recibieron medicación con
antibióticos, antiinflamatorios o analgésicos. Por el contrario todos los pacientes tratados
con de hipoclorito sódico recibieron antibióticos y se añadió un agente antiinflamatorio
en caso necesario. Pese a ello, el tratamiento con SSO fue superior para reducir la
incidencia de las reacciones agudas tras el tratamiento del conducto radicular en
comparación con la solución de hipoclorito sódico al 2,5%. Además, los pacientes con
fallo del tratamiento en el grupo de SSO pudieron ser exitosamente tratados de nuevo con
la solución. Por consiguiente, ninguno de los sujetos en el grupo de SSO perdió dientes. A
destacar que los procedimientos agresivos de irrigación e infiltración realizados con la
SSO no podrían haberse realizado con ningún otro antiséptico actualmente en uso debido
a la posible necrosis de los tejidos circundantes.
Lamentablemente, el grupo de control tratado con hipoclorito sódico era histórico. Será
pues necesario realizar un correcto estudio controlado prospectivo aleatorizado para
validar totalmente los resultados. Sin embargo, estos resultados apoyan la eficacia y falta
de toxicidad de SSO para la prevención de las reacciones agudas después del tratamiento
del conducto radicular.
Bibliografía
Barrera-Zavala A, Guillen-Rojas M, Escobedo Anzures J, Rendon J, Ayala O & Gutiérrez
AA. A pilot study on source control of peritonitis with a neutral pH super oxidized
solution. XV Congreso Nacional de Cirugía (AEC) Sevilla, España, 25-28 Oct, 2005.
Dalla Paola, E. Brocco, A. Senesi, S.Ninkovic, M. Merico, D.DeVido. Use of
dermacyn™, a new antiseptic agent, for the local treatment of diabetic foot ulcers.
DGFW European Wound Healing Meeting. 2005. Stuttgart. 15-17 Sept, 2005.
Flores-Martinez MA. Periodontic Applications of Microcyn. 2006. Presentado para
publicación.
Gutiérrez AA. The Science Behind Stable, Super-Oxidized Water. Exploring the various
applications of super-oxidized solutions. Wounds. 2006, Jan. Suppl. 7-10.
Horiba N, Hiratsuka K, Onoe T, Yoshida T, Suzuki K, Matsumoto T, Nakamura H.
Bactericidal effect of electrolyzed neutral water on bacteria isolated from infected root
canals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999, 87:83-87
Landa-Solis, González-Espinosa D, Guzman B, Snyder M, Reyes-Terán G, Torres K and
Gutiérrez AA. MicrocynTM a novel super-oxidized water with neutral pH and
disinfectant activity. J Hosp Infect 2005, 61: 291-299
Miranda A. Reducing Bacterial Infectious Complications from Burn Wounds. A look at
the use of Oculus Microcyn60 to treat wounds in Mexico. Wounds. 2006, Jan. Suppl. 1719.
Nakagawa H, Hiraguchi H, Uchida H, Tanabe N. Effect of rinsing hydrocolloid
impressions using acidic electrolyzed water on surface roughness and surface hardness of
stone models. J Oral Sci 2002, 44:141-146.
Walton R, Torabinejad M (Eds). Principles and Practice of Endodontics, 3rd Edition.
Elsevier. 2002. pp 331-344.
ART 01
Dalla Paola
IT
Gutierrez
USA
Miranda
Mx
Super-Oxidized Solution (SOS) Therapy for Infected Wounds
Diabetic Foot Ulcers
(IWJ)
The Science behind stable, Super-Oxidized water,
Exploring the various applications of SOW
Reducing Bacterial Infectious Complications from
Burn Wounds
Wounds
(IWJ)
Wounds
(IWJ)
2006
x
x DFU
PI = Providone Iodine
PVD = Peripheral Vacular Disease
SH = Sodium Hypochlorite
PU - Pressure Ulcers
HP = Hydrogen Peroxide
n.a.
x
x
2006
x
x
x Burns
"Silver",
Saline
2006
x DFU
TWC = Traditional Wound Care
x
x
P.I.
x DFU, LU, PU, Burns
64
50%
reduction
8
x DFU, burns, other
n.a.
x
ART 03
Bongiovanni USA
Nonsurgical Management of Chronic Wounds in
Patients with Diabetes
JVU
2006
x
x
x DFU, LU, PU, Burns
n.a.
x
ART 04
Dalla Paola
IT
Super-Oxidized Solution (SOS) Therapy for Infected
IWJ, AAWC
Diabetic Foot Ulcers
2006
x
x
x DFU
P.I.
x
ART 05
Dalla Paola
IT
Treatment of Diabetic Foot Ulcer: An Overview
Strategies for Clinical Approach
2006
x
x DFU
IT
Clinical Outcome of Wide Postsurgical lesions in the
Infected Diabetic Foot Managed with 2 different local
LEW
treatment regimes compared using Quasi
Experimental Study Design: A preliminary comm.
2007
NL
A Cytotoxic analysis of antiseptic medication on skin
BJOD
substitutes and autograft
2007
JHI
2005
x
x
IWJ
2007
x
x
2007
x
x
JCPSP
2007
x
x
IWJ
2007
x
x
ART 07
Le Duc
ART 08
Landa-Solis Mx
Microcyn: a novel super-oxidized water with neutral
pH and disinfectant activity
ART 09
Martinezde Jezus
Mx
Efficacy and Safety of Neutral pH superoxidized
solution in severe diabetic foot infections
ART 10
Medina,
Gonzalez
Mx
Super-oxidized solution inhibits IgE-antigen-induced
IntImp
degranulation and cytokine release in mast cells
ART 11
Hadi
ART 12
Gonzalez
Treating infected Diabetic Wounds with
India Superoxidized water as anti-septic agent: a
preliminary experience
Effects of pH-neutral, super-oxidized solution on
Mx
human dermal fibrobvlasts in vitro
Comparative Efficacy and Tolerability of Oxum
India against Providone Iodine Application in the Postcaesarean Section Wound Management
ART 13
Anand
ART 14
Chittoria
India
ART 15
Dhusia
Comparative Efficacy and Tolerability of Microcyn
India Superoxidized Solution (Oxum) against Providone
Iodine Application in Orodental Infections
ART 16
Zhang
China
Indian
Medical
gazette
The role of Super-Oxidized Solution in the
Nepal Med.
management of Diabetic Foot Ulcer: Our Experience Coll. J.
The clinical efficacy of Dermacyn on deep partial
thickness burn wounds
2007
x
x
2007
Indian
Medical
gazette
2008
Report
2008
x
x
x
x
x
x
x
x
Reduction of
Odor
Skin Irritation
Limb Salvage
x
decrease
108
MCN 43
P.I. 55
15
MCN 145
MCN 95%
PI 212
PI 34%
(P<0.003
(minor amp).
)
n.a.
x
x
MCN 0
PI 18
x
MCN 0
PI 1
x
n.a.
P.I.
x
Allergy
Sodium
hypochl
x
Diabetic
Wounds
Saline
x
Fibroblast
16
x
x
x
25
x DFU
n.a.
x
20
x Dental
P.I.
x
20
x Burns
Silver
x
20
Improve Wound Bed Vascularity via increased capillary
perfusion and accelerationof the development of
neovascularity
MCN62%
Sal.20%
(7days)
Positive Wound dehiscence MCN 14 and PI 21
patients.
x
x
P.I.
8 different cases where Super Oxidized Solution
actually resolved the problems
(also prevention of amputation)
x
x
x
x
n.a.
Medium
HP
Better cosmetic results and less chelation
Article about general DFU wound care progressions
where MCN has its standard place.
n.a.
Postx Caesarean
Wounds
x
Method: Daily dressing changes.
Healed at 6 months: MCN 87.5% and PI 51.4%
(P<0.008).
Reinfection : with MCN 4 and PI 9 patients.
x
50
x
n.a.
x
50
Microbial kill of MCN against gram positive and gram
negative bacteria, virusses and fungi.
x
PVD,
DFU,
MRSA
x
21
x
DFU, LU,
PU, Burns
x
18
x
Ps,
MRSA,
DFU,
burns
MCN 100%
decrease
110
x
Additional Features
Positive Wound dehiscence MCN 14 and PI 21
patients.
Burns
several
x DFU
x
x
x
PVD,
DFU,
MRSA
x
Efficacy
x
x
MCN 0
PI 18
CLI, CVI,
trauma,
surgery
P.I.
x Toxicity
x
x
DFU
Hospitalization
64
x
x
Control
x
x
x
x
Product
MCN 43
P.I. 55
2006
x
decrease MCN 100%
108
DMCT
x
Positive Features
110
Superoxidized Water Improves Wound Care
Outcomes in Diabetic Patients
Goretti,
Piagessi
# subjects
40
x
Bongiovanni USA
ART 06
Industrial
x
ART 02
CDR
Animal Care
Usefull for:
Human Care
In Vivo
Subject
Focus
Poster
In Vitro
Abstract
Article
x
CVI = Chronic Venous Insufficiency
LU = Leg Ulcers
Decease of antibiotics
2006
BKA = Below Knee Amputations
Simple
Wounds
(IWJ)
Ps = Pseudomonas infection
MCN = Microcyn Technology Platform
Accepted by
patients
Super-Oxidized Dermacyn in Lower-Extremity
Wounds
Year
MRSA = Methicillin resistant S.Aureas
Safe
(non-toxic)
USA
Source
DFU = Diabetic Foot Ulcer
CLI = Critical Limb Ischemia
For variety of
wounds
Allie, D
Title
Case study
Author
Study report
Doc#
Definition:
Control Product
LITERATURE: Studies, Articles and Posters
B-C Ulcers
- Bactericidal (incl. B.Atrophaeus) & Fungicidal active
- Inactivates HIV-1 completely (virucidal claim with
EPA)
- Reduces Viral Load completely after 10min.
MCN after 2 days 100% odor reduction (PI: 25%).
MCN 90% improved outcome (vs. 62% of control)
MCN 81% Cellulitis reduction (vs. 44% of control)
x
n.a.
MCN is a mast-cell stabilizer! MCN inhibits 90% of the
histamine release induced by allergens or Calcium
ionophores. And also the late secretion of pro
inflammatory molecules.
MCN is anti-allergic and anti-inflammatory!
yes
An economical alternative to the other available
antiseptic agents
n.a.
x
MCN does not induce cell death, accelerated
senescence, DNA oxidation nor RNA degradation.
n.a.
x
Safe and effective and faster healing time.
n.a.
x
21
n.a.
x
20
n.a.
x
25
no
x
x
x
x
MCN debrides necrotic tissue, reduces microbial load,
promotes granulation and decreases the healing time,
without damaging the normal tissue or complications.
Evident that MCN results in a significant greater
reduction of pain after 3 and 7 days. Also all other
symptoms show the same trend.
10% faster healing time due to control of infection,
abating inflammation, improving topical circulation,
promoting the movement of proliferation of
fibroblastic cells.
ART 17
Dharap
India
Efficacy and Safety of Oxum in Treatment of the
Venous Ulcer
ART 18
Piagessi
IT
A Randomized Controlled Trial to examine the
efficacy and safety of a new Super-Oxidized Solution
IJLEW
for the management of wide Postsurgical lesions of
the Diabetic Foot
JIMA
Super-Oxidized Solution (Dermacyn Wound Care)
as Adjuvant Treatment in the
Postoperative Management of Complicated Diabetic IJLEW
Foot Osteomyelitis
x
x
x
2010
x
x
x DFU
ART 19
AragónSánchez
ES
PST 01
Allie, D
USA
Dermacyn: A novel superoxidized water facilitates
wound healing. Early experience in lower extremity
wounds and limb salvage
SAWC
2006
x
PST 02
Dalla Paola
IT
Use of Dermacyn, a new antiseptic agent, for the
local treatment of Diabetic Foot Ulcers
EWMA
2005
x
PST 03
Gonzalez
Mx
PST 04
Goretti,
Piagessi
IT
Effects of pH-neutral, super-oxidized solution on
IWJ
human dermal fibrobvlasts in vitro
Clinical Outcome of Wide Postsurgical lesions in the
Infected Diabetic Foot Managed with 2 different local
LEW
treatment regimes compared using Quasi
Experimental Study Design: A preliminary comm.
PST 06
Monaghan
UK
Dermacyn as the Local Treatment for infected
Diabetic Foot Wounds a case series
PST 07
Peterson
USA
PST 08
ISDF
Venous
Ulcers
2008
2013
2007
2007
x
x
x
x
x
52
52
x
x DFU
P.I.
x
110
110
HP
x
x
Fibroblast
x
DFU
x DFU
Dermacyn Effective in Treatment of chronic Wounds
with extensive Bioburden while reducing Local Pain SAWC
Levels
2007
x
x
x
x Recalcitrant wounds
Ramaswami USA
The role of Super-Oxidized Solution in Wound
Treatment
SAWC
2007
x
x
x
PST 09
Ricci
IT
Clinical Results about an antimicrobial solution in the
EWMA
treatment of infected chronic wounds
2007
x
x
PST 11
Suri
India
Role of Neutral pH Superoxidized Water in the
healing of Diabetic Foot Ulcers
2007
PST 13
Uribe
Mx
Effect of a Neutral pH Super-Oxidized Solution in the ETRS &
Healing of Diabetic Foot Ulcers
ICAAC
Methicilin-resistent Staphylococcus aureus - problem
EWMA
in health care
Super-Oxidized water for mesh hernioplasty in
AHS
glossy contaminated fields. An experimental study.
PST 14
Veverkova
CZ
MartinezMunive
Mx
PST 16
Thatcher
USA
The anti-viral Efficacy of a New Super-Oxidized
Solution
PST 17
Thatcher
PST 18
20
TWC
x
PST 15
20
x DFU
x
x
x
x
x
2007
P.I.
no
x
2007
DFU symp.
30
P.I.
x
x
x
x Diabetic Foot Osteomyelitis
x
x
n.a.
P.I.
14
MCN 31 MCN 98.0%
MCN 0%
TWC 64 TWC 92.3% TWC 13.4%
x
x
18
15
x
n.a.
x
n.a.
x
CLI, DFU,
CVI
x
MCN 0
PI 1
n.a.
x
n.a.
x
15
several
x
5
5
n.a.
x Chronic Wounds
several
x
3
3
n.a.
x
x Chronic Wounds
P.I.
x
20
20
x
x
x DFU
Saline
x
50
50
x
x
x DFU
Saline
x
40
40
x
2005
x
ICAAC
2007
x
x
USA
The anti-bacterial Efficacy of a New Super-Oxidized
ICAAC
Solution
2007
x
Thatcher
USA
Activity of a pH Neutral Super-Oxidized Solution
against Bacteria Selected for Sodium Hypochlorite
Resistance.
ICAAC
2007
x
PST 19
SanchezMiranda
Mx
Anti-inflammatory effects of an oxychlorine
compound in a murine model of passive cutaneous
anaphylaxis
WUWHS
2008
PST 20
Regulski
USA
Efficacy and compatibility of combination Therapy
with Super-Oxidized Solution and a Skin Substitute
for Lower Extremity Wounds
SAWC
2008
ABS 01
MirandaAltamirano
Mx
Treatment of 2nd and 3rd Degree Burns in 48
Pediatric Patients without Routine Antibiotics using
New "Super-Oxidized water Technology" Microcyn
TSS
submission
2005
x
x
x
x
MRSA
x other
x
x
x
Virusses
Saline
x
x
x
Bacteria
n.a.
x
x
Resistant
Bacteria
40%
bleach
x
x
MCN reduces in Ulcer Size, bacterial burden and the
clinical signs of soft tissue infection
Wounds failed to heal despite of aggressive local
wound care, soon after initiating MCN the wounds
closed. Also significant reduction of pain!
x
Wound treatments were unsuccesssful, and with MCN
1 wound healed after 1 month and 2 wounds after 3
months
White blood cells decreased more significantly (45% vs.
20%). Very good results in reduction of clinical signs
and pain relief. Odor with MCN gone after 2 days
(control after 9 days)
x
Economic requirements for the treatment of MRSA are
evident
MCN log reduction far more better then Saline and
much less abscess formation
The load of enveloped and non-enveloped virusses
exposed to MCN for 1 minute was reduced by a log10
factor > 5. Complete inactivation was seen after 5 min.
n.a.
n.a.
x
48
48
n.a.
x
x
46
x
x
x
10
x
Reduction in cellulites, decrease of Bioburden, and
growth of good granulation tissue at the base of the
ulcers. Early closure of the wounds (78% vs. 40%) and
less other wound care procedures.
Epithelization period 33% shorter with MCN (induced by
0.5-0.7mm per day). Total closure with MCN=35 days
and with Saline 60 days. Wound healing effect not only
antimicrobial activity!
n.a.
12
Fourteen consecutive patients who underwent
conservative surgery for DFO, were treated
in the postoperative period with DWC. No side effects,
no allergies nor skin dermatitis were found. Limb
salvage was successfully achieved in 100% of the
cases. Healing was achieved in a median period of 6.8
weeks.
At surgical timw 75% of Ulcers in MCN group had
negative Micro soecimen vs. 48% of Ulcers in PI group
(P < 0.005)
MCN does not induce cell death, accelerated
senescence, DNA oxidation nor RNA degradation.
Method: Daily dressing changes.
Healed at 6 months: MCN 87.5% and PI 51.4%
(P<0.008).
Plantar
Foot
Ulcers
MCN 35 10% BKA vs.
Sal. 60 25% in contr.
Method: Daily installation.
Healed at 6 months: MCN 90% and PI 55%
Does not oxidize fibroblast.
Does not cause skin complications.
Infected
CW
12
n.a.
A spectrum of 46 bacterial species exposed to MCN for
at least 30 seconds were reduced by a log10 factor >
4.5. This was the limit of detection.
10
n.a.
After 2 minutes all isolated bacteria had a reduction with
MCN of a log10 factor > 5.
6
6
n.a.
Can potentially be used to ameliorate the inflammatory
process induced by IgE-antigen-induced mast cell
degranulation or chemical irritation of the skin in atopic
eczema.
9
n.a.
MCN might induce faster epithelialization than Saline.
x
x Mast Cells
Saline
x
x
x
Lower extr.
Wounds
Saline
x
9
n.a.
x
48
x Burns
40%
reduction
27
Saline
x
Diabetic
Foot
Infections
x
2005
Activity against micro-organisms, including MRSA and
VREF. MCN has an anti-allergic roleby inhibiting Ig-E
antigen induced granulation and cytokine release by
acting as a mast cell stabiliser. MCN promotes
tissue regenaration.
x
stage II/III
B-C-D
Ulcers
MCN 0
PI 15
MCN 145
MCN 95%
PI 212
PI 34%
(P<0.003
(minor amp).
)
n.a.
MCN 6W
Sal. 7W
50%
no
n.a.
x
x
No antibiotics, either systematic or topical were used.
No infections were encountered. Third degree burns of
10cm in diameter healed completely without skin grafts.
Better cosmetic results and less chelation. Hospital
days reduced from 20 to 10 days
(cost saving = $19.000 per day)
RPT 01
Martinezde Jesus
Mx
A Prospective, Randomized, Single-Blind, Clinical
Investigation of a Neutral pH Superoxidized Water in Report
Patients with Infected Diabetic Foot Ulcers
2004
RPT 02
Flores
Mx
Periodontic Applications of Microcyn
Draft report
2005
RPT 03
Flores
Mx
Super-Oxidized Solution (SOS) irrigation in Root
Canal Treatment
Report
2005
RPT 04
Landsman
USA
An Open-Three Arm, Pilot Study Of The Safety And
Clinical Efficacy Of Topical Dermacyn Wound Care
DFCon
Versus Oral Levofloxacin Versus Combined Therapy
For Mild Diabetic Foot Inf.
2008
x DFU
P.I &
Saline
x
24
x Dental
Chlorhexidin
e
x
14
x
x Dental
SH
x
109
129
n.a.
x
x DF
Levofloxacin
x
20
20
n.a.
x
x
x
21
x
no
n.a.
x
n.a.
x
100% MCN patients had reduction of Fetid Odor (c:
25%).
MCN reduced cellulitis with 81% vs. 44% of c.
90% improvement of wound with MCN vs. 62% with c.
94% of MCN groupd had improved tissue and skin
around wound instead of 31% with control.
x
x
Resolution of the Gingivitus was only two to four weeks.
Bleeding upon brushing resolved with 24 hours till 4
days.
Within 2 weeks bone regenaration was observed.
MCN works for Gingivitus and Periodontitus
Acute local reaction after toot canal treatment occurred
less with MCN (2 vs. 16 patients).
Affected teeth with MCN only 2 while with control 23.
Patients could chew within 24h (instead of 72h).
x
Clinical success; MCN: 93.3% ; Levo/Saline: 56.3% ;
Levo/MCN: 83%.
No serious adverse events reported

dossier microdacyn

Transcription

Similar documents

Mast cells

FALL 2006 149 II Festival Internacional de Artes

2 ARRESTADOS POR LA 2 ARRESTADOS POR

Nivel 2 - Aspectos Culturales

Nivel 3

Descargar PDF - Newton College

MI Monthly Formation

HOY_Feb 2013_Jean.pub

S aureus: eradicated in - Asociacion Medica de Puerto Rico

EN ENSENADA SE VIVE BIEN

Tesis Falcó Gracia - Universidad Miguel Hernández

the empire - Games Workshop