Copper-catalyzed 1,1-alkynylalkylation of alkynes: access toward conjugated enynes

A copper-catalyzed 1,1-alkynylalkylation of alkynes with α-haloacetamides for the construction of conjugated enynes has been developed.

Are left ventricular muscle area and radiation attenuation associated with overall survival in advanced pancreatic cancer patients treated with chemotherapy?

AIM

To evaluate whether cardiac muscle area and radiation attenuation, determined using pre-chemotherapy computed tomography (CT), are associated with therapeutic response and overall survival (OS) in chemotherapy-treated advanced pancreatic cancer (APC) patients.

MATERIALS AND METHODS

Ninety-eight chemotherapy-treated APC patients who underwent pre-chemotherapy CT between 2009 and 2018 were considered. Left ventricular muscle area (LVMA) and left ventricular muscle radiation attenuation (LVMRA) were measured using pre-chemotherapy arterial-phase CT. OS and progression-free survival (PFS) were analysed using Kaplan-Meier curves. Univariate and multivariate Cox regression analyses were performed to analyse potential factors affecting OS and PFS.

RESULTS

Patients with low LVMRA, low LVMA at baseline CT, and multiple metastases had a significantly shorter median OS than patients with high LVMRA, high LVMA, and without multiple metastases (8.8 versus 14 months, p=0.017; 12.2 versus 18.1 months, p=0.038; 7.3 versus 13.5 months, p<0.001, respectively). Patients with low LVMRA and distant metastasis had a shorter median PFS than patients with high LVMRA and those without distant metastasis (4.9 versus 8.3 months, p=0.032; 5.4 versus 9.9 months, p=0.002, respectively). Moreover, the mean LVMRA was the highest in the partial response group (p=0.028).

CONCLUSION

LVMRA could well predict PFS and OS in chemotherapy-treated APC patients.

Combined therapy of infusion of DC from rats with higher expression of IDO and CD40L on rejection post heart transplantation

OBJECTIVE

Indoleamine 2, 3-dioxygenase (IDO) can inhibit rejection of graft via inducing T cell apoptosis. CD40L monoclonal antibody (mAb) inhibits T cell activation. However, the effects of the combination of infusion of dendritic cell (DC) from IDO over-expressed donor mice and CD40L mAb on the treatment of graft rejection after heart transplantation have not been reported.

MATERIALS AND METHODS

Allogeneic heart transplantation mouse model was established. Recipient mice were divided into three groups, including control group, IDO group (in which DC donors received adenoviral vector of IDO) and combined therapy group (which received both IDO over-expressed DC infusion and CD40L mAb injection post transplantation). Survival time and cardiac function were observed, with IDO expression being quantified. Flow cytometry (FCM) was used to analyze T cell apoptosis, while enzyme linked immunosorbent assay (ELISA) was adopted to test the levels of interferon-γ (IFN-γ), interleukin-2 (IL-2), interleukin-10 (IL-10) and interleukin-6 (IL-6).

RESULTS

IDO expression was significantly elevated in both IDO and combined therapy groups, with enhanced T cell apoptosis compared to control group (p < 0.05). Both groups had better survival time and cardiac functions compared to control group, along with increased IL-10/IL-6 expression and suppressed INF-γ and IL-2 expression (p < 0.05). However, combined therapy had a better efficiency compared to IDO group (p < 0.05).

CONCLUSIONS

Combined therapy of high IDO expressed mouse DC perfusion with CD40L mAb can elongate the survival time of recipient heart and inhibit rejection reaction via facilitating T cell apoptosis. Meanwhile, combined therapy could also regulate the expression of some immune suppressant factors and mediate the Th1/Th2 cytokine balance.

Notch3 signaling activation in smooth muscle cells promotes extrauterine growth restriction-induced pulmonary hypertension

BACKGROUND AND AIMS

Early postnatal life is a critical developmental period that affects health of the whole life. Extrauterine growth restriction (EUGR) causes cardiovascular development problems and diseases, including pulmonary arterial hypertension (PAH). PAH is characterized by proliferation, migration, and anti-apoptosis of pulmonary artery smooth muscle cells (PASMCs). However, the role of PASMCs in EUGR has not been studied. Thus, we hypothesized that PASMCs dysfunction played a role in EUGR-induced pulmonary hypertension.

METHODS AND RESULTS

Here we identified that postnatal nutritional restriction-induced EUGR rats exhibited an elevated mean pulmonary arterial pressure and vascular remodeling at 12 weeks old. PASMCs of EUGR rats showed increased cell proliferation and migration features. In EUGR-induced PAH rats, Notch3 signaling was activated. Relative mRNA and protein expression levels of Notch3 intracellular domain (Notch3 ICD), and Notch target gene Hey1 in PASMCs were upregulated. We further demonstrated that pharmacological inhibition of Notch3 activity by using a γ-secretase inhibitor DAPT, which blocked the cleavage of Notch proteins to ICD peptides, could effectively inhibit PASMC proliferation. Specifically knocked down of Notch3 in rat PASMCs by shRNA restored the abnormal PASMC phenotype in vitro. We found that administration of Notch signaling inhibitor DAPT could successfully reduce mean pulmonary arterial pressure in EUGR rats.

CONCLUSIONS

The present study demonstrated that upregulation of Notch3 signaling in PASMCs was crucial for the development of EUGR-induced PAH. Blocking Notch3-Hey1 signaling pathway in PASMCs provides a potential therapeutic target for PAH.

S-nitrosylation of Src by NR2B-nNOS signal causes Src activation and NR2B tyrosine phosphorylation in levodopa-induced dyskinetic rat model

Abnormality in Src PSD-95 NR2B signaling complex assemble occurs in levodopa-induced dyskinesia (LID). N-methyl-D-aspartate receptor (NMDAR) subunit NR2B tyrosine phosphorylation mediated by Src family protein tyrosine kinases is closely associated with dyskinesia. Src autophosphorylation (p-Src) is an important part of Src-catalyzed phosphorylation of NR2B. In addition, the neuronal nitric oxide synthase (nNOS)-derived NO (nNOS/NO) signal which was also involved in dyskinesia recently was proved to participate in the regulation of Src function. Yet, the detailed signal mechanism about the interactions of NR2B, nNOS, and Src is still unknown. In the present study, we investigated the influences of nNOS on Src activation and NR2B tyrosine phosphorylation in dyskinetic rat model by immunoblotting and immunoprecipitation. The results demonstrated that chronic levodopa treatment resulted in downregulation of p-nNOS-S847, one marker of nNOS overactivation. Coinstantaneously, the S-nitrosylation (SNO-Src) and autophosphorylation (p-Src) of Src and NR2B tyrosine phosphorylation were upregulated in dyskinetic rat model. Conversely, administration of 7-NI, one nNOS inhibitor, reversed all these effects of levodopa treatment. Besides, NR2B-containing NMDAR (NR2B/NMDAR) antagonist CP-101,606 could upregulate p-nNOS-S847 and thus attenuate nNOS activation and simultaneously reduce the SNO-Src, p-Src, and NR2B tyrosine phosphorylation. Taken together, the S-nitrosylation of Src is caused by nNOS/NO signal, which is overactivated via Ca²⁺ influx dependent on NR2B/NMDAR, and subsequently facilitates Src auto-tyrosine phosphorylation and further phosphorylates NR2B. The "NR2B/NMDAR-nNOS/NO-SNO-Src-p-Src-NR2B/NMDAR" signaling cycle may be the molecular basis of NR2B tyrosine phosphorylation upward positive feedback, which demonstrates the possibility as one latent target for dyskinesia therapy.

[The attentional bias of emotion in medical workers of emergency department in one hospital and it's relationship with mood state]

Objective: To study the characteristics of attentional bias to emotional stimulus in medical workers of emergency department and explore the relationship between the emotional Stroop effect and mood states, thus providing a reference to the assessment and intervention of emergency medical workers' mental health. Methods: Two kinds of emotional Stroop tasks with words and pictures and the Profile of Mood States (POMS) were administered to thirty-six medical workers of emergency department and thirty-six medical workers of other departments. Results: The reaction time to negative and positive words and pictures were all higher than the reaction time to neutral stimulus, thus showing the significant Stroop effect in medical workers. The Stroop effect to negative emotional stimulus in medical workers of emergency department was significantly smaller than that in medical workers of other departments, while the difference of Stroop effect to positive stimulus was not significant between the two groups. Correlation analyses revealed that the correlations between Stroop effect size to positive pictures and tension and angry of POMS were all negatively significant (r value was -0.314 and -0.330 respectively) , and the correlation between Stroop effect size to negative pictures and fatigue was negatively significant (r=-0.303) . Conclusions: There is a significant emotional Stroop effect in medical workers. Although the ability of anti-interference to emotional stimulus in medical workers of emergency department was better than medical workers of the other departments, the long-term avoidance to negative emotional stimulus was still has a negative effect on the mood states of individuals.

Expression and significance of peripheral myeloid-derived suppressor cells in chronic hepatitis B patients

BACKGROUND

Myeloid-derived suppressor cells (MDSCs) exert their suppressive effects on multiple immune response and contribute to the development of many diseases. However, limited data is available on the involvement of MDSCs in human chronic HBV infection.

OBJECTIVE

To investigate whether the progression of chronic HBV infection was associated with imbalance of MDSCs.

METHODS

The percentages of MDSCs, regulatory T (Treg), Th1 and Tc1 cells in the peripheral blood from chronic hepatitis B (CHB) patients and healthy controls (HC) were determined by flow cytometry. Plasma levels of IL-10, TGF-β and IFN-γ were measured using enzyme-linked immunosorbent assay. The potential association of the frequencies of MDSCs with clinical parameters was assessed.

RESULTS

The percentages of MDSCs and Treg cells were significantly higher in CHB patients than those in HC. The percentages of MDSCs were negatively correlated with Th1 cells. Increased plasma IL-10 level and decreased IFN-γ level were found in CHB patients compared with HC. Moreover, the frequencies of MDSCs and plasma IL-10 levels were positively correlated with serum HBV DNA loads, as well as liver function impairment.

CONCLUSION

The expanded peripheral MDSCs may contribute to poor viral clearance and disease progression during chronic HBV infection.

An Effective α/β Nucleating Agent Compoundfor the Preparation of Polypropylene

The crystallization behavior and mechanical properties were investigated by mixing the traditional α-form nucleating agent (sodium benzoate, SB) and commercialized β-form nucleating agent (TMB-5) in isotactic polypropylene (iPP). Mechanical properties were evaluated by universal testing machines. X-ray diffraction (XRD) and differential scanning calorimetry (DSC) were conducted to illustrate the crystallization behavior. Polarized optical microscopy (POM) was adopted to observe the crystal morphologies. The experimental results show that the weight ratio of two types of nucleating agents determines the final crystal structure and mechanical properties of iPP. When the weight ratio of [SB] : [TMB-5] is 4 : 1, the impact strength and flexural modulus of iPP reach a maximum value. Compared with the single component β-form nucleating agent, the compound nucleating agent exhibits significant synergistic effect and shows better mechanical properties. It is expected that this new nucleation system will have potential industrial applications.

Trends in use of lymphadenectomy in surgery with curative intent for intrahepatic cholangiocarcinoma

BACKGROUND

The role of routine lymph node dissection (LND) in the surgical treatment of intrahepatic cholangiocarcinoma (ICC) remains controversial. The objective of this study was to investigate the trends of LND use in the surgical treatment of ICC.

METHODS

Patients undergoing curative intent resection for ICC in 2000-2015 were identified from an international multi-institutional database. Use of lymphadenectomy was evaluated over time and by geographical region (West versus East); LND use and final nodal status were analysed relative to AJCC T categories.

RESULTS

Among the 1084 patients identified, half (535, 49·4 per cent) underwent concomitant hepatic resection and LND. Between 2000 and 2015, the proportion of patients undergoing LND for ICC nearly doubled: 44·4 per cent in 2000 versus 81·5 per cent in 2015 (P < 0·001). Use of LND increased over time among both Eastern and Western centres. The odds of LND was associated with the time period of surgery and the extent of the tumour/T status (referent T1a: OR 2·43 for T2, P = 0·001; OR 2·13 for T3, P = 0·016). Among the 535 patients who had LND, lymph node metastasis (LNM) was noted in 209 (39·1 per cent). Specifically, the incidence of LNM was 24 per cent in T1a disease, 22 per cent in T1b, 42·9 per cent in T2, 48 per cent in T3 and 66 per cent in T4 (P < 0·001). AJCC T3 and T4 categories, harvesting of six or more lymph nodes, and presence of satellite lesions were independently associated with LNM.

CONCLUSION

The rate of LNM was high across all T categories, with one in five patients with T1 disease having nodal metastasis. The trend in increased use of LND suggests a growing adoption of AJCC recommendations in the treatment of ICC.

The effect of aspirin on circulating tumor cells in metastatic colorectal and breast cancer patients: a phase II trial study

PURPOSE

Aspirin could reduce the risk of cancer metastasis. Circulating tumor cells (CTCs) are a key factor of cancer metastasis, but no evidence has revealed how aspirin affects CTCs and its epithelial-mesenchymal transition (EMT). Here, we conducted a clinical trial to investigate how aspirin affects CTCs in metastatic colorectal cancer (MCC) and breast cancer patients (MBC).

METHODS

The trial is retrospective registered at clinicaltrials.gov (NCT02602938). The eligible patients are given 100 mg aspirin q.d. for 8 weeks, and CTCs are evaluated at baseline, 4 and 8 weeks for absolute number, phenotype (epithelial type, E+, mesenchymal type, M+, and biophenotypic type, B+), and vimentin expression.

RESULTS

Data on 21 MCC and 19 MBC patients are analyzed, and it revealed that the CTC numbers decreased with aspirin treatment in MCC (p < 0.001) but not MBC (p = 0.0532); besides, ratio of E+ CTCs increased (p = 0.037) and M+ CTCs decreased at 2 months in MCC (p = 0.013), but neither the ratio of E+ or M+ CTCs changes significantly in MBC; vimentin expression of M+ CTCs is higher than E+ and B+ CTCs either in MBC or MCC patients at baseline (p < 0.01); and aspirin suppresses the vimentin expression in M+ (p = 0.002)and B+ (p = 0.006) CTCs of MCC and M+ CTCs of MBC (p = 0.004); besides it find vimentin expression in B+ (p = 0.004) or M+ (p < 0.001), CTCs are markedly decreased in patients with total CTC numbers declined.

CONCLUSION

Aspirin could decrease CTCs numbers and block EMT transition in MCC patients and part of MBC patients.

RNA-sequencing study of peripheral blood mononuclear cells in sporadic Ménière's disease patients: possible contribution of immunologic dysfunction to the development of this disorder

To date, the pathogenesis of Ménière's disease (MD) remains unclear. This study aims to investigate the possible relationship between potential immune system-related genes and sporadic MD. The whole RNA-sequencing (RNA-seq) technology was used to analyse the transcriptome of peripheral blood mononuclear cells of three MD patients and three control individuals. Of 366 differentially expressed genes (DEGs), 154 genes were up-regulated and 212 genes were down-regulated (|log₂ fold change| > 1 and P < 0·05). Gene ontology (GO) enrichment analysis illustrated that immune relevant factors played a key role in the pathogenesis of MD. Of 366 DEGs, we focused upon analysing the possible immune-related genes, among which the significantly up-regulated genes [glutathione S-transferase mu 1 (GSTM1), transmembrane protein 176 (TMEM176)B, TMEM176A] and down-regulated genes [solute carrier family 4 member (SLC4A)10 and SLC4A1] especially drew our attention. The mRNA expression levels of GSTM1, TMEM176B, TMEM176A, SLC4A1 and SLC4A10 were analysed by quantitative reverse transcription-polymerase chain reaction (qRT-PCR). The serum concentration of GSTM1, TMEM176B and SLC4A10 proteins were measured by enzyme-linked immunosorbent assay (ELISA). Considering the results of qRT-PCR and ELISA, it was noteworthy that GSTM1 exhibited the highest fold change between two groups, which was consistent with the deep sequencing results by RNA-seq. In conclusion, our study first offers a new perspective in MD development on the basis of RNA expression patterns, suggesting that immune factors might be involved in the MD pathogenesis. Remarkably, GSTM1 might be a possible candidate gene for the diagnostic biomarker of MD and provides the basis for further biological and functional investigations.

Comparative efficacy of five long-term weight loss drugs: quantitative information for medication guidelines

Quantitative information is scarce in current obesity medication guidelines, and they do not clearly reflect the differences in the efficacy characteristics among various drugs. This study quantitatively assessed the efficacy characteristics of five FDA-approved long-term weight loss drugs. Potentially eligible studies were obtained from public databases. Using the differences in the weight change from baseline between the drug group and the corresponding placebo group as the major indicator of efficacy, a time-effect model was established, and crucial pharmacodynamic parameters, such as the maximal efficacy, drug onset time and rate of body weight regain after the maximal efficacy point, were used to reflect the differences in efficacy among the five drugs. Finally, 50 reports (involving 43,443 participants) were included. After deducting the placebo effects, the maximal efficacies (95% CI) of orlistat (120 mg), lorcaserin, naltrexone-bupropion, phentermine-topiramate (PT, 7.5/46 mg) and liraglutide were -2.94 (-5.82, -1.27), -3.06 (-4.39, -1.71), -6.15 (-9.78, -3.25), -7.45 (-9.76, -3.88) and -5.50 (-10.62, -2.97) kg at weeks 60, 54, 67, 59 and 65 respectively, and their rates of body weight regain were 0.51, 0.48, 0.91, 1.27and 0.43 kg per year respectively. The 1-year dropout rates of orlistat, lorcaserin, naltrexone-bupropion, PT and liraglutide were 29.0, 40.9, 49.1, 34.9 and 24.3% respectively. In addition, a significant dose-effect correlation was observed for orlistat and PT. This study provides valid quantitative information for medication guidelines.

Tyrosine phosphorylation of Kv1.5 is upregulated in intrauterine growth retardation rats with exaggerated pulmonary hypertension

Intrauterine growth retardation (IUGR) is associated with the development of adult-onset diseases, including pulmonary hypertension. However, the underlying mechanism of the early nutritional insult that results in pulmonary vascular dysfunction later in life is not fully understood. Here, we investigated the role of tyrosine phosphorylation of voltage-gated potassium channel 1.5 (Kv1.5) in this prenatal event that results in exaggerated adult vascular dysfunction. A rat model of chronic hypoxia (2 weeks of hypoxia at 12 weeks old) following IUGR was used to investigate the physiological and structural effect of intrauterine malnutrition on the pulmonary artery by evaluating pulmonary artery systolic pressure and vascular diameter in male rats. Kv1.5 expression and tyrosine phosphorylation in pulmonary artery smooth muscle cells (PASMCs) were determined. We found that IUGR increased mean pulmonary artery pressure and resulted in thicker pulmonary artery smooth muscle layer in 14-week-old rats after 2 weeks of hypoxia, while no difference was observed in normoxia groups. In the PASMCs of IUGR-hypoxia rats, Kv1.5 mRNA and protein expression decreased while that of tyrosine-phosphorylated Kv1.5 significantly increased. These results demonstrate that IUGR leads to exaggerated chronic hypoxia pulmonary arterial hypertension (CH-PAH) in association with decreased Kv1.5 expression in PASMCs. This phenomenon may be mediated by increased tyrosine phosphorylation of Kv1.5 in PASMCs and it provides new insight into the prevention and treatment of IUGR-related CH-PAH.

Quantitative analysis of efficacy and associated factors of calcium intake on bone mineral density in postmenopausal women

A model-based meta-analysis method was performed to quantitatively analyze the efficacy characteristics of calcium intake in BMD increase among postmenopausal women. We found that age and calcium intake dose were key factors affecting the efficiency and onset of BMD change, and daily 1200 mg calcium was suggested to be a beneficial dosage.

INTRODUCTION

This paper aims to quantify the efficacy of calcium intake in preventing bone mineral density (BMD) decrease among postmenopausal women and to investigate the factors that may affect the efficacy.

METHODS

Comprehensive literature search was conducted in PubMed and EMBASE from January 2016. Placebo-controlled or no-treatment controlled randomized trials focused on calcium intake for the management of osteoporosis in postmenopausal women were included. The clinical and demographic characteristics of participants and efficacy data, defined as the mean percentage change of spine BMD (L2-L4) at each observation time point compared with that of baseline, were extracted from the studies. Model-based meta-analysis (MBMA) was used to describe the time course of BMD change by calcium intake and identify the related factors.

RESULTS

This study includes 17 trials involving 2537 subjects. The results showed that a classic pharmacodynamic maximal effect (E _max) model could describe the time course of BMD change by calcium intake. Using this model, we found that age and calcium intake dose were key factors affecting the efficiency and onset of BMD change. A 60-year-old woman administered with 800 mg/day calcium can achieve a maximum BMD increasing rate of 2.38%, and the time to reach 50% of this maximum (known as onset time) was 9.44 months. An increase of 0.0817% per year was noted in the maximal effect value for women aged between 50 and 83 years. For calcium dose interval from 250 to 2000 mg/day, the onset time was expressed as 9.44 × (dose/800)^-1.33 months. Two-year calcium intake of 700, 1200, and 2000 mg/day resulted in a maximum efficacy of BMD of 68.0, 81.3, and 89.6%, respectively. This indicates that the final efficacy had already reached the plateau (>80% E _max) under the 1200-mg/day dose.

CONCLUSION

Calcium intake can effectively postpone the tendency of BMD decrease in postmenopausal women. An increased calcium dose contributes to the shortening of the onset time. Considering the drug-acting rate and safety into account, menopausal women can be administered with a rational dose of 1200 mg/day to reduce bone loss.

Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study

Peroral endoscopic myotomy (POEM) has been widely applied to the treatment of achalasia. The aim of this study is to retrospectively investigate the long-term outcome of POEM in patients with achalasia. Patients undergoing POEM at our center with a minimum follow-up of 3 years were enrolled in this study. Relief of patients' symptom was defined as the primary outcome. Secondary outcomes included lower esophageal sphincter pressure, esophageal emptying, symptoms relapse, and clinical reflux adverse events. The Chi-square test was performed to determine the potential predictors of surgical failure. Sixty-seven patients (aged 40.7 ± 15.3 years) were recruited in the study, with a mean follow-up period of 40.1 ± 2.8 months. At the final follow-up, the median Eckardt score reduced from 7.6 ± 2.3 preoperatively to 1.9 ± 1.7 (P < 0.001), the lower esophageal sphincter pressure was reduced from 35.4 ± 13.7 mmHg preoperatively to 8.9 ± 4.1 mmHg (P < 0.001), and the height of the barium column at 5 min after barium swallowed was reduced from 9.7 ± 1.6 cm preoperatively to 2.9 ± 2.1 cm (P < 0.001). Eight patients had symptoms relapse and nine patients developed reflux esophagitis. Type III achalasia was found to be indicative of surgical failure. POEM was a promising treatment for patients with achalasia, which can yield a long-term relief of the symptom and a low rate of clinical reflux adverse events.

[One of the pitfalls in the surgical treatment of maisonneuve fractures: a case report]

There exist controversies in the surgical treatment of maisonneuve injury with regard to reduction and fixation of syndesmosis and management of proximal fibular fracture. It is very important for the orthopaedic surgeons to learn more techniques and avoid pitfalls from clinical practice. We summarized the clinical data of 1 failed case, a 20-year-old girl with big body weight who underwent a primary surgery for the treatment of maisonneuve fracture with minimally invasive reduction and fixation of ankle syndesmosis and posterior malleolus and open reduction and internal fixation of medial malleolus, then a revision surgery for the treatment of iatrogenic syndesmotic malreduction with open reduction and re-stabilization of ankle syndesmosis supplemented with open reduction and internal fixation of proximal fibular facture. The malreduction of distal fibula was not found until finishing the postoperative computed tomography (CT) scan 2 weeks after the primary surgery, then the patient experienced an revision surgery including removal of the screws installed primarily for fixation of ankle syndesmosis, and open reduction and internal fixation of proximal fibular fracture, and limited open reduction and re-stabilization of ankle syndesmosis. Then the patient rehabilitated regularly under the direction of the surgeon who performed these two operations, and the postoperative recovery was smooth, then the hardwares for fixation of ankle syndesmosis and fracture of proximal fibula and medial malleolus were removed at different postoperative time. The patient experienced an excellent outcome at the end of the 3-year follow-up. The reasons for the failure in this case might include the overemphasized minimally invasive technique in the process of reduction, inaccurate assessment of intraoperative fluoroscopy and postoperative radiographs, and inappropriate utilization of the reduction clamp. Attention should be paid to the fact that an obliquely placed clamp for closed reduction of diastasis of ankle syndesmosis could result in syndesmotic malreduction. The worsened alignment of the fracture end of proximal fibula observed by intraoperative fluoroscopy may alert surgeons to syndesmotic malreduction. Partial exposure of syndesmosis and anatomical reduction and fixation of proximal fibular fracture may be useful measurres to avoid malreduction of ankle syndesmosis in the surgical treatment of maisonneuve injury in some patient, especially the patient with critically destabilized ankle.