European Journal of Cardio-thoracic Surgery 11 (1997) 399 – 405

Penetrating cardiothoracic war wounds

Bojan Bioc' inaa,*, Z& eljko Sutlića, Ino Husedz' inovića, Igor Rudez' a, Ranko Ugljena,
Dalibor Leticaa, Zoran Slobodnjakb, Jerolim Karadz' a b, Vojtjeh Bridac,
Tomislav Vladović-Reljab, Ivan Jelića

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a
Department of Cardiac Surgery, Clinic of Surgery, Clinical Hospital Centre ‘Dubra6a’, 10 000 Zagreb, Croatia
b
Department of Thoracic Surgery, Clinical Hospital for Thoracic Diseases, Uni6ersity of Zagreb, Zagreb, Croatia
c
Clinic for Cardio6ascular Diseases, Clinical Hospital Centre, Clinic for Cardio6ascular Diseases, Uni6ersity of Zagreb, Zagreb, Croatia

Received 26 September 1994; revised 25 September 1996; accepted 23 October 1996

Abstract

Objecti6e: Penetrating cardiothoracic war wounds are very common among war casualties. Those injuries require prompt and
specific treatment in an aim to decrease mortality and late morbidity. There are a few controversies about the best modality of
treatment for such injuries, and there are not many large series of such patients in recent literature. Methods: We analysed a group
of 259 patients with penetrating cardiothoracic war wounds admitted to our institutions between May 1991 and October 1992.
Results: There were 235 (90.7%) patients with thoracic wounds, 14 (5.4%) patients with cardiac wounds and in 10 (3.7%) patients
both heart and lungs were injured. The cause of injury was shrapnel in 174 patients (67%), bullets in 25 patients (9.7%), cluster
bomb particles in 45 patients (17.3%) and other (blast etc.) in 15 patients (6%). Patients, 69, had concomitant injuries of various
organs. The initial treatment in 164 operated patients was chest drainage in 76 (46.3%) patients, thoracotomy and suture of the
lung in 71 (43.2%) patients, lobectomy in 12 (7.3%) patients and pneumonectomy in 5 (3%) patients. Complications include pleural
empyema and/or lung abscess in 20 patients (8.4%), incomplete reexpansion of the lung in 10 patients (4.2%), osteomyelitis of the
rib in 5 patients (2.1%) and bronchopleural fistula in 1 patient (0.4%). Secondary procedures were decortication in 12 patients, rib
resection in 5 patients, lobectomy in 2 patients, pneumonectomy in 4 patients, reconstruction of the chest wall in 2 patients and
closure of the bronchopleural fistula in 1 patient. The cardiac chamber involved was right ventricle in 12 patients, left ventricular
in 6 patients, right atrium in 7 patients, left atrium in 3 patients, ascending aorta in 2 patients and in 1 patient which involved
descending aorta, right ventricle and coronary artery (left anterior descending) and inferior vena cava, respectively. The primary
procedure was suture in 17 patients (in 10 patients with the additional suture of the lung), suture + extraction of the foreign body
in 4 patients, 2 of them with cardiopulmonary bypass. Complications were pericardial effusion in 6 patients, arrhythmia in 2
patients, myocardial infraction in 1 patient and migration of the foreign body in 1 patient. Patients, 7, died, five of the group with
concomitant injuries, two of thoracic and one of cardiac injuries (5, 1.2 and 4.2%, respectively). Conclusions: Penetrating
cardiothoracic wounds are among the most serious injuries in war, either in combat or among civilians. In spite of their nature,
they can be treated successfully with relatively low mortality and morbidity. © 1997 Elsevier Science B.V.

Keywords: War; Thoracic injury; Cardiac injury; Wound

1. Introduction of war injuries with significant early and late mor-

Penetrating wounds to the chest are common
amongst combat casualties and represent a subgroup
* Corresponding author. Tel.: + 385 1 2987444, ext. 2515; fax:
+385 1 263695.
bidity and mortality [1]. In various reports from
World War II to the most recent conflicts their
incidence varies from 6 to 8% [12] of all war injuries.
In this paper we present a group of patients with
penetrating injuries to the chest during the war in
Croatia.

1010-7940/97/$17.00 © 1997 Elsevier Science B.V. All rights reserved.

PII S 1 0 1 0 - 7 9 4 0 ( 9 6 ) 0 1 1 2 4 - 4
400 B. Bioc' ina et al. / European Journal of Cardio-thoracic Surgery 11 (1997) 399–405

2. Materials and methods Table 1

Site of Injury
In this paper we analyze patients with cardiothoracic Site of injury Number of patients %
war injuries admitted to Croation medical institutions
from May 1991 to October 1992 according to their age, Thoracic wounds
sex, type of injury (cardiac, thoracic, cardiothoracic Right lung 101 43
with/without concomitant injuries), as well as to their Left lung 90 38
Both lungs 44 19
symptoms on admission, place of the primary surgical Right ventricle (RV) 12 50
treatment, evacuation time from the site of injury to the Left ventricle (LV) 6 25
place of primary surgical treatment, symptoms on ad- Right atrium (RA) 7 29
mission and type of missile. Main organ/part of the Cardiac/cardiothoracic wounds
organ involved, type of primary and secondary surgical Left atrium (LA) 3 12.5
Ascending aorta 2 8.4
treatment and type of primary and secondary complica- Descending aorta 1 4.2
tions have also been analyzed. In this paper we also RV+LAD 1 4.2
show incidence of complications associated with vari- Inferior vena cava (IVC) 1 4.2

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ous treatment modalities and mortality rate in different
type of injuries.
From May 1991 to October 1992, 259 patients were
admitted to our institutions with penetrating chest
wounds. There were 223 (86%) males and 36 (14%)
females. The average age of patients was 32 years 4
months (range from 9 to 57 years, S.D. 4.4 years).
Patients, 57 (22%), came to our hospital directly from
the front-line without previous surgical treatment in the
hospital. Patients, 128 (49.5%) had previously been
operated on in other hospitals and then evacuated,
while 74 patients required medical treatment only, ei-
ther in our hospital or elsewhere. Patients were treated
either medically or they were selected for primary surgi-
cal treatment. In our institutions selection criteria for
medical treatment only were haemodynamic stability,
small (less than 10 mm in diameter) shrapnel and
absence of significant pleural effusion or pneumotho-
rax. Patients who were selected to surgical treatment in
our institution received closed chest drainage (CCD) as
a primary treatment and underwent thoracotomy if
either drainage exceeded 300 ml/h or total drainage was
bigger than 1000 ml. Patients who underwent immedi-
ate thoracotomy were those in haemorrhagic shock or
patients where cardiac or oesophageal injury was sus-
pected. However, selection criteria for either form of
treatment in field hospitals was much less clear and
probably varied very much according to local condi-
tions.
Postoperative care included closed suction drainage
in all surgical patients, drains were removed after chest
X-ray (CXR) confirmed full expansion of the lung after
drains being clamped for at least 12 h. Complications
were treated in the usual manner; patients with atelecta-
sis were treated with repeated chest drainage, occasion-
ally chest drains were put under fluoroscopic control.
Patients with chronic empyema were treated either by
empyema tube or underwent decortication procedure.
Rib osteomyelitis indicated rib resection, while chronic
atelectasis with infection led to lung resection in some
patients.
3. Results
The evacuation period from the tune of injury to the
surgical treatment could be identified with accuracy in
92 patients (35.5%), and it varied from 20 min to more
than 12 h (median 3 h). There were 235 patients with an
isolated injury of the lung, 191 (81%) of them with a
single lung injuries, 90 (38%) patients with a left lung
injury and 101 patients (43%) with a right lung injury.
Patients, 44 (19%), had both lungs injured.
Patients, 14, were admitted with penetrating wounds
to the heart and in 10 patient’s both heart and lungs
were injured, which was 5.4% and 3.7% of all patients,
respectively. The site of heart injury was the right
ventricle in 12 (50%) patients, left ventricle in 6 (25%)
patients, right atrium in 7 (29%) patients, left atrium in
3 (12.5%) patients, ascending aorta in 2 (8.4%) patients,
descending aorta in 1 (4.2%) patient, the right ventricle
and left anterior descending coronary artery (LAD) in 1
(4.2%) patient and inferior vena cava in 1 (4.2%) pa-
tient (Table 1).
The cause of injury was shrapnel in 174 patients
(67%), bullets in 25 patients (9.7%), cluster bomb parti-
cles in 45 patients (17.35) and other (blast, gravel, stab
wounds in close combat etc.) in 15 patients (6%) (Table
2).
Symptoms and signs on admission could be identified
for all patients. Among the patients with thoracic
wounds, 98 (41.7%) of them had proven haematotho-
Table 2
Cause of injury
Number of patients %
Shrapnel 174 67
Bullet 25 9.7
Cluster bomb particles 45 17.3
Other (blast, grave, stab, wound) 15 6
 B. Bioc' ina et al. / European Journal of Cardio-thoracic Surgery 11 (1997) 399–405 401

Table 3 Table 5
Symptoms and signs Treatment

Symptoms Number of patients % Procedure Number of pa- %

tients
Thoracic wounds
Haemathothorax 98 41.7 Thoracic wounds
Haemothopneumo thorax 32 13.6 Chest drainage 76 46.3
Pneumothorax 31 13.1 Thoractomy/lung repair 71 43.2
Flail chest 11 4.6 Lobectomy 12 7.3
Haemorrhagic shock 60 25.5 Pneumonectomy 5 3
Cardiac/cardiothoracic wound Cardiac/cardiothoracic wounds
Cardiac arrest 5 20.8 Suture 17 71
Beck’s triad 10 42.6 Suture+extraction of the foreign 4 16
CXR/enlarged cardiac shadow 14 58 body
CXR/metal particle 12 50 Non-surgical treatment 3 12
Restlesness 16 67
Haemathothorax 4 16

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rax, diagnosed either by CXR or on subsequent thora-
cotomy.
Haematopneumothorax was present in 32 (13.6%)
patients and isolated pneumothorax in 31 (13.1%).
Eleven (4.6%) patients were admitted with the flail
chest. Sixty (25.5%) patients were in haemorrhagic
shock on admission (Table 3). Many patients had con-
comitant injuries of various degrees and we counted
only such injuries that required major surgical proce-
dure under the same or another general aesthesia.
There were 69 (37.2%) such patients. Among them 12
(6.4%) suffered injuries to the head, neck or central
nervous system (CNS), 39 (21.1%) wounds to the limbs
with bone and/or blood vessel involvement, 31 (16.7%)
patients had penetrating abdominal wounds and 16
(8.6%) had other injuries (burns etc.). In 2 (1.1%)
patients there was an injury of the oesophagus and in 5
patients (2.7%) the diaphragm was injured (Table 4).
All oesophageal and injuries were diagnosed intraoper-
atively. Surprisingly, none of the patients was admitted
with a cardiac arrest.
Among the patients with cardiac/cardiothoracic
wounds five of them (20.8%) had a recorded cardiac
arrest at the time of admission, requiring either cardiac
massage or emergency room thoracotomy. Beck’s triad
was evident in 10 (42.6%) patients suggesting pericar-
dial tamponade. On a plain CXR film there was en-
Table 4
Concominant injuries
Site of injury Number of patients
Thoracic+cardiac injuries N= 185
Head, neck, CNS 12
Limbs 9vascular 39
Abdominal 31
Other (burns, eye, ear) 16
Oesophagus 2 1.1
Diaphragm 5 2.7
larged cardiac shadow in 14 (58%) patients with a
visible metal particle in 12 (50%) patients. Restlessness
was present in 16 (67%) patients, and four (16%) pa-
tients had haematothorax (three left, one right, Table
3). The most common surgical procedure was CCD. It
was performed as an initial procedure in 76 (46.3%)
patients with a pure thoracic injury and in one patient
with a cardiac wound.
The operative approach was standard posterolateral
thoracotomy (unilateral or bilateral) in 70 cases, ante-
rior thoracotomy in 29 cases (10 pure thoracic injuries
and 19 for cardiac/cardiothoracic injuries) and median
sternotomy in 10 cases (2 cardiac injuries and 8 bilat-
eral lung injuries). As a method of operative treatment
thoracotomy with lung repair or minor resection pre-
vailed; it was done in 71 (43.2%) patients. In a few
patients lung resection was employed; lobectomy was
performed in 12 (7.3%) patients and pneumonectomy in
5 (3%) of them. (Table 5) Among patients with pene-
trating cardiac or cardiothoracic wounds the simple
suture was a procedure of choice in 17 (71%) patients.
Suture and extraction of the foreign body was done
in four (16%) cases, twice with the aid of cardiopul-
monary bypass (CPB). Three patients (12%) received
minor surgical CCD or medical treatment only (Table
5). In 16 out of 24 patients (66.6%) a retained metal
particle could be identified within the chest 13 (54%)
within the heart or the pericardium and in three
(12.5%) in a contralateral lung from the site of injury,
suggesting pulmonary embolization. The diagnosis of a
retained shrapnel was done using fluoroscopy and CXR
in all cases and in all 14 cardiac cases the additional
%
ECHO was done which revealed the exact position of
the retained foreign body (Fig. 1).
6.4 Noticed complications in thoracic patients were
21.1 pleural empyema with/or lung abscess in 20 (8.4%)
16.7 patients, incomplete reexpansion of the lung in 10
8.6
(4.2%) patients, osteomyelitis of the rib in 5 (2.1%)
patients and bronchopleural fistula in 1 (0.4%) patient.
There was a trend towards higher incidence of late
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Fig. 1. Diagnosis of a retained shrapnel using fluoroscopy (a) and CXR (b).

complications in patients who received only CCD, al- patients with cardiac injury and late (more than 1
though it was not statistically significant (Tables 6 and month after injury) arrhythmias in 2 (8.4%) patients.
7). (Table 6) Both patients had retained shrapnel within
Late pericardial effusion was present in 6 (25%) the heart. In one patient rhythm disturbance was
 B. Bioc' ina et al. / European Journal of Cardio-thoracic Surgery 11 (1997) 399–405 403

Table 6 Table 8
Complications Secondary procedures

Complication Number of patients % Procedure Number

Thoracic wounds Decortication 12

Pleural empyema/lung abcess
Incomplete reexpansion
Osteomyelitis of the rib
Bronchopleural fistula
Pericardiac effusion
Cardiac/cardiothoracic wounds
Arrhytmias
MI
Migration of the foreign body
supraventricular and in 1 patient there were short
20 8.4
10 4.2
5 2.1
1 0.4
6 25
2 8.4
1 4.2
1 4.2
Lobectomy 2
Pneumonectomy 4
many controversies in primary surgical treatment of
such injuries. The used civilian practice in all penetrat-
ing thoracic injuries, including gunshot wounds (GSW)
is conservative, applying CCD as an initial procedure in
almost all cases, and subsequent thoracotomy in case of
complications [6,8]. Strict criteria for early thoracotomy
or resuscitating room thoracotomy are well described

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episodes of ventricular tachycardia (VT), all of them elsewhere [17,5,13]. Contrary to that opinion, a few
self-terminating. authors recommend thoracotomy and the repair of
Secondary procedures for complications included intrathoracic injuries as a method of choice, claiming
decortication and/or drainage of a lung abscess were good results [12]. The reasons for such an option would
done in 12 patients, reconstruction of the chest wall in be the higher skill level necessary for the management
2 patients, rib resection in 5 patients, lobectomy in 2 of CCD, and especially in lower incidence of a tension
patients, pneumonectomy in 4 patients and closure of pneumothorax in ventilated patients [17].
the bronchopleural fistula in 1 patient (Table 8). The Our group of patients is not homogeneous. Fewer
remaining 10 patients were treated either by empyema patients received primary surgical treatment in our
tube (6 patients) or they were transferred to other institutions, while a majority of others were evacuated
hospitals before finishing their treatment. either from field hospitals or from small district hospi-
Seven patients died, 5 out of 69 (7.2%) with concomi- tals where principles of treatment varied upon local
tant injuries, two and one with thoracic and cardiac conditions. Some patients received medical treatment
injury (1.2 and 4.2%, respectively, Table 9). only. The evacuation time was also significantly vari-
able and was apparently one of the important factors
that influenced final results.
Our results should be considered as ‘early results’
4. Discussion
(mean follow up is 16 months). Despite the fact that we
are dealing with heterogeneous group, some character-
Penetrating cardiothoracic war injuries (PCWI) are
istics of this group can be detected; a high shrap-
common injuries in almost all war combats in 20th
nel:bullet ratio as a cause of injury, high incidence of
century [1,10,7,17,15,3]. In all published series since
thoracotomy as a primary method of treatment and low
World War II their incidence is stable and they con-
incidence of lung reactions. Low incidence of postoper-
tribute to 6–8% of all combat wounds [12]. There are
ative complications with low hospital mortality are also
Table 7
shown. Each of these aspects needs to be discussed.
Secondary complications II High incidence of shrapnel wounds could probably be
attributed to two factors: the defensive character of
Yes No Total P most combats in suburban areas or in the countryside
kept the majority of soldiers entrenched. Lack of ar-
Atelectasis
CCD 7 71 76
mour protection significantly increased their exposure
Thoractomy 3 68 71 0.19 to airstrikes and artillery fire, but on the other hand it
Medical treatment 0 0 74
Empyema Table 9
CCD 11 65 76 Mortality
Thoractomy 5 66 71 0.18
Medical treatment 4 70 74 Number of Dead %
Osteomyelitis patients
CCD 1 75 76
Thoractomy 2 69 71 0.4 Isolated thoracic injuries 166 2 1.2
Medical treatment 2 72 74 Cardiac/cardiothoracic injuries 24 1 4.2
Thoracic+concomitant injuries 69 5 7.2
Thoractomy versus CCD.
404 B. Bioc' ina et al. / European Journal of Cardio-thoracic Surgery 11 (1997) 399–405
contributed to the lower incidence of burns than re-
ported elsewhere [15]. In a typical urban war series
[17] 43% of injuries are caused by bullets, while in
newer reports from the Middle East conflicts up to
14% of bullet injuries were reported, in spite of very
good armour protection [15].
In our series thoracotomy was used as a primary
method of surgical treatment in 88 (53.6%) patients,
much more frequently than in civilian reports [9,6] as
well as many war trauma reports [10,14]. The ratio of
thoracotomy to CCD in our report is close to the
results of those authors who recommend an aggressive
surgical approach and who claim better results using it
[17,13,5]. We believe that in a military setting thoraco-
tomy combined with early extubation has a number of
comparative advantages: it allows effective control of
air leaks, haemorrhage, complete removal of clots and
foreign material from the thoracic cavity and proper
placement of chest tubes. It also allows the early diag-
nosis of concomitant injuries of the heart, the di-
aphragm and the oesophagus. A trend, observed in
our series, towards higher incidence of complications
in patients treated only with CCD has been previously
reported [14,15], however, there are other authors who
report excellent results with the so called ‘conservative’
approach [6]. The majority of our patients injured by
cluster bomb particles received only medical treatment
(34 out of 45 patients, 75.5%). Most of the other
patients who received only medical treatment were
wounded by small shrapnel and occasionally (3 pa-
tients) by a bullet. The low incidence of postoperative
complications and low hospital mortality after pene-
trating war thoracic injuries has been previously re-
ported [17,15], even in poor medical conditions [14].
Although the low hospital mortality in our series is
probably biased by the long evacuation tune as has
been showed elsewhere [2], we think that adequate
control of haemorrhage, removal of all foreign mate-
rial from the pleural space and properly placed pleural
drainage with early extubation and ambulation are
factors that contributed to satisfactory results. On the
other hand, the number of patients treated by lung
resection is low. In some series with the ‘aggressive’
approach this percentage is as high as 21% [17]. Low
recession rate in our group could be explained (at least
for the patients operated on in our institutions) by our
attitude towards lung preservation, supported by our
and others [3] experiences and probably by the lack of
specalized thoracic surgeons in district hospitals. At-
tempts to preserve lung tissue correspond well to the
low number of secondary resections in our series, al-
though some patients had left our hospital before their
treatment was finished. The most frequent operative
approach was posterolateral thoracotomy, followed by
the anterior thoracotomy with an occasional transster-
nal extension. In a small group of patients median
sternotomy was successfully used for bilateral lung
repair, as shown elsewhere.
In the group of patients with cardiac wounds, a
small number of patients does not allow for reliable
conclusions. Cardiac arrest in 21% of patients and
apparent pericardial tamponade in 42% of patients
indicated emergency operation in most of them. In our
experience, left anterior thoracotomy with a possibility
of transsternal extension is a method of choice, as it
has been shown in many previous reports [11,4]. We
did not observe any difference in survival between
patients with cardiac arrest and those without it, but
it may be due to a long evacuation time and by the
fact that only survivors were evacuated from field
hospitals.
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Retained foreign bodies within the heart cause a
problem. Our series is among a larger series in medical
literature existing since 1945 [16]. An attempt to re-
move a foreign body on an elective basis was done
twice and was successful in both cases. In 1 patient
shrapnel migrated from the atriocaval junction to the
right ventricle and in another patient the metal parti-
cle was protruding from the left ventricular wall into
the ventricular cavity. In five of six cases, pericardial
effusion was successfully controlled by repeated peri-
cardial asperations, and in 1 patient a drain had to be
put into the pericardium. All rhythm disturbances (2
patients) were easily controlled medically. None of the
patients with pulmonary migration of the shrapnel
showed symptoms or abnormal findings apart of
CXR. Serial ECHO examination in 9 patients (follow
up 10–26 months, mean 16 months) showed no
changes in the foreign body position.
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Appendix A. Conference discussion
Dr Mc Guigan (Belfast, UK): It is refreshing to hear someone who
actually deals with trauma, teaching it. The authors are to be
congratulated on two scores. Firstly, the dedication and hard work
which led them as thoracic surgeons to manage devastating and
life-threatening injuries with excellent results. Secondly and equally
important, most wartime experience has been anecdotal but these
carefully recorded data allow the rest of the world to see how chest
injuries can be managed optimally by trained thoracic surgeons.
Unfortunately, in the USA and in much of Europe such injuries are
treated by surgeons who do not specialize in thoracic surgery.
I would like to ask what the thoracotomy rate for bullet injury was.
Secondly, I must say that I regard the pneumonectomy rate in your
series as rather high. In Belfast our thoracotomy rate was 82% which
is a reflection of senior thoracic surgeons dealing with chest wounds.
Our case load may have been different as we were within minutes of
most of the violence. Surgeons involved in war zones have relatively
high thoracotomy rates because;
(1) There are relatively higher proportions of high velocity penetrat-
ing wounds.
(2) Large numbers of cases mean that experience in intra-operative
technique is rapidly acquired.
(3) There is a focus on trauma within the unit and this has priority
in theatre.
(4) Senior thoracic surgeons are not distracted by the usual compet-
ing attractions in civilian life.
405
Zacharia had successful results from high thoracotomy rates in the
Lebanon, Fischer showed how the earlier conservative management
of the Vietnam war was replaced by more active treatment. From the
first world war famous surgeons in all three main armies began to
carry out thoracotomies to avoid an unacceptably high mortality. As
with previous generations it seems to take a war to remind us that
skilled surgeons with high thoracotomy rates get the best results in
major chest trauma.
Dr Bioc' ina: We thought that thoracotomy was the method of
choice, first, because of high incidence of death with improperly
placed chest drains and another thing was that we didn’t have enough
nursing staff to maintain drains patent. In that case we thought it was
better to open the patient to repair lungs properly, to control bleeding
point and to put two big and properly placed chest drains and that
reduced our incidence of tension pneumothorax dramatically.
Another thing we showed in our own series, there is still a trend,
but we got another set of data, at the moment we have more than 350
patients, which were not presented here, that patients with chest
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drainage only, they did considerably worse in terms of long-term
complications, residual empyema. In some way that is logical, be-
cause when you get a military wound or a shrapnel wound, shrapnel,
when it enters the chest, it usually pushes a piece of cloth or a piece
of gravel or a piece of soil, whatever, within the chest. If you drain
these patients only, there is a high probability of late infection. So
that was our rationale.
Another rationale about the cardiac wounds, some centres recom-
mended extraction of the foreign bodies and there is a cumulative
experience by Symbas referred in 1986 of 224 cases, but the overall
incidence of late complication like arrhythmias and embolization and
clot formation within the ventricle was quite low.
Dr Magdi Yacoub (London, England): Not wanting to belittle your
fantastic efforts, I think that the issue here is how to stop these
injuries rather than how to treat them and my question is, how are
the authors and perhaps how is the society going to contribute
towards that?
Dr Bioc' ina: Sorry?
Dr Piwnica (Paris, France): Dr Magdi said it was all right to treat
the lesions but it would be much better to stop the war, and what is
your solution and what is the association’s solution? I think we
should all pray.
Dr Bioc' ina: I think it is beyond my competence to stop the war.
Dr Piwnica: We agree with Dr Magdi and we are very sorry to see
such pictures, but if we really want to go beyond wishful thinking, if
anybody has any idea, we are ready to contribute to that.
Dr Biocina: Dr Magdi, I do appreciate your comment. Thank you
very much.