Safety and efficacy of pharmacomechanical thrombolysis for acute and subacute deep vein thrombosis patients with relative contraindications

To evaluate the safety and efficacy of pharmacomechanical thrombolysis (PMT) performed for patients with relative contraindications.From June 2014 to December 2016, 112 patients with acute or subacute proximal deep vein thrombosis (DVT) were enrolled in this study. 60 patients (including 27 acute DVT patients and 33 subacute DVT patients) were treated with catheter-directed thrombolysis (CDT), and 52 patients with relative contraindications (including 25 acute DVT patients and 27 subacute DVT patients) with PMT. Assessment of venous recanalization was conducted using venography the time Inferior vena cava filter is removed, and complications were used to compare safety and efficacy between the groups.The outcomes of acute DVT patients no matter which kind of therapy performed, CDT or PMT, were significant better than subacute DVT patients (PCDT = .04 and PPMT = .01). However, there was no significant difference between CDT acute group and PMT acute group or between CDT subacute group and PMT subacute group (Pacute = .80 and Psubacute = .84). For complications of all patients, there was no mortality and major bleeding occurred.PMT could be a safe and effective management for DVT patients with relative contraindications, and the acute DVT may achieve better outcomes when they receive CDT or PMT.

Early patellar dislocation can lead to tibial tubercle lateralization in rabbits

PURPOSE

To investigate the effects of early patellar dislocation on the tibial tubercle location.

METHODS

Sixty knees from 30 healthy 1-month-old New Zealand white rabbits were randomly divided into two groups of 30 knees each. Group A (control group) comprised the left knees, which underwent no surgical procedures. Group B comprised the right knees, which underwent patellar dislocation surgery. Computed tomography (flexion 0°) was performed preoperatively and 6 months post-operatively. Measurements included the tibial tuberosity-trochlear groove distance (TT-TG) and tibial tubercle lateralization.

RESULTS

No significant difference in the TT-TG or tibial tubercle lateralization was found between the two groups preoperatively. Six months post-operatively, however, the mean TT-TG in Group A (no patellar dislocation) and Group B (patellar dislocation) was 1.0 ± 0.4 and 3.0 ± 0.7 mm, respectively (p < 0.05). The mean tibial tubercle lateralization also showed a significant difference between Groups A and B at 6 months post-operatively (0.5 ± 0.1 and 0.6 ± 0.0, respectively; p < 0.05).

CONCLUSIONS

Early patellar dislocation can lead to tibial tubercle lateralization and an increased TT-TG. Clinically, early intervention for adolescent patients with patellar dislocation will be important.

LEVEL OF EVIDENCE

Prospective comparative study, Level II.

[Two-year clinical and radiological outcomes of minimally invasive surgery for severe adult degenerative scoliosis]

Objectives: To evaluate the efficacy of restoring the balance in the coronal and sagittal planes and to evaluate clinical outcomes in the treatment of severe adult degenerative scoliosis patients using staged lateral lumbar interbody fusion (LLIF) and percutaneous transpedicle screw fixation (pTSF). Methods: A retrospective analysis was made on 13 patients with severe adult degenerative scoliosis treated with staged surgery in Ruijin Hospital between May, 2014 and July, 2015. The operation data were collected, including operation time, estimated blood loss, and complications. Preoperative and postoperative standing anteroposterior and lateral lumbar radiographs were obtained by EOS image system in all patients for measurement of sagittal and coronal plane alignment. All patients were available for at least 24 months of following-up (18-32 months). Paired sample t test was used to compare the parameters of each group pre- and post-operation. Results: All of the 13 patients received LLIF with staged transpedicle screw fixation. Mean operation time was (231±48) minutes and (155±33) minutes for two-stage surgery. Mean blood loss was (253±80) ml during one-stage LLIF surgery and (326±99) ml during two-stage pTSF surgery. The interval between two surgical procedures was from 7 to 42 days (mean 14 days). In the coronal plane, the mean Cobb angle of curves was 43.1°±7.3° preoperatively, and it was 11.4°±4.0°after one-stage LLIF (t=10.16, P<0.001) and 5.5°±1.9° after two-stage pTSF (t=6.14, P<0.001). In the sagittal plane, lumbar lordosis (LL) changed after each procedure was as follows: LLIF from 16.8°±8.4° to 30.1°±6.8° (t=5.21, P<0.001) and PSF to 37.1°±4.0° (t=5.04, P<0.001). Sagittal vertical axis (SVA) was reduced from (10.5±2.4) cm to (5.3±2.1) cm after one-stage LLIF (t=8.52, P<0.001) and to (3.1±1.5) cm after two-stage pTSF (t=5.51, P<0.001). In the spino-pelvic parameter, pelvic incidence(PI)-LL mismatch decreased from 33.6°±9.6° to 17.8°±4.5° (t=5.31, P<0.001) after LLIF and to 9.9°±3.7° after pTSF (t=4.68, P<0.001). The visual analogue scale (VAS) of low back pain and leg pain and the Oswestry dability Index (ODI) improved significantly at the last follow-up (t=10.42, 8.94, 19.20, all P<0.01). Conclusions: LLIF significantly improves segmental and coronal plane alignment in patients with degenerative lumbar scoliosis, and these patients can be effectively corrected by staged minimally invasive surgery.

A Modified Method of Activity-based Costing for Objectively Reducing Cost Drivers in Hospitals

Objectives: Activity-based costing (ABC) is widely used to precisely allocate indirect costs to medical services. In the ABC method, the indirect cost is divided among the medical services in proportion to the volume of “cost drivers”, for example, labor hours and the number of hours of surgery. However, the workload of data collection of cost drivers can be time-consuming and a considerable burden if there are many cost drivers. The authors aim to develop a method for objectively reducing the cost drivers used in the ABC method.

Methods: In the ABC method, the cost driver is assigned for each activity. We assume that these activities and cost drivers are the best combination. Our method, that is cost driver reduction (CDR), can objectively select surrogates of the cost drivers for each activity in ABC from candidate cost drivers. Concretely, the total indirect cost of an activity is temporarily allocated to the medical services using each candidate of cost drivers. The difference between the costs calculated by each candidate and the proper cost driver used in ABC is calculated to evaluate the similarity by the evaluation function.

Results: We estimated the cost of laboratory tests using our method and revealed that the number of cost drivers could be reduced from seven in the ABC to four. Similarly, the results of cost estimation obtained by our method were as accurate as those calculated using the ABC.

Conclusions: Our method provides two advantages compared to the ABC method: 1) it provides results that are as accurate as those of the ABC method, and 2) it is simpler to perform complicated estimation of hospital costs.

General-purpose readout electronics for white neutron source at China Spallation Neutron Source

The under-construction White Neutron Source (WNS) at China Spallation Neutron Source is a facility for accurate measurements of neutron-induced cross section. Seven spectrometers are planned at WNS. As the physical objectives of each spectrometer are different, the requirements for readout electronics are not the same. In order to simplify the development of the readout electronics, this paper presents a general method for detector signal readout. This method has advantages of expansibility and flexibility, which makes it adaptable to most detectors at WNS. In the WNS general-purpose readout electronics, signals from any kinds of detectors are conditioned by a dedicated signal conditioning module corresponding to this detector, and then digitized by a common waveform digitizer with high speed and high precision (1 GSPS at 12-bit) to obtain the full waveform data. The waveform digitizer uses a field programmable gate array chip to process the data stream and trigger information in real time. PXI Express platform is used to support the functionalities of data readout, clock distribution, and trigger information exchange between digitizers and trigger modules. Test results show that the performance of the WNS general-purpose readout electronics can meet the requirements of the WNS spectrometers.

Ratio of the tibial tuberosity-trochlear groove distance to the tibial maximal mediolateral axis: A more reliable and standardized way to measure the tibial tuberosity-trochlear groove distance

BACKGROUND

Tibial tuberosity-trochlear groove distance(TT-TG) is a measurement to assist in the diagnosis and treatment of patellar instability, however it still has some limitations. Our study was to modify the accepted measurement method and seek a more reliable and standardized method.

METHODS

The data of 65 healthy controls and 49 patients with bilateral patellar instability from 2010 to 2016 were collected and analyzed by CT. The TT-TG, tibial maximal mediolateral axis (MML), and their ratio [i.e., the modified-TT-TG (M-TT-TG)] were compared between the two groups.

RESULTS

The MML (71.9±12.0 vs. 71.3±10.9) was not significantly different between the two groups (P>0.05). However, the TT-TG(18.1±6.0 vs. 13.1±2.9) and M-TT-TG (0.25±0.08 vs. 0.19±0.04) were significantly different between the two groups (P<0.05). A TT-TG of >15mm was found in 24.5% of healthy controls and 71.5% of patients. The healthy controls with a TT-TG of >15mm were compared with the patients; although no significant difference was found in the TT-TG (16.8±1.5 vs. 18.1±6.0), the healthy controls had a significantly larger MML (76.9±12.7 vs. 71.9±10.9) and significantly smaller M-TT-TG (0.22±0.04 vs. 0.25±0.08). A total of 53.1% of patients but only 6.9% of healthy controls had an M-TT-TG of >0.25.

CONCLUSION

The M-TT-TG is a more reliable and standardized way to measure the effect of the TT-TG with the goal of reducing the false-positive rate associated with the standard measurement technique. The normal M-TT-TG ranges from 0.11 to 0.25, with an M-TT-TG of >0.25 being associated with patellofemoral malalignment.

LEVEL OF EVIDENCE

III.

Clinical outcomes of medial collateral ligament injury in total knee arthroplasty

Intraoperative injury to the medial collateral ligament (MCL) during total knee arthroplasty (TKA) is a rare but severe complication. The main treatment methods are primary repair and revision with a more constrained implant; however, the clinical outcomes of primary reconstruction without a constrained implant have rarely been reported.A retrospective study was performed to evaluate the prevalence of iatrogenic injury to the MCL during primary TKA, and to report the clinical outcomes of MCL reconstruction without the use of a constrained device.A total of 1749 patients (2054 knees) underwent primary TKA between 2007 and 2013 and were retrospectively evaluated. Seventeen patients (0.83%) experienced an MCL injury intraoperatively, and the remaining 1732 patients (2037 knees) were considered as the controls. We attempted to reconstruct the MCL with an unconstrained prosthesis in all patients. The Knee Society Score (KSS) was used to evaluate knee function after an average 51-month follow-up (range, 36-72 months).No patients were lost during the follow-up period. In the MCL injury group, the mean KSS was 84.7 for function and 87.7 for pain, while the scores were 87.9 and 90.6, respectively, in the control group. No patient treated with MCL reconstruction without increased prosthetic constraint experienced knee instability requiring revision.MCL reconstruction without a constrained implant achieved excellent results for MCL injury during TKA.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Improved ACL reconstruction outcome using double-layer BPTB allograft compared to that using four-strand hamstring tendon allograft

BACKGROUND

This study compared the clinical outcomes of anterior cruciate ligament reconstruction using double-layer bone-patellar tendon-bone (DBPTB) allografts and four-strand hamstring (4SHS) grafts.

METHODS

This prospective randomized controlled trial included 101 patients. Of these, 50 patients received DBPTB allografts, and 51 received 4SHS grafts. Evaluations included KT-1000 arthrometer measurements, Lachman tests, pivot-shift tests, the International Knee Documentation Committee (IKDC) classification and Lysholm scores at three year postoperative follow-up.

RESULTS

Two DBPTB patients (four percent) and nine 4SHS patients (17.6%) had graft failures, which was significantly different (P=0.028). The DBPTB group had significantly better Lachman test, IKDC knee score and Lysholm score results than the 4SHS group (P<0.05). However, these differences were below the threshold for clinical significance.

CONCLUSIONS

DBPTB allografts had fewer graft failures at three years than 4SHS grafts for anterior cruciate ligament reconstruction; and there were statistically significant differences but not clinically significant differences between DBPTB and 4SHS grafts in terms of the KT1000 test, IKDC and Lysholm scores.

[Sunitinib induces autophagy via suppressing Akt/mTOR pathway in renal cell carcinoma]

OBJECTIVE

To determine the mechanism of sunitinib-induced autophagy in renal cell carcinoma cells.

METHODS

MTS assay was applied to detect the cell viability alteration under the treatment of sunitinib (2, 8 μmol/L). The sunitinib-induced autophagy as well as cell apoptosis was measured and compared after knocking down autophagy-related protein Beclin1 and microtubule associated protein 1 light chain 3 fusion protein (LC3) by RNA interference. The transmission electron microscope was used to observe the formation of autophagosomes in ACHN cells. The fluorescence microscope was used to monitor distribution and aggregation of endogenous LC3-II. The expressions of protein such as LC3-II, the autophagic regulation molecules protein kinase B/ mammalian target of rapamycin (Akt/mTOR) and the symbol of apoptosis poly ADP-ribose polymerase (PARP) were capable to be detected by immunoblotting assay.

RESULTS

Sunitinib was able to significantly trigger cell viability loss in the renal carcinoma cell ACHN, which was both in a concentration-dependent and time-dependent manner (P<0.05). After reducing the autophagy by knocking down Beclin1 and LC3, the number of cleavage of PARP was increased remarkably, whereas there was nearly not any cleavage in the mock group. By the transmission electron microscope, there were more autophagic vacuoles in ACHN cells after being administrated with sunitininb compared with the control. And the nuclear-to-cytosol translocation as well as aggregation of LC3-II was presented after sunitinib treatment by the fluorescence microscope, which was the proof of the enhanced autophagy. According to the immunoblotting, sunitinib was able to increase the accumulation of LC3-II . At the same time, the result of sunitinib combined with chloroquine, a drug which blocked the fusion of autophagosomes and lysosomes, demonstrated that the increasing amount of LC3-II was due to the enhanced autophagy flux by sunitinib treatment in ACHN cells. However, phosphorylation of Akt as well as mTOR was decreased at the same time. The rapamycin (mTOR inhibitor) or knocking down Akt subunits could change the sunitinib-induced LC3 -II accumulation, whereas overexpression of Akt subunits decreased the autophagic flux, indicating that Akt/mTOR was the target of sunitinib in autophagy.

CONCLUSION

Sunitinib induced autophagy via suppressing Akt/mTOR pathway, and the autophagy was involved in apopotosis.

Characteristics of Four Upward-Pointing Cosmic-Ray-like Events Observed with ANITA

We report on four radio-detected cosmic-ray (CR) or CR-like events observed with the Antarctic Impulsive Transient Antenna (ANITA), a NASA-sponsored long-duration balloon payload. Two of the four were previously identified as stratospheric CR air showers during the ANITA-I flight. A third stratospheric CR was detected during the ANITA-II flight. Here, we report on characteristics of these three unusual CR events, which develop nearly horizontally, 20-30 km above the surface of Earth. In addition, we report on a fourth steeply upward-pointing ANITA-I CR-like radio event which has characteristics consistent with a primary that emerged from the surface of the ice. This suggests a possible τ-lepton decay as the origin of this event, but such an interpretation would require significant suppression of the standard model τ-neutrino cross section.

EMLA Anaesthetic Cream for Sharp Debridement of Venous Leg Ulcers: A Double-Masked, Placebo-Controlled Study

Objective:

The aim of this double-masked, placebo-controlled trial was to confirm the anaesthetic effect of EMLA cream compared with placebo when used for sharp debridement of venous leg ulcers and to test its feasibility with respect to the usual procedure.

Methods:

One hundred and ten patients with venous ulcers were randomised to EMLA or placebo cream treatment for 30-45 min. Pain from debridement was evaluated by the patient on a 100 mm visual analogue scale (VAS) and by the physician on a verbal scale.

Results:

The median VAS scores were 16.5 and 52 in EMLA- and placebo-treated patients, respectively (p<0.00001), a clinically relevant difference. On the vertebral scale 61% of EMLA patients and 21% of placebo patients were placed in the category of no pain (pO.OOOl). The physicians found debridement with EMLA easier to perform (p<0.01).

Conclusion:

Debridement of venous leg ulcers using topical anaesthesia is easy and safe, with adequate pain relief in both in- and outpatients.

Evaluation of tumour vascular distribution and function using immunohistochemistry and BOLD fMRI with carbogen inhalation

AIM

To evaluate oxygenation changes in rat subcutaneous C6 gliomas using blood-oxygen-level dependent (BOLD) functional magnetic resonance imaging (fMRI) combined with non-haemodynamic response function (non-HRF) analysis.

MATERIALS AND METHODS

BOLD fMRI were performed during carbogen inhalation in 20 Wistar rats bearing gliomas. Statistical maps of spatial oxygenation changes were computed by a dedicated non-HRF analysis algorithm. Three types of regions of interest (ROIs) were defined: (1) maximum re-oxygenation zone (ROI_max), (2) re-oxygenation zones that were less than the maximum re-oxygenation (ROI_non-max), and (3) zones without significant re-oxygenation (ROI_none). The values of percent BOLD signal change (PSC), percent enhancement (ΔSI), and significant re-oxygenation (T) were extracted from each ROI. Tumours were sectioned for histology using the fMRI scan orientation and were stained with haematoxylin and eosin and CD105. The number of microvessels (MVN) in each ROI was counted. Differences and correlations among the values for T, PSC, ΔSI, and MVN were determined.

RESULTS

After carbogen inhalation, the PSC significantly increased in the ROI_max areas (p<0.01) located in the tumour parenchyma. No changes occurred in any of the ROI_none areas (20/20). Some changes occurred in a minority of the ROI_non-max areas (3/60) corresponding to tumour necrosis. MVN and PSC (R=0.59, p=0.01) were significantly correlated in the ROI_max areas. In the ROI_non-max areas, MVN was significantly correlated with PSC (R=0.55, p=0.00) and ΔSI (R=0.37, p=0.00).

CONCLUSIONS

Statistical maps obtained via BOLD fMRI with non-HRF analysis can assess the re-oxygenation of gliomas.

[Sunitinib induces autophagy via suppressing Akt/mTOR pathway in renal cell carcinoma]

OBJECTIVE

To determine the mechanism of sunitinib-induced autophagy in renal cell carcinoma cells.

METHODS

MTS assay was applied to detect the cell viability alteration under the treatment of sunitinib (2, 8 μmol/L). The sunitinib-induced autophagy as well as cell apoptosis was measured and compared after knocking down autophagy-related protein Beclin1 and microtubule associated protein 1 light chain 3 fusion protein (LC3) by RNA interference. The transmission electron microscope was used to observe the formation of autophagosomes in ACHN cells. The fluorescence microscope was used to monitor distribution and aggregation of endogenous LC3-II. The expressions of protein such as LC3-II, the autophagic regulation molecules protein kinase B/ mammalian target of rapamycin (Akt/mTOR) and the symbol of apoptosis poly ADP-ribose polymerase (PARP) were capable to be detected by immunoblotting assay.

RESULTS

Sunitinib was able to significantly trigger cell viability loss in the renal carcinoma cell ACHN, which was both in a concentration-dependent and time-dependent manner (P<0.05). After reducing the autophagy by knocking down Beclin1 and LC3, the number of cleavage of PARP was increased remarkably, whereas there was nearly not any cleavage in the mock group. By the transmission electron microscope, there were more autophagic vacuoles in ACHN cells after being administrated with sunitininb compared with the control. And the nuclear-to-cytosol translocation as well as aggregation of LC3-II was presented after sunitinib treatment by the fluorescence microscope, which was the proof of the enhanced autophagy. According to the immunoblotting, sunitinib was able to increase the accumulation of LC3-II . At the same time, the result of sunitinib combined with chloroquine, a drug which blocked the fusion of autophagosomes and lysosomes, demonstrated that the increasing amount of LC3-II was due to the enhanced autophagy flux by sunitinib treatment in ACHN cells. However, phosphorylation of Akt as well as mTOR was decreased at the same time. The rapamycin (mTOR inhibitor) or knocking down Akt subunits could change the sunitinib-induced LC3 -II accumulation, whereas overexpression of Akt subunits decreased the autophagic flux, indicating that Akt/mTOR was the target of sunitinib in autophagy.

CONCLUSION

Sunitinib induced autophagy via suppressing Akt/mTOR pathway, and the autophagy was involved in apopotosis.

Mesenchymal stem cells regulate cytoskeletal dynamics and promote cancer cell invasion through low dose nitric oxide

Bone marrow-derived mesenchymal stem cells (BMSCs) can be recruited to tumor sites and integrate into the stroma of tumors. When co-cultured with BMSCs, otherwise weakly metastatic nasopharyngeal carcinoma cells (NPC) showed improved metastatic ability. BMSCs in the tumor environment displayed the characteristics of macrophages. Nitric oxide produced by BMSCs in tumor environment could translocate caldesmon to podosome in Ca2+/calmodulin manner and promoted metastatic ability of NPC cells through invadopodia formation, with which the NPC cells degrade the extracellular matrix. Thus, we concluded that the BMSCs promoted cell migration and invasion through nitric oxide-induced paracrine signals.

Upregulation of cytoskeleton protein and extracellular matrix protein induced by stromal-derived nitric oxide promotes lung cancer invasion and metastasis

Lung cancer commonly metastasizes to lymph nodes, brain and bones, which is the main cause of death. It is still a challenge to detect molecular biomarkers for early diagnosis and therapeutics of lung cancer. Our previous study found that bone marrow-derived stroma cells (BMSCs) under tumor microenvironment produced nitric oxide (NO), which was induced by inducible nitric oxide synthase (iNOS), and promoted invasion and metastasis of cancer cells by remodeling cytoskeleton. The aim of this study is to elucidate the relationship between the expressions of iNOS, cytoskeleton protein caldesmon, OPN, and clinical parameters especially the metastasis of lung cancer. We found that nitric oxide can remodel cytoskeleton and promoted the mobility of lung cancer cells. The expressions of iNOS, caldesmon, and OPN are closely correlated to metastasis of lung cancer. The intracranial metastatic tissue samples of lung cancer showed significantly higher expression of iNOS, caldesmon and OPN. A flow-cytometry analysis for peripheral blood of lung cancer patients showed increased EPCAM+/OPN+ cells in circulation of patients with bone metastasis compared to that of patients without metastasis, which is indicative of cancer circulating cells. The concentration of serum OPN was also positively related to the bone metastasis of lung cancer. Taken together, these results suggested that iNOS, caldesmon and OPN may work as biomarkers for metastasis of lung cancer.

Preparation and analysis of a new bioorganic metallic material

In this study, a synthetic peptide has been utilized to react with 304 stainless steel aiming to generate a bioorganic stainless steel using a facile technique.

Protein engineering of a new recombinant peptide to increase the surface contact angle of stainless steel

Biofouling seriously affects the properties and service life of metal materials.

First Report of Powdery Mildew Caused by Blumeria graminis on Festuca arundinacea in China

Tall fescue (Festuca arundinacea Schreb), a predominant cool-season perennial grass, is widely used as forage and turf grasses in China. In July 2013, powdery mildew was observed on 10 F. arundinacea lawns (about 0.5 ha in total) in Urumchi, Xinjiang Province, China, with 20 to 30% of the area being infected. Signs of the disease initially appeared as irregular white mycelial colonies on the adaxial surface of infected leaves. As the disease progressed, the colonies covered the whole adaxial surface and white patches appeared on the abaxial surface of infected leaves. Conidiophores were unbranched and cylindrical with swollen bases, measuring 13.3 to 15 × 16.7 to 20 μm, and borne vertically on hyphae. Each conidiophore produced 10 to 18 conidia in a chain. The conidia were oval, one-celled, and colorless, measuring 8.1 to 9.8 × 26 to 29.7 μm. Cleistothecia were black, spherical, and 164.3 to 207.3 μm in diameter, each of which contained 9 to 26 asci. Asci were oblong or ovate, measuring 32.1 to 40 × 85.7 to 96.4 μm. Asci were petiolate, containing eight ascospores. Ascospores were round to oval, colorless, one-celled, measuring 19.1 to 22.5 × 11.7 to 13.6 μm. Based on morphological characteristics of the anamorph and the teleomorph, the fungus was identified as Blumeria graminis (DC.) Speer. Additionally, the internal transcribed spacer (ITS) of 563 bp was amplified from DNA of conidia using ITS1 and ITS4 primers (4). The ITS sequence was deposited in GenBank (Accession No. KF545644). The ITS sequence showed 100% homogeneity with those of B. graminis on Poa pratensis in Swizerland (AB273540) and on P. bulbosa in Iran (AB273551) (1), which further confirmed the identification. Ten 3-week-old healthy plants were inoculated by spraying a spore suspension (1 × 10⁵ conidia ml^-1) made from conidia brushed from infected plants, and 10 plants sprayed with sterile distilled water were served as controls. All the plants were placed in the same growth chamber at 20°C, 80% humidity, and 16-h photoperiod. Twenty days after inoculation, typical signs and symptoms of powdery mildew were observed on all the inoculated plants, whereas no symptoms were observed on the controls. Microscopic and ITS analysis showed that the fungus on the inoculated plants is identical to that on diseased field plants. B. graminis on F. arundinacea has been observed in a few European countries (1), Israel (3), and the United States (2). To our knowledge, this is the first report of powdery mildew caused by B. graminis on F. arundinacea in China, which will increase the difficulty to prevent powdery mildew on grasses including cereals. References: (1) U. Braun. The Powdery Mildews (Erysiphales) of Europe. Gustav Fischer Verlag, Jena-Stuttgart-New York, 1995. (2) F. M. Dugan and G. Newcombe. Pacific Northwest Fungi. 2:1-5, 2007. (3) S. O. Voytyuk et al. Biodiversity of the Powdery Mildew Fungi (Erysiphales, Ascomycota) of Israel Vol. 7. Biodiversity of Cyanoprocaryotes, Algae and Fungi of Israel. Koeltz Scientific Books, 2009. (4) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, San Diego, 1990.

First Report of Powdery Mildew Caused by Erysiphe betae on Swiss Chard in China

Swiss chard (Beta vulgaris L. subsp. cicla) is a widely planted vegetable in China. From May to June 2013, an outbreak of powdery mildew on Swiss chard cultivar Fangzheng was observed in the commercial fields in Zhoukou city of Henan Province, located in central China. More than 80% of the plants exhibited symptoms of the disease. At the beginning of infection, circular, white, dust-like colonies of powdery mildew occurred mainly on adaxial surfaces of leaves. As the disease progressed, white mycelia covered the foliar parts of plant. No cleistothecia were found on or in collected samples. Upon microscopic evaluation, conidiophores were unbranched with the length of 63 to 126 and width of 7 to 10 μm (n = 50), produced conidia singly, and composed of a cylindrical foot cell followed by one to three short cells. Conidia were colorless, hyaline, ovoid, measured 29 to 40 × 12 to 18 μm (n = 100), lacked fibrosin bodies, and produced germ tubes on the ends of the conidia. The fungus was identified as Erysiphe betae according to the morphological features (1). To verify the identity, the internal transcribed spacer (ITS) region was amplified with the universal primers ITS1 and ITS4 (2) and sequenced. The ITS sequence obtained was assigned as Accession No. KF268348 in GenBank, which showed 100% homogeneity with two ITS sequences of E. betae isolates from UK (DQ164432 and DQ164436). Koch's postulates were conducted by inoculating 15 healthy 5-week-old plants (cv. Fangzheng) with detached infected leaves, which grew in a growth chamber under 22/16°C (day/night), 50% relative humidity, 120 μmol/m²/s light and a 16-h photoperiod. Fifteen non-inoculated plants grew in another growth chamber with the same conditions as control. Symptoms consistent with the infected field plants were observed on the inoculated plants, while no symptoms were found on the control plants. Microscopic observation revealed that the pathogen growing on the inoculated plants was consistent with the morphology of the original fungus. To our knowledge, this is the first report of E. betae infection on Swiss chard in China (3). References: (1) S. Francis. Mol. Plant Pathol. 3:119, 2002. (2) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, San Diego, CA, 1990. (3) R. Y. Zheng et al. Page 63 in: Flora Fungorum Sinicorum, Vol. 1, Erysiphales. Science Press, Beijing, 1987.

Early experience with the Excluder® iliac branch endoprosthesis

AIM

Dilation of one or both common iliac arteries (CIAs) is a major concern in endovascular aneurysm repair (EVAR). One option for CIA aneurysm repair is hypogastric embolization followed by endograft extension into the external iliac artery. However, hypogastric occlusion does not always go unpunished and it may lead to ischemic complications. Aim of the paper was to evaluate early results with the Gore® Excluder® Iliac Branch Endoprosthesis (IBE) in the treatment of iliac aneurysms associated or not with abdominal aortic aneurysms.

METHODS

Between November 2013 and April 2014, in our Institution 7 Gore IBE were implanted in 5 patients. Technical success, 30-day mortality and complications were investigated.

RESULTS

Technical success and branch patency was 100%. There was no 30-day mortality. In 1 of the 2 bilateral cases an endovascular relining with bare stents was required due to a compression of iliac legs at level of aortic bifurcation.

CONCLUSION

Use of Gore IBE device in the treatment of aorto-iliac disease is feasible and safe. Late results are necessary to evaluate the performance of this endograft in the long term.

Additive effects of antiresorptive agents and exercise on lumbar spine bone mineral density in adults with low bone mass: a meta-analysis

INTRODUCTION

Exercise has been recommended to increase bone mass and prevent osteoporosis. While current treatment of osteoporosis mainly involves the use of antiresorptive agents, it is unclear whether there are any additive effects in improving bone mass when antiresorptive agents and exercise are jointly used.

METHODS

A structured and comprehensive search of databases was undertaken along with hand searching of key journals and reference lists. The combined interventions of antiresorptive agents and exercise were examined for their additive effects on lumbar spine bone mineral density (BMD) among adults with low bone mass. Trial quality was assessed using the Jadad quality score. Study outcomes for analysis, absolute change (grams per square centimeter) or relative change (in percent) in BMD, at the lumbar spine were compared by calculating standardized mean difference (SMD) using fixed and random effect models.

RESULTS

Seven randomized controlled trials (RCT) met the predetermined inclusion criteria. The increase in lumbar spine BMD of the combined-intervention group was significantly greater than that of the antiresorptive agent-alone group (fixed effect model: SMD = 0.55; 95% confidence interval (CI) = 0.36, 0.75; overall effect Z-value = 5.51; p < 0.00001). Subgroup analyses also showed consistent results. Methodological quality of most included studies was scored 3 by the Jadad criterion, and publication bias was slight according to funnel plots.

CONCLUSION

It was found that combining antiresorptive agents with exercise had additive effects on improving lumbar spine bone mass gains in adults with low bone mass. To verify the additive effects further, more RCTs with longer duration and larger sample sizes are needed.

Current results of total endovascular repair of thoracoabdominal aortic aneurysms

Minimally invasive surgical solutions for patients with extensive aortic disease are eagerly awaited, since open repair is often associated with high rates of morbidity and mortality. In the last decade, the development of fenestrated and branched aortic endografts has offered a therapeutic option to patients deemed unsuitable for major surgery. Preliminary studies showed promising early results, while mid- and long- term data are scarce. The aim of this paper was to review current results of total endovascular repair of thoracoabdominal aortic aneurysms (TAAA) with a single model of endograft in the published literature. A literature search was conducted, and our two-center experience with fenestrated and branched endografts in the treatment of TAAA, with the Cook Zenith endograft, is presented. Early results show perioperative mortality rates ranging from 0% to 21%, spinal cord ischemia from 0% to 33.3%. At a mean follow up ranging from 9 to 19 months, reinterventions are needed in 3.3% to 25% of the cases, with a mid term visceral branch patency of 90% to 100%. Current experiences with total endovascular TAAA repair show promising results, in selected centers with large experience in complex aortic endografting. With increasing follow- up times, need for reintervention is growing, while aneurysm-related deaths remain rare. Long-term results are still lacking, but these encouraging data and further technological developments will support wider adoption of the technique.

Effects of ischemic preconditioning in the late phase on homing of endothelial progenitor cells in renal ischemia/reperfusion injury

OBJECTIVE

The aim of this study was to determine whether the mobilization and recruitment of endothelial progenitor cells (EPCs) contribute to the protection of kidneys from ischemia/reperfusion (I/R) injury after ischemic preconditioning (IPC) during the late phase.

METHODS

Seventy-five male Sprague-Dawley rats were divided into the following groups: sham-operated (group A; n = 25), ischemia/reperfusion hosts that underwent 45 minutes of left renal artery ischemia (group B; n = 25), and ischemic preconditioning-treated group (group C; n = 25). Group C underwent 3 cycles of 5 minutes of occlusion and 5 minutes of reperfusion followed by 24 hours of reperfusion before the following 45 minutes of occlusion. Serum samples were collected and renal tissues harvested for histological examination terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, immunohistochemical staining, and Western blot analysis to determine the expression levels of CD34, VEGFR-2 (Vascular Endothelial Growth Factor Receptor 2)/flk-1, vascular endothelial growth factor (VEGF), and stromal cell-derived factor-1α (SDF-1α).

RESULTS

Compared with group B, the levels of blood urea nitrogen (BUN), serum creatinine (Scr) and acute tubulointerstitial injury at 24 hours after operation were significantly reduced in group C. At 72 hours, tubular epithelial cell apoptosis was also decreased (17.6 ± 4.45 vs 63.8 ± 6.10; P < .01). CD34+ and flk-1+ cells that mostly accumulated in the medullopapillary parenchyma were significantly increased at 72 hours (P < .05). Expression levels of VEGF and SDF-1α were also significantly higher in group C (P < .05).

CONCLUSION

The present work suggested that IPC protected kidneys from IR injury in the later phase through enhanced mobilization and recruitment of EPCs. VEGF and SDF-1α may play important roles in this protective effect.

Plaque debulking for femoro-popliteal occlusions: techniques and results

Although currently there is a trend of using percutaneous transluminal angioplasty (PTA) and stenting for the treatment of long occlusions of superficial femoral artery, many studies reported comparable results in terms of mid- and long-term patency between PTA and stenting and plaque debulking techniques such as remote endarterectomy, directional atherectomy catheter atherectomy and laser guided atherectomy. A successful debulking procedure is strongly associated with patients comorbidities, length of lesions and clinical presentation. In the last decade many new devices have been proposed to improve debulking results. Despite encouraging data about technical feasibility and limb salvage rate, debulking is still associated with a low rate of long-term primary and secondary patency. However, randomized clinical trials are expected and can hopefully provide conclusions on the effective durability of these procedures.

No benefit from carotid intervention in fatal stroke prevention for >80-year-old patients

BACKGROUND

Invasive management of patients ≥80 years of age with carotid stenosis may be questionable. The higher likelihood of stroke needs to be balanced with the increased perioperative risk and the reduced life expectancy of this ageing population. The purpose of this study was to evaluate the clinical relevance of carotid stenosis revascularisation in octogenarians.

METHODS

All patients ≥80 years of age who received carotid revascularisation in 2001-2010 were reviewed for perioperative and 5-year outcomes. The experience was comprehensive of carotid endarterectomy (CEA) and carotid stenting (CAS) performed during the training frame when age was not a contraindication for this procedure. Mortality rates were compared to those of octogenarians of the same geographical territory according to all-cause and stroke-related mortality national statistics datasets.

RESULTS

A total of 348 procedures performed in ≥80-year-old patients (272 males) were reviewed: 162 (46.6%) were by CAS and 169 (48.6%) were for symptomatic disease. Perioperative stroke/death rate was 5.5% and was non-significantly higher for symptomatic disease (7.1% vs. 3.9% asymptomatic; p = 0.24), after CAS (6.2% vs. 4.8% CEA; p = 0.64) and in females (6.6% vs. 5.1% males; p = 0.57). At median follow-up of 36.18 months, 95 deaths and 21 new ischaemic strokes (12 fatal) occurred with 5-year Kaplan-Meier freedom from stroke of 84.8% (78.7%, symptomatic vs. 90.3% asymptomatic; p = 0.003). According to national datasets, in 80-85-year-old resident population 5-year mortality was 29.9% (23.4% females, 40.6% males) and ischaemic stroke-related mortality was 14.9% (16.8% females, 13.0% males). Corresponding figures from treated population showed a 5-year mortality of 49.4%, higher in males (39.5% females, 52.5% males) and ischaemic stroke-related mortality of 20.2%, higher in females (40.0% females, 15.6% males). Comparing data from the study population with residents' figures, ischaemic stroke-related mortality hazard was significantly higher in the study females: odds ratio (OR) 3.2, 95% confidence interval (CI) 1.16-9.17; p = 0.029 (for males: OR 0.97, 95%CI 0.89-1.10; p = 0.99).

CONCLUSIONS

Despite perioperative stroke/death risks being lower compared with CAS, the benefit of surgical carotid revascularisation in old patients remains controversial due to limited life expectancy and high fatality of stroke in this ageing population. Invasive treatment of carotid stenosis may not be warranted in most patients ≥80 years of age with carotid stenosis, especially when female and asymptomatic.

Chapter VI: Follow-up after revascularisation

Structured follow-up after revascularisation for chronic critical limb ischaemia (CLI) aims at sustained treatment success and continued best patient care. Thereby, efforts need to address three fundamental domains: (A) best medical therapy, both to protect the arterial reconstruction locally and to reduce atherosclerotic burden systemically; (B) surveillance of the arterial reconstruction; and (C) timely initiation of repeat interventions. As most CLI patients are elderly and frail, sustained resolution of CLI and preserved ambulatory capacity may decide over independent living and overall prognosis. Despite this importance, previous guidelines have largely ignored follow-up after CLI; arguably because of a striking lack of evidence and because of a widespread assumption that, in the context of CLI, efficacy of initial revascularisation will determine prognosis during the short remaining life expectancy. This chapter of the current CLI guidelines aims to challenge this disposition and to recommend evidentially best clinical practice by critically appraising available evidence in all of the above domains, including antiplatelet and antithrombotic therapy, clinical surveillance, use of duplex ultrasound, and indications for and preferred type of repeat interventions for failing and failed reconstructions. However, as corresponding studies are rarely performed among CLI patients specifically, evidence has to be consulted that derives from expanded patient populations. Therefore, most recommendations are based on extrapolations or subgroup analyses, which leads to an almost systematic degradation of their strength. Endovascular reconstruction and surgical bypass are considered separately, as are specific contexts such as diabetes or renal failure; and critical issues are highlighted throughout to inform future studies.

Chapter I: Definitions, epidemiology, clinical presentation and prognosis

The concept of chronic critical limb ischaemia (CLI) emerged late in the history of peripheral arterial occlusive disease (PAOD). The historical background and changing definitions of CLI over the last decades are important to know in order to understand why epidemiologic data are so difficult to compare between articles and over time. The prevalence of CLI is probably very high and largely underestimated, and significant differences exist between population studies and clinical series. The extremely high costs associated with management of these patients make CLI a real public health issue for the future. In the era of emerging vascular surgery in the 1950s, the initial classification of PAOD by Fontaine, with stages III and IV corresponding to CLI, was based only on clinical symptoms. Later, with increasing access to non-invasive haemodynamic measurements (ankle pressure, toe pressure), the need to prove a causal relationship between PAOD and clinical findings suggestive of CLI became a real concern, and the Rutherford classification published in 1986 included objective haemodynamic criteria. The first consensus document on CLI was published in 1991 and included clinical criteria associated with ankle and toe pressure and transcutaneous oxygen pressure (TcPO(2)) cut-off levels <50 mmHg, <30 mmHg and <10 mmHg respectively). This rigorous definition reflects an arterial insufficiency that is so severe as to cause microcirculatory changes and compromise tissue integrity, with a high rate of major amputation and mortality. The TASC I consensus document published in 2000 used less severe pressure cut-offs (≤ 50-70 mmHg, ≤ 30-50 mmHg and ≤ 30-50 mmHg respectively). The thresholds for toe pressure and especially TcPO(2) (which will be also included in TASC II consensus document) are however just below the lower limit of normality. It is therefore easy to infer that patients qualifying as CLI based on TASC criteria can suffer from far less severe disease than those qualifying as CLI in the initial 1991 consensus document. Furthermore, inclusion criteria of many recent interventional studies have even shifted further from the efforts of definition standardisation with objective criteria, by including patients as CLI based merely on Fontaine classification (stage III and IV) without haemodynamic criteria. The differences in the natural history of patients with CLI, including prognosis of the limb and the patient, are thus difficult to compare between studies in this context. Overall, CLI as defined by clinical and haemodynamic criteria remains a severe condition with poor prognosis, high medical costs and a major impact in terms of public health and patients' loss of functional capacity. The major progresses in best medical therapy of arterial disease and revascularisation procedures will certainly improve the outcome of CLI patients. In the future, an effort to apply a standardised definition with clinical and objective haemodynamic criteria will be needed to better demonstrate and compare the advances in management of these patients.

Chapter V: Diabetic foot

Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade.

Results of the "endovascular treatment first" policy for infrapopliteal disease

Even though differences between first-bypass vs. first-endovascular approach in below the knee (BTK) lesions have never been adequately compared, endovascular strategy first approach can be currently successfully used to treat BTK lesions in patients with critical limb ischemia (CLI). Success however is strongly associated with risk groups, severity of disease and degree of clinical presentation beside the method of revascularization. From available data, the best results of endovascular first approach for BTK lesions can be achieved with multivessel and tibial (more than peroneal alone) recanalization and Rutherford 4 or 5 ischemia changes, especially if the correct angiosome can be revascularized (direct flow to the feeding artery of the foot) and there is no renal failure. For patients in Rutherford class 6 and extensive gangrene/tissue loss, BTK endovascular strategy alone does not seem to provide ideal results. Outcomes of interventional therapy for BTK lesions are consistently better when applied in experienced centers with the use of more advanced technology and use of eluting materials. According to limited but randomized evidence, drug-eluting stent (DES) placement might be recommended in BTK lesions under 40 mm long since yields significantly better results than angioplasty alone or implantation of bare metal stents in this lesion subset. Nevertheless, this policy raises doubts on the efficacy of treatment due to limitations in generalizability of outcomes in common hospital settings and related costs. Furthermore, there are still no consistent numbers to provide the efficacy of this approach and long-term data are lacking. Waiting for the long-term results of ongoing trials and new researches, a more comprehensive analysis of outcomes with BTK endovascular first strategy can be provided in the next future.

Long-term results of iliac aneurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases

BACKGROUND

Iliac branch device (IBD) technique has been introduced as an appealing and effective solution to avoid complications occurring during repair of aorto-iliac aneurysm with extensive iliac involvement. Nevertheless, no large series with long-term follow-up of IBD are available. The aim of this study was to analyse safety and long-term efficacy of IBD in a consecutive series of patients.

METHODS

Between 2006 and 2011, 100 consecutive patients were enrolled in a prospective database on IBD. Indications included unilateral or bilateral common iliac artery aneurysms combined or not with abdominal aneurysms. Patients were routinely followed up with computed tomography. Data were reported according to the Kaplan-Meier method.

RESULTS

There were 96 males, mean age 74.1 years. Preoperative median common iliac aneurysm diameter was 40 mm (interquartile range (IQR): 35-44 mm). Sixty-seven patients had abdominal aortic aneurysm >35 mm (IQR: 40-57 mm) associated with iliac aneurysm. Eleven patients presented hypogastric aneurysm. Twelve patients underwent isolated iliac repair with IBD and 88 patients received associated endovascular aortic repair. Periprocedural technical success rate was 95%, with no mortality. Two patients experienced external iliac occlusion in the first month. At a median follow-up of 21 months (range 1-60) aneurysm growth >3 mm was detected in four iliac (4%) arteries. Iliac endoleak (one type III and two distal type I) developed in three patients and buttock claudication in four patients. Estimated patency rate of internal iliac branch was 91.4% at 1 and 5 years. Freedom from any reintervention rate was 90% at 1 year and 81.4% at 5 years. No late ruptures occurred.

CONCLUSIONS

Long-term results show that IBD use can ensure persistent iliac aneurysm exclusion at 5 years, with low risk of reintervention. This technique can be considered as a first endovascular option in patients with extensive iliac aneurysm disease and favourable anatomy.