The persistence of seroprotective levels of antibodies after vaccination with PreHevbrio, a 3-antigen hepatitis B vaccine

Prevention of hepatitis B virus (HBV) infection by vaccination can potentially eliminate HBV-related diseases. PreHevbrio™/PreHevbri® is a 3-antigen (S, preS1, preS2) HBV vaccine (3A-HBV) recently licensed for adults in the US, EU and Canada. This study evaluated antibody persistence in a subset of fully vaccinated and seroprotected (anti-HBs ≥ 10 mIU/mL) Finnish participants from the phase 3 trial (PROTECT) of 3A-HBV versus single-antigen HBV vaccine (1A-HBV). 465/528 eligible subjects were enrolled (3A-HBV: 244; 1A-HBV: 221). Baseline characteristics were balanced. After 2.5 years, more 3A-HBV subjects remained seroprotected (88.1 % [95 %CI: 84.1,92.2]) versus 1A-HBV (72.4 % [95 %CI: 66.6,78.3)], p < 0.0001) and had higher mean anti-HBs [1382.9 mIU/mL (95 %CI: 1013.8,1751.9) versus 252.6 mIU/mL (95 %CI: 127.5,377.6), p < 0.0001]. In multiple variable logistic regression analysis including age, vaccine, initial vaccine response, sex and BMI, only higher post dose 3 (Day 196) antibody titers significantly reduced the odds of losing seroprotection.

Performance of a cryo-cooled crystal monochromator illuminated by hard X-rays with MHz repetition rate at the European X-ray Free-Electron Laser

Due to the high intensity and MHz repetition rate of photon pulses generated by the European X-ray Free-Electron Laser, the heat load on silicon crystal monochromators can become large and prevent ideal transmission in Bragg diffraction geometry due to crystal deformation. Here, we present experimental data illustrating how heat load affects the performance of a cryogenically cooled monochromator under such conditions. The measurements are in good agreement with a depth-uniform model of X-ray dynamical diffraction taking beam absorption and heat deformation of the crystals into account.

No Difference in Ligamentous Strain or Knee Kinematics Between Rectangular or Cylindrical Femoral Tunnels During Anatomic ACL Reconstruction With a Bone-Patellar Tendon-Bone Graft

BACKGROUND

As our understanding of anterior cruciate ligament (ACL) anatomy has evolved, surgical techniques to better replicate the native anatomy have been developed. It has been proposed that the introduction of a rectangular socket ACL reconstruction to replace a ribbon-shaped ACL has the potential to improve knee kinematics after ACL reconstruction.

PURPOSE

To compare a rectangular femoral tunnel (RFT) with a cylindrical femoral tunnel (CFT) in terms of replicating native ACL strain and knee kinematics in a time-zero biomechanical anatomic ACL reconstruction model using a bone-patellar tendon-bone (BTB) graft.

STUDY DESIGN

Controlled laboratory study.

METHODS

In total, 16 fresh-frozen, human cadaveric knees were tested in a 5 degrees of freedom, computed tomography-compatible joint motion simulator. Knees were tested with the ACL intact before randomization to RFT or CFT ACL reconstruction using a BTB graft. An anterior translation load and an internal rotation moment were each applied at 0°, 30°, 60°, and 90° of knee flexion. A simulated pivot shift was performed at 0° and 30° of knee flexion. Ligament strain and knee kinematics were assessed using computed tomography facilitated by insertion of zirconium dioxide beads placed within the substance of the native ACL and BTB grafts.

RESULTS

For the ACL-intact state, there were no differences between groups in terms of ACL strain or knee kinematics. After ACL reconstruction, there were no differences in ACL graft strain when comparing the RFT and CFT groups. At 60° of knee flexion with anterior translation load, there was significantly reduced strain in the reconstructed state ([mean ±standard deviation] CFT native, 2.82 ± 3.54 vs CFT reconstructed, 0.95 ± 2.69; RFT native, 2.77 ± 1.71 vs RFT reconstructed, 1.40 ± 1.76) independent of the femoral tunnel type. In terms of knee kinematics, there were no differences when comparing the RFT and CFT groups. Both reconstructive techniques were mostly effective in restoring native knee kinematics and ligament strain patterns as compared with the native ACL.

CONCLUSION

In the time-zero biomechanical environment, similar graft strains and knee kinematics were achieved using RFT and CFT BTB ACL reconstructions. Both techniques appeared to be equally effective in restoring kinematics associated with the native ACL state.

CLINICAL RELEVANCE

These data suggest that in terms of knee kinematics and graft strain, there is no benefit in performing the more technically challenging RFT as compared with a CFT BTB ACL reconstruction.

Materials Imaging and Dynamics (MID) instrument at the European X-ray Free-Electron Laser Facility

The Materials Imaging and Dynamics (MID) instrument at the European X-ray Free-Electron Laser (EuXFEL) facility is described. EuXFEL is the first hard X-ray free-electron laser operating in the MHz repetition range which provides novel science opportunities. The aim of MID is to enable studies of nano-structured materials, liquids, and soft- and hard-condensed matter using the bright X-ray beams generated by EuXFEL. Particular emphasis is on studies of structure and dynamics in materials by coherent scattering and imaging using hard X-rays. Commission of MID started at the end of 2018 and first experiments were performed in 2019.

Acute coronary syndrome and thrombophilia in young patients:clinical data, experience

Introduction

There is an increasing number of young patients with acute coronary syndromes. The gold standard for diagnosis and treatment remains coronary angiography and primary percutaneous coronary intervention (PPCI). Especially in young individuals there are cases with large thrombus burden and almost none angiographically visible coronary atherosclerosis, which raises major concerns about the etiological cause for such events. Thrombophilia can lead to repeated and unexplained thrombus formation and that is why recently there is an increasing interest in the relationship between thrombophilia and acute coronary syndrome (ACS) in early age. Still there's no precise treatment algorithm.

Purpose

To diagnose and evaluate the frequency of thrombophilia in patients presenting with first ACS in young age and to alter future treatment in order to prevent further events and improve prognosis.

Methods

We evaluated all patients with first ACS from age&lt;40 for men and women &lt;50 in our hospital for 3 years. All patients were diagnosed and treated with PPCI. Complete family history was taken. We performed laboratory tests for the most frequent gene mutations, responsible for thrombophilia factor V Leiden, PAI –1 4G/5G, prothrombin G20210A, MTHFR - C677T, MTHFR A 1287C, MTHFR A 1298C and glycoprotein IIb/IIIa in all patients.

Results

210 patients with ACS were admitted with 36 young patients (age men &lt;40 and women &lt;50). In all we performed screening for thrombophilia. 32 individuals (5 women and 27 men; mean age of 46) had a distinct genetic variation which can be attributed to thrombophilia. 85% of them had family history for ischemic heart disease. The conventional risk factors for coronary artery disease (CAD), including arterial hypertension, dyslipidemia, smoking, and diabetes were presented respectively in 43%, 57%, 43% and 3% in the group. The most often diseased artery was the left anterior descending artery (LAD). The genetic evaluation results were 20% homozygotes of pathogenic variation of factor V of Leiden, 7% heterozygotes of pathogenic form of factor V of Leiden 25% PAI 1 4G/5G homozygotes, 11% PAI 1 4G/5G heterozygotes, 13% prothrombin G20210A homozygotes and 2% prothrombin G20210A heterozygote. In 28% the index event was a repeated ACS and 4% has had a previous ischemic stroke. We then consulted all of them with haemathologist and altered further discharge treatment (in 100% new oral anticoagulants (NOAC) was added to dual antipatled therapy). In follow up at the first year 70% were left on aspirin 100mg and NOAC and 10% were considered high risk and were left on two NOAC.

Conclusion

Thrombophilia is an indipendant risk factor for myocardial infarction in young patients and should not be easily overlooked. In them screening for thrombophilia could be beneficial, especially for the follow-up treatment and improvement of the late prognosis. Such detection could prevent subsequent AMI.

Funding Acknowledgement

Type of funding source: Private hospital(s)

A prospective multicentre randomized all-comers trial to assess the safety and effectiveness of the ultra-thin-strut sirolimus-eluting coronary stent Supraflex: 2-year results of the TALENT trial

Background and purpose

Supraflex is a sirolimus-eluting stent with a biodegradable polymeric coating and 60um ultra-thin struts. In the TALENT study, we found the Supraflex stent was non-inferior to the Xience stent for a device-oriented composite endpoint (DOCE, defined as cardiac death, target-vessel myocardial infarction, or clinically indicated target lesion revascularisation) at 12 months in an all-comer population. Additionally, per-protocol analysis showed a significantly lower clinically indicated target lesion revascularisation (CI-TLR) in the Supraflex group than in the Xience group. We now present the 2-year follow-up results.

Methods

The TALENT study was a prospective, randomised, single-blind, multicentre study across 23 centres in Europe. Eligible participants underwent percutaneous coronary intervention in an all-comers fashion in vessels of 2.25–4.5 mm. Patients were randomized (1:1) to implantation of either Supraflex or Xience (NCT02870140).

Results

Between October 21, 2016 and July 3, 2017, 720 patients with 1046 lesions were randomly assigned to Supraflex, and 715 patients with 1030 lesions to Xience. At 24 months, DOCE had occurred in 49 patients (6.9%) in the Supraflex group and in 56 patients (7.9%) in the Xience group (absolute difference −1.0% [95% CI: −3.7 to 1.7], Plog-rank=0.491). Per-protocol analysis at 24 months showed CI-TLR occurred in 21 and 30 patients in the Supraflex and Xience, respectively (3.3% versus 4.5%, absolute difference −1.2%, [95% CI: −3.3 to 0.9], Plog-rank=0.267).

Conclusion

In an all-comer population, at 2-year follow-up, the use of Supraflex stent was at least as safe and efficacious as Xience stent. However, the significantly lower rate of CI-TLR shown in patients treated with Supraflex at 1-year was no longer retained in the 2-year results. Whether theoretical advantage of ultra-thin strut drug eluting stents Supraflex can translate into clinical benefit or not will be further elucidated through a total of 3 years of follow-up.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): SMT

Implication of real-time telemonitoring system in the diagnostics of cardiac diseases

Objectives

We assessed the implication of a live telemonitoring system Check Point Cardio with real-time remote diagnostics in the diagnosis of a wide range of cardiac diseases- from rhythm disturbances to ischaemic heart disease.

Methods and results

In the period between 10.01.2017 and 10.01.2019 a total of 14172 patients were monitored. The mean monitoring period for the whole group was 7.76 (±4.5) days. The primary indication for real-time monitoring was rhythm and conduction abnormalities (66%) and ischemia detection (34%). In 2087 (14,8%) of the patient a clinically significant pathological finding was observed. A total of 603 (4,3%) patients were referred to a planned hospitalization with the most common reasons- ST segment deviation (450 pts), clinically significant bradycardia due to AV block- (21 pts); Sinus arrest/SA block (90 pts) and pacemaker malfunction in 20 patients, wide complex tachycardia was observed in 7 patients.

In addition to that 42 patients were referred to an emergent hospitalization after a contact by our team. From those patients 30 were with ST segment elevation, 10 were with ST- segment depression and 2 were with sustained wide complex tachycardia.

Conclusion

Real-time telemonitoring accompanied with real-time remote diagnostics is a reliable method for diagnosis of wide-range cardiac diseases. The possibility of immediate diagnosis and contact with the patient, combined with GPS localization, allows a fast reaction in case of an emergent situation.

Funding Acknowledgement

Type of funding source: None

Hip capsular strain varies between ligaments dependent on both hip position- and applied rotational force

PURPOSE

To noninvasively characterize the ligament strain in the hip capsule using a novel CT-based imaging technique.

METHODS

The superior iliofemoral ligament (SIFL), inferior iliofemoral ligament (IIFL), ischiofemoral ligament (IFL) and pubofemoral ligament (PFL) were identified and beaded in seven cadavers. Specimens were mounted on a joint motion simulator within an O-arm CT scanner in - 15°, 0°, 30°, 60°, and 90° of flexion. 3 Nm of internal rotation (IR) and external rotation (ER) were applied and CT scans obtained. Strains were calculated by comparing bead separation in loaded and unloaded conditions. Repeated-measures ANOVA was used to evaluate differences in strain within ligaments between hip positions.

RESULTS

For the SIFL, strain significantly decreased in IR at 30° (p = 0.045) and 60° (p = 0.043) versus 0°. For ER, there were no significant position-specific changes in strain (n.s.). For the IIFL, strain decreased in IR and increased in ER with no significant position-specific differences. For the IFL, strain increased with IR and decreased with ER with no significant position-specific differences. Finally, in the PFL there was a significant flexion angle-by-load interaction (p < 0.001; ES = 0.566), with peak strains noted at 60˚, however pair-wise comparisons failed to identify significant differences between positions (n.s.). Strain decreased in ER, with no significant position-specific differences.

CONCLUSION

The SIFL and IIFL limit hip external rotation with greater effect in higher flexion angles, while the IFL and PFL limit hip internal rotation. Following hip arthroscopy, consideration should be given to restricting external rotation as traditional capsulotomies cause injury to the SIFL and IIFL.

P183 Cor medusae

A 75-years-old man presented in our cardiology service with easy fatigue, shortness of breath and palpitations for last two months. His ECG showed atrial fibrillation and LBBB. Until now he was not anticoagulated. We performed first transthoracic echocardiography and found reduced EF - 33%, with global hypokinesia of the LV and LV hypertrophy. Many atrial and ventricular septal perforating arteries. Dilated right coronary sinus. Mild mitral, aortic and tricuspid regurgitation with no pulmonary hypertension. We identified a strongly curved vascular structure in right atrioventricular groove. We performed coronary CT angiography and found abnormal coronary vessels "Cor Medusae" (coronary arteriovenous fistula). Giant RCA - 31mm in diameter with many branches, one of them has comuniction with left atrium and one of the other comunicate with truncus pulmonalis. LAD, LCx and D1 came from truncus pulmonalis. A very rare congenital condition. On a cardiology discussion we decided to apply conservative treatment.

Abstract P183 Figure. CT reconstruction cor medusae

P1962Impact of Dual Antiplatelet Therapy duration on clinical outcome after stent implantation for coronary bifurcation lesions: results from the Euro Bifurcation Club - P2BiTO - registry

Background

Duration of Dual Antiplatelet Therapy (DAPT) following Acute Coronary Syndromes (ACS) or Stable Coronary Artery Disease (SCAD) treated with coronary stenting is still debated. Although current guidelines consider several “clinical” criteria to decide for short DAPT (<6 months), standard DAPT (12 months) and prolonged DAPT (>12 months), the relationship between DAPT duration, treatment of bifurcations and its impact on clinical outcome has been poorly investigated in real world registries.

Purpose

We evaluated the impact of DAPT duration on clinical outcomes in consecutive all-comers patients treated with stenting of coronary artery bifurcation lesions included in the Euro Bifurcation Club -P2BiTO - registry.

Methods

Data on 5036 consecutive patients who underwent PCI on coronary bifurcation at 17 major coronary intervention centres between January 2012 and December 2014 were collected. The primary endpoint of the study was the cumulative occurrence of Major Adverse Cardiac Events (MACCE), defined as a composite of overall-death death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and stroke during the follow-up; the secondary endpoints were the single occurrence of any of the above mentioned events.

Results

Data on DAPT duration was available for 3992 patients (79%). Patients were divided into 3 groups: Group 1) DAPT <6-months (n=720); Group 2) DAPT >6-months but <12-month (n=1602); Group 3) DAPT >12-months (n=1670). Follow up was completed in 3935 (98%) patients with a median of 20 months (C.I.=12–28). At 24 months after the index procedure, MACCE occurred more frequently in the DAPT <6-month group (Group 1) as compared with both Group 2 and 3 (respectively, 102 (14%) versus 154 (10%) and 164 (10%), HR: 0.72 (0.64–0.82), p<0.001). This difference remains after adjustment for clinical and angiographic characteristics (HR: 0.66 (0.58–0.77), p<0.001). On the contrary, no significant difference was found between Group 2 and Group 3 patients. At the Kaplan-Meier analysis (Figure 1), freedom from MACCE survival was significantly lower in patients receiving DAPT for less than 6 months (Log-Rank: 29.5, p<0.001).

Figure 1. Kaplan-Meier curves

Conclusions

In the P2BiTO registry, short DAPT duration of less than 6 months was associated with a significantly higher risk of MACCE compared to longer DAPT in a real-world registry of patients treated for coronary artery bifurcation stenosis.

P3105Cardiopulmonary exercise testing normal values for young athletes and non-athletes

Introduction

Cardiopulmonary exercise testing (CPET) is an important diagnostic method to evaluate athletes and non-athletes, however we do not have widely accepted normal values for correct evaluation and interpretation in the young.

Goals

Our aim was to compare CPET parameters of young athletes and non-athletes and determine reference values.

Methods

Exercise tests were performed in young non-athletes, aged <18 years between 2011 to 2016 at Mayo Clinic. Athletes underwent detailed sports cardiology screening including CPET at Semmelweis University Heart and Vascular Center between 2016 and 2018. Individuals with cardiovascular disease were excluded. We created 2 subgroups in both sexes: 12–14 years (Group 1), 15–17 years (Group 2). Statistical analysis was performed using SAS with analysis of variance under the general linear model adjusting for age, body mass index and test effort based on peak respiratory exchange ratio (RER).

Results

A total of 212 athletes (92% male, 15.5±0.6ys) and 207 non-athletes (68% male, 15.0±0.7ys) were included in the analysis. In Group 1 boys, athletes have higher peak HR (200.0±9.2 vs 188.5±16.8 bpm, p<0.0001), HR reserve (117.1±14.5 vs 108.9±19.8 bpm p<0.05), VO2 max (53.7±6.6 vs 44.7±9.1 mL/kg/min p<0.0001), ventilation (VE) (120.3±25.0 vs 70.7±21.6 L/min p<0.0001) and RER (1.12±0.0 vs 1.07±0.08, p <.001) compared to controls. In Group 2 boys, there was no difference in peak HR and HR reserve, but athletes have higher VO2 max (57.2±4.7 vs 45.3±9.3 mL/kg/min, p<0.0001) and VE (150.7±23.7 vs 104.1±25.9 L/min, p<0.0001), similarly as Group 2 girls: VO2 max (46.3±3.6 vs 34.9±8.5 mL/kg/min p<0.0001), VE (118.7±12.5 vs 68.4±20.6 L/min, p<0.0001). In male athletes, peak HR (200.6±9.2 vs 196.5±7.4 bpm p<0.05) and HR recovery (34.2±9.8 vs 29.8±11.1 bpm p<0.05) decreases with age, while VO2 max (53.7±6.6 vs 57.2±4.7 mL/kg/min, p<0.001) and VE (120.3±24.9 vs 150.7±23.7 L/min, p<0.0001) increases. Lower cut-off values were determined in each group (Figure).

Lower-cut off values

Conclusion

We created a unique Mayo-Semmelweis database of young athletes and non-athletes. As a result of intensive training, athletes show higher levels of CPET variables vs non-athletes. Our study provides CPET reference values in the pediatric age group, applying them could contribute to correct evaluation and interpretation of CPET, increasing its diagnostic potential.

P4566Comparison of standard renal denervation procedure versus novel distal and branch vessel ablation with brachial arterial access

Objectives

We assessed a novel approach to percutaneous renal denervation for uncontrolled hypertension consisting of ablation beyond the proximal main renal artery (Y-pattern), including the primary branches, and compared it to the standard procedure applied only within the main vessel. We also assessed the safety and practicality of a brachial access approach.

Methods and results

Renal denervation was performed on 119 consecutive patients (60±13 years). In 68 of the patients, femoral arterial vascular approach was used and in 51 brachial. In 80 patients treated with the standard ablation, 12.0±3.0 total ablations (both sides) were applied while 20.4±3.9 total ablations were delivered for the group of 39 patients with Y-pattern denervation (P<0.001). Technically successful renal denervation was achieved in all patients. Office blood-pressure levels at baseline were 170±17/93±10 mm Hg for the standard group and 169±13/96±9 mm Hg for the Y-pattern group. No major adverse events occurred during the procedure or in the postprocedural in-hospital period. Renal denervation was associated with significant decreases in both office and ambulatory systolic and diastolic blood pressure in both groups. The reduction in 24-hour mean ambulatory systolic blood pressure at 6 months was significantly greater (P=0.002) for the Y-Pattern group (−22.1±15.4 mm Hg) compared to the Standard group (−11.8±16.2 mm Hg). Changes in diastolic office and ambulatory pressure were also significantly greater at 6 months in the Y-pattern ablation group. Indices of blood pressure variability improved in both groups.

Between group comparison of blood pressure and other parameters at follow up Standard Y-Pattern P (Standard vs Y) Change in Office Diastolic Blood Pressure (mmHg)   1 Month −8.0±13.2* −9.8±8.5* 0.49   3 Months −6.3±6.9* −6.4±9.0* 0.96   6 Months −5.0±9.0* −9.9±10.8* 0.01 Change in Ambulatory Diastolic Pressure (mmHg)   24-Hour −5.2±8.4* −6.2±10.0* 0.61   Daytime −3.2±9.4* −5.6±10.0* 0.24   Night Time −7.6±8.4* −6.5±11.5* 0.56 Antihypertensive Medication Classes 4.9±1.1* 5.3±0.8* 0.07 otal Number of Lesions† 12.0±3.0 20.4±3.9 <0.001

Conclusion

Renal denervation using a Y-pattern ablation strategy combined with a greater number of lesions is safe and resulted in significant greater decreases in mean 24-hour ambulatory systolic and diastolic blood pressure compared to the conventional

Self-structuring in Zr1-xAlxN films as a function of composition and growth temperature

Nanostructure formation via surface-diffusion-mediated segregation of ZrN and AlN in Zr_1−xAl_xN films during high mobility growth conditions is investigated for 0 ≤ × ≤ 1. The large immiscibility combined with interfacial surface and strain energy balance resulted in a hard nanolabyrinthine lamellar structure with well-defined (semi) coherent c-ZrN and w-AlN domains of sub-nm to ~4 nm in 0.2 ≤ × ≤ 0.4 films, as controlled by atom mobility. For high AlN contents (x > 0.49) Al-rich ZrN domains attain wurtzite structure within fine equiaxed nanocomposite wurtzite lattice. Slow diffusion in wurtzite films points towards crystal structure dependent driving force for decomposition. The findings of unlikelihood of iso-structural decomposition in c-Zr_1−xAl_xN, and stability of w-Zr_1−xAl_xN (in large × films) is complemented with first principles calculations.

Disabling Pansclerotic Morphea of Childhood Poses a High Risk of Chronic Ulceration of the Skin and Squamous Cell Carcinoma

Disabling pansclerotic morphea of childhood (DPMC) is a rare and severe variant of scleroderma. This report presents 3 cases that presented to the authors and studies 25 patients from the literature (English language only) for the presence of chronic nonhealing ulcers of skin and skin cancer. The authors identified a total of 30 patients (9 male and 21 female) aged between 1 and 37 years at time of presentation. All cases were less than 14 years old when the disease started. The majority of patients had an aggressive course with deep sclerotic lesions leading to joint contractures and immobility. Five patients suffered from chronic nonhealing leg ulcers (17%), but ulcers were present on other parts of the body (upper limbs, trunk, head) as well (n = 6). Four patients died because of complications of the disease such as sepsis or gangrene. Two patients developed a squamous cell carcinoma at the age of 16 years and 19 years, respectively (6.7%). The available treatment of DMPC-associated ulcers is unsatisfying. Only temporary improvements have been seen in a minority of patients. We report on marked improvement of chronic leg ulcers by a combination of sildenafil 3 × 20 mg/day and repeated application of a porcine small intestinal submucosal acellular matrix.

Delta deletion 4977 in mitochondrial DNA in patients with idiopathic Parkinson's disease

AIM

To determine the presence of delta deletion 4977 in mitochondrial DNA in patients with Idiopathic Parkinson's disease (IPD).

MATERIAL AND METHODS

This has been a prospective, clinically genetic study, lasting for whole two years. The clinical part of this study was made at the University Clinic of Neurology in Skopje, Unit for extrapyramidal diseases. The laboratory-genetic part of the study was elaborated at the Laboratory for molecular biology at the Institute for Biology, Faculty of Sciences, University "Sts. Cyril and Methodius". This study comprised a total of 32 subjects with a clinically verified diagnosis for idiopathic Parkinson's disease; 18 men and 14 women (with mean age of 52.7 years). Control group consisted of 31 randomly selected, literally healthy persons, at similar age, with similar gender distribution, and no clinical and anamnestic data for parkinsonism or similar clinical entities.

RESULTS

Objective neurologic results of all 32 investigated subjects (100%) showed presence of rigor, tremor and bradykinesia.The difference tested between the investigated and control group, concerning the present or absent deletion and heteroplasmia, has been highly statistically significant (p=0.001).

CONCLUSION

It could be concluded with a great statistical significance that deletion 4977 in mitochondrial genome has been registered more frequently in the group of patients with IPD (Tab. 10, Fig. 6, Ref. 36).

Aorto-bifemoral revascularisation after radiation, peritonitis and colostomy

The success of all vascular interventions depends mainly on the chosen strategy and access, especially in patients with severe co-morbidities, preceding operations or infection. In these cases the combination of retroperitoneal approach and extra-anatomical bypasses makes the revascularization possible. We present a clinical case of a patient after radiotherapy, peritonitis and colostomy with persistent pain in the lower extremities and angiographic finding of bilateral occlusion in the aorto-iliac segment. We did a right retroperitoneal aorto-femoral reconstruction and a crossover femoro-femoral bypass. It is also possible to perform visceral and renal arterial reconstructions with the retroperitoneal approach. In addition, symptomatic and ruptured aneurysms, as well as infected aortic grafts can be operated on with optimal results, without a notable increase in mortality.

Local structure of layered oxide electrode materials for lithium-ion batteries

Li-ion batteries are promising candidates for electrical energy storage in applications ranging from portable electronics to hybrid and electric vehicles. In this context, layered compounds in the Li(1+delta)(TM(x)Mn(1-x))(1-delta)O(2) family (TM = transition metal) have received much attention due to their high capacity and stability. In this Research News article we describe recent advances on structural characterization of Li-ion electrode materials using state-of-the-art electron microscopy. Direct evidence of the monoclinic nature of Li(2)MnO(3) has been provided. It has been demonstrated that differences in Z-contrast imaging between Li(2)MnO(3) and LiTMO(2) may be used to screen samples for phase separation in the 10-100 nm scale.

Clinical, neurophysiologic, neuropsychological findings and short genetic analysis in patients with idiopathic Parkinson's disease

The aim of this paper is to analyze the results of correlation of clinical symptoms and their characteristics with the results of neurophysiologic, neuropsycologic investigations and short genetic analyses in patients with Idiopathic Parkinson's disease (IPD).

MATERIAL AND METHODS

The paper is a prospective and retrospective study of 15 IPD patients and 25 patients with different forms of parkinsonism.

RESULTS

Patients with idiopathic Parkinson's disease had all cardinal symptoms characteristic for the disease: tremor, rigidity and reduced postural reflexes in 100%.

CONCLUSION

Clinical, neurophysiologic, neuropsychologic and neuroimaging methods of investigations showed changes that are nonspecific in proportions corresponding to those in available literature (Tab. 3, Fig. 2, Ref. 11).

[Adjuvant and individual application of lumbar sympathectomy at patient with arterial disease in lower limb]

The first lumbar sympathectomy for treatment of arterial occlusive disease of the lower extremity was performed in 1924 by Julio Diez of Buenos Aires. The standart anatomy textbooks indicate, as a rule that the lumbar sympathetic trunk contains four or five ganglia. The overall anatomic denervation is important for achievement of an adequate sympathectomy of a given segment of an extremity. Criteria and indications for complete sympathetic block are still not clear. Exceptionally important for the improvement of the reology of the lower limbs is the option for a direct increase of the collaterals' debit which could be achieved by extensive profundoplasty. As an addition to the arterial reconstructions, the sympathectomy increases the passability of small vessel anastomosis and the recovery of traumatized arteries. Unilateral or bilateral lumbar sympathectomy is performed by retroperitonal access. From 01.01.2008 till 01.11.2008 in our clinic were performed 117 isolated and after arterial reconstruction lumbar sympathectomies.

[Surgical treatment for stenotic lesion of the subclavian artery]

We present a case of a 56-year-old male patient who was admitted at the clinic with complains of pain and blue-colored index finger of the left hand since a couple of days. He has an anamnesis of claudication of the left arm. After the contrast CT-angiogram, which showed a 80% stenosis of the left subclavian artery, the patient had an allergic reaction. This changed our initial plan for an endovascular intervention and we proceeded to an open surgical procedure. Because of the suitable anatomical characteristics we did a replantation of the subclavian artery to the common carotid artery. The postoperative period went smoothly. Six months after the intervention the patient is feeling fine. He has pulse on the radial and ulnar arteries and no sign of the necrosis of the index linger. Subclavian-carotid transposition is a safe method for the treatment of steno-occlusive lesions of the subclavian artery. Except the ortograde physiological blood flow through the vertebral artery and the construction of only one anastomosis, the main advantage over the bypass surgery is not using autogenous or heterogenous prosthetic material.

Detection of single atoms and buried defects in three dimensions by aberration-corrected electron microscope with 0.5-A information limit

The ability of electron microscopes to analyze all the atoms in individual nanostructures is limited by lens aberrations. However, recent advances in aberration-correcting electron optics have led to greatly enhanced instrument performance and new techniques of electron microscopy. The development of an ultrastable electron microscope with aberration-correcting optics and a monochromated high-brightness source has significantly improved instrument resolution and contrast. In the present work, we report information transfer beyond 50 pm and show images of single gold atoms with a signal-to-noise ratio as large as 10. The instrument's new capabilities were exploited to detect a buried Sigma3 {112} grain boundary and observe the dynamic arrangements of single atoms and atom pairs with sub-angstrom resolution. These results mark an important step toward meeting the challenge of determining the three-dimensional atomic-scale structure of nanomaterials.

[Endovascular procedures in case of cancers engaging the vessels of the small pelvis]

Cervix cancer is quite common nowadays. Its progress is followed by painful symptomatology, urosepsis, lymphedem, flebothrombosis and ischemia of the lower limbs. The surgical treatment and the following chemotherapy and radiotherapy causes proliferation of the fibroid tissue, which embraces and presses the vessels of the small pelvis. We are to depict two clinical cases in which the choice of the percutaneous transluminal angioplasty and the implementation of a covered stent - graft is preferable to the open surgery. During the predilatation with a balloon catheter, our first patient suffered of a vessel rupture, visualized on the intraoperative angiogram. The rupture of vessel during angioplasty usually demands open surgical correction, but endovascular procedure can provide a fast, efficient, and less aggressive method. Covered stent-grafts are applicable for both treatment and stabilization of vessel lesions.

Sublimation of atomic layers from a chromium surface

We employ low-energy electron microscopy to study the kinetics of thermal etching, or sublimation, of Cr(001) at approximately 1100 K. Atomic layers are removed from the surface by spontaneous nucleation and growth of two-dimensional vacancy islands, by rotation of spiral steps, and by island decay. The growth rates of vacancy islands and the rotation frequencies of double spirals are measured as a function of temperature, and the results are correlated with activation barriers of surface processes. Mass transport between the surface and bulk is shown to be unimportant.

The objective severity assessment of atopic dermatitis (OSAAD) score: validity, reliability and sensitivity in adult patients with atopic dermatitis

BACKGROUND

The Objective Severity Assessment of Atopic Dermatitis (OSAAD) score is a recently developed scale for evaluation of severity of atopic dermatitis, constructed from the assessment of epidermal barrier function, and properties using noninvasive bioengineering methods and computer-assisted estimates of disease extent. The method has been validated for use in infants and children with atopic dermatitis and compared with a referent scoring system.

OBJECTIVES

The aim of the present study was to test the validity, reliability and sensitivity of the OSAAD score as an objective tool for the assessment of the severity of atopic dermatitis in adult patients.

METHODS

Thirty-two adult patients with atopic dermatitis were included in the study. To assess the validity of the OSAAD score we tested it against the Severity Scoring of Atopic Dermatitis (SCORAD) index of the European Task Force on Atopic Dermatitis as a referent clinical severity scale, and the serum levels of interleukin (IL)-16 as a laboratory variable for monitoring the activity of atopic dermatitis. Responsiveness to change was assessed in a longitudinal study comparing OSAAD, SCORAD and serum levels of IL-16 before and after treatment. To test the reliability of the OSAAD score we studied the interobserver variability of the score recorded by three independent board-certified dermatologists in 16 patients and compared it with SCORAD.

RESULTS

We report a significant correlation between the OSAAD and the SCORAD index as an acknowledged referent severity scale. The OSAAD score correlated significantly with the serum levels of IL-16 in the acute stage of atopic dermatitis. In a longitudinal study, the OSAAD score decreased significantly, parallel with improvement of the skin findings and a significant decrease in the SCORAD score and IL-16 serum levels. We report improved interobserver variability for the OSAAD score compared with SCORAD.

CONCLUSIONS

This is the first study validating the OSAAD score as a sensitive and reliable tool for the assessment of the severity of atopic dermatitis in adult patients.

Directed self-assembly of Ge nanostructures on very high index, highly anisotropic Si(hkl) surfaces

Families of very high-index planes, such as those which bifurcate spontaneously to form a hill-and-valley structure composed of opposing facets, provide natural templates for the directed growth of position-controlled self-organized nanostructures with shapes determined by the facet width ratio R. For example, deposition of a few ML of Ge on Si(173 100 373), corresponding to R(113/517) = 1.7, results in a field of 40-nm-wide Ge nanowires along [72 187] with a uniform period of 60 nm.

[Initial experience in endovascular treatment of abdominal aortic aneurysms in Bulgaria]

The abdominal aneurysm imposes prominent epidemiological impact due to its high incidence and life threatening complications. The first steps in endovascular treatment of abdominal aneurysms in Bulgaria are herein described. Five bifurcated and one straight stent-grafts were implanted in the ,,St.Ekaterina" University Hospital for the period from February till May 2004. Satisfactory therapeutic result was achieved in all cases. The continuing follow-up of the patients proved favorable tolerability. The good therapeutic response, lack of perioperative mortality, and low complication rate provide evidence that endovascular repair can have beneficial implication in patients with abdominal aneurysms and high operative risk.

Dislocation-driven surface dynamics on solids

Dislocations are line defects that bound plastically deformed regions in crystalline solids. Dislocations terminating on the surface of materials can strongly influence nanostructural and interfacial stability, mechanical properties, chemical reactions, transport phenomena, and other surface processes. While most theoretical and experimental studies have focused on dislocation motion in bulk solids under applied stress and step formation due to dislocations at surfaces during crystal growth, very little is known about the effects of dislocations on surface dynamics and morphological evolution. Here we investigate the near-equilibrium dynamics of surface-terminated dislocations using low-energy electron microscopy. We observe, in real time, the thermally driven nucleation and shape-preserving growth of spiral steps rotating at constant temperature-dependent angular velocities around cores of dislocations terminating on the (111) surface of TiN in the absence of applied external stress or net mass change. We attribute this phenomenon to point-defect migration from the bulk to the surface along dislocation lines. Our results demonstrate that dislocation-mediated surface roughening can occur even in the absence of deposition or evaporation, and provide fundamental insights into mechanisms controlling nanostructural stability.

Coherent nano-area electron diffraction

We describe the new coherent nano-area electron diffraction (NED) and its application for structure determination of individual nanostructures. The study is motivated by the challenge and the general lack of analytical techniques for characterizing nanometer-sized, heterogeneous phases. We show that by focusing electrons on the focal plane of the pre-objective lens using a 3rd condenser lens and a small condense aperture, it is possible to achieve a nanometer-sized highly parallel illumination or probe. The high angular resolution of diffraction pattern from the parallel illumination allows over-sampling and consequently the solution of phase problem based on the recently developed ab initio phase retrieval technique. From this, a high-contrast and high-resolution image can be reconstructed at resolution beyond the performance limit of the image-forming objective lens. The significance of NED for nanostructure characterization will be exemplified by single-wall carbon nanotubes and small metallic clusters. Imaging from diffraction patterns, or diffractive imaging, will be demonstrated using double-wall carbon nanotubes.

Verrucous carcinoma of the axilla: case report and review

BACKGROUND

Verrucous carcinoma, a variant of squamous cell carcinoma, is distinct from squamous cell carcinoma in morphology and behavior. It preferentially occurs on the oropharyngeal mucosa, the urogenital mucosa, and the soles. In contrast to its malignant clinical picture, the tumor grows locally invasive but is histologically benign and metastasizes rarely.

METHODS

We report the uncommon occurrence of a large verrucous carcinoma on apparently uninvolved skin in the right axilla in a 47-year-old male.

RESULTS

Histologic examination reveals a cauliflower-like tumor consisting of deep invaginated epidermal proliferation with rabbit burrow-like, keratin-filled sinus formations; the basement membrane, however, remains intact. Immunohistology showed positivity for pancytokeratin (KL-1) and cytokeratin (CK) 18 and negativity for CK7, and assessment of the proliferative activity of the tumor cells revealed low percentage of Ki-67 expression. Furthermore, there were only scattered cells expressing p53 or bcl-2. Polymerase chain reaction excluded the presence of human papillomavirus. After complete excision, no signs of recurrence occurred over a follow-up period of three years.

CONCLUSION

Verrucous carcinoma should be distinguished from typical squamous cell carcinoma. The clinicopathological features, differential diagnosis, and therapy are discussed here together with the molecular biologic aspects of the tumor.

[Angioplasty and stenting of extracranial cerebral vessels]

The stroke is one of the major causes for death and invalidization in the modern society. In about 30% of the cases the stroke is attributed to stenosis of a supraaortic vessel. In the last few years the percutaneous angioplasty and stenting is an alternative method of the classical surgical treatment--the carotid thrombendarterectomy. Crucial moment in the evolution of the method is the introduction in the practice of the systems for distal embolic protection of the brain and the routine implantation of stents with new design. One of the main conditions for successful and noncomplicated stenting is the respect of a strict procedural protocol. In the article we present the results of 17 cases with angioplasty and stenting of supraaortic vessels performed in our Clinic in the period 07.02.2001-01.07.2001. The immediate success rate is 100%. No major complications (stroke, myocardial infarction and death) were registered. In the midterm follow-up there were no thrombosis and restenosis of the implanted stents. We present four interesting case reports: 1. One stage stenting of right coronary artery and right internal carotid artery, 2. Stenting of a subocclusive right internal carotid stenosis with balloonexpandable stent and 3. Stenting of a vertebral artery as the unique brain supplying vessel and 4. Stenting of subocclusive aortoostial lesion of the brachiocephalic trunk in a patient with totally occluded contralateral internal carotid artery.

CONCLUSIONS

Stenting of supraaortic vessels is a safe and reliable method when performed by experienced operator and when are applied the ultimate methods of cerebral protection and the new stent designs. The carotid stenting is a reliable alternative of the surgery and gains more and more popularity.

[The first case of one stage endovascular treatment of the stenosis in the celiac trunk, bilateral renal arteries, and right common iliac arteries]

Although not very often diagnosed, the acute and chronic mesenterial ischemia is advancing and life threatening condition. When associated with multivascular pathology compromising the perfusion and causing multiple organ failure the choice of treatment is a challenge. In such cases the radical surgical treatment is associated with high morbidity and mortality. In recent years endovascular methods of treatment (angioplasty and stenting) are gaining popularity in the treatment of these patients. We report a case of chronic mesenteric ischemia that caused abdominal angina and weight loss in a 63-year-old man with renovasal hypertension, renal insufficiency and peripheral vascular disease. Angiographic study revealed multivascular pathology including total occlusion of the superior mesenteric artery, 90% stenosis of the celiac trunk, bilateral high grade renal stenoses and obstructive pathology of both iliac arteries. One stage successful endovascular treatment was performed in the three vascular territories. In the Celiac trunk, left renal artery and right common iliac artery were implanted stents. A double right renal artery was treated successfully with kissing balloon. A clinical follow-up demonstrated success with no recurrence of abdominal pain, body weight gain, better control of the hypertension and improvement of the renal function. This is the first reported case of one stage endovascular treatment of a visceral artery, bilateral renal arteries and iliac artery. This case report illustrates the value of endovascular treatment in a patient with atherosclerotic narrowing of multiple abdominal visceral arteries.

[Endovascular therapy of acute traumatic vascular peripheral dissections using self-expandable stents]

Percutaneous peripheral and coronary interventions as well as surgical procedures can be complicated by dissections and traumatic lesions of peripheral arteries. Posttraumatic peripheral dissections can be threatening for the extremities and often their management might be a challenge. Open surgery requires wide exposure and dissection of posttraumatic tissues. Endovascular techniques using selfexpandable stents gains popularity because of high efficiency, safety and good results. This technique is associated with decreased trauma, no requirements for anesthesia, short hospital stay. We present two cases of posttraumatic iliac dissections treated with self expandable stents.

Size-dependent detachment-limited decay kinetics of two-dimensional TiN islands on TiN(111)

In situ high-temperature (T(a)=1050-1250 K) scanning tunneling microscopy was used to determine the coarsening and decay kinetics of two-dimensional TiN adatom and vacancy islands on atomically smooth TiN(111) terraces. We report the first observation of an abrupt decrease in decay rates, irrespective of T(a), of adatom islands with areas less than a critical value of 1600 A(2). However, no decay rate transition was observed for vacancy islands. We attribute the size-dependent island decay behavior, which is consistent with detachment-limited kinetics, to anisotropic attachment and detachment barriers.