Emergent Total Endovascular Arch Repair for Contained Aortic Arch Rupture: Another Tool in the Box

To date, emergent total endovascular aortic arch repair has not been described in the literature. We present a 67-year-old female with a poorly differentiated posterior mediastinal sarcoma. Imaging obtained was concerning for intravascular extension of the tumor into the thoracic aorta. While awaiting radiation therapy, the patient complained of worsening chest and arm pain, vital signs demonstrating tachypnea and hypoxia. Subsequent imaging revealed an increase in vascular erosion, concerning for a contained rupture, with complete obliteration of the left mainstem bronchus. The patient was emergently taken for percutaneous endovascular repair of her aortic arch. A three-vessel physician modified fenestrated graft was created and deployed with concurrent stenting of the innominate, left carotid, and left subclavian arteries. Interval computed tomography angiography revealed patency in all stented vessels, with no endoleak and no evidence of pseudoaneurysm. The patient was able to undergo chemotherapy with favorable decrease in tumor burden. Total endovascular aortic arch repair, when planned carefully, is an attractive option in high-risk patients who are otherwise not ideally suited for open total arch replacement.

First Direct Measurement Constraining the ^{34}Ar(α,p)^{37}K Reaction Cross Section for Mixed Hydrogen and Helium Burning in Accreting Neutron Stars

The rate of the final step in the astrophysical αp process, the ^{34}Ar(α,p)^{37}K reaction, suffers from large uncertainties due to a lack of experimental data, despite having a considerable impact on the observable light curves of x-ray bursts and the composition of the ashes of hydrogen and helium burning on accreting neutron stars. We present the first direct measurement constraining the ^{34}Ar(α,p)^{37}K reaction cross section, using the Jet Experiments in Nuclear Structure and Astrophysics gas jet target. The combined cross section for the ^{34}Ar,Cl(α,p)^{37}K,Ar reaction is found to agree well with Hauser-Feshbach predictions. The ^{34}Ar(α,2p)^{36}Ar cross section, which can be exclusively attributed to the ^{34}Ar beam component, also agrees to within the typical uncertainties quoted for statistical models. This indicates the applicability of the statistical model for predicting astrophysical (α,p) reaction rates in this part of the αp process, in contrast to earlier findings from indirect reaction studies indicating orders-of-magnitude discrepancies. This removes a significant uncertainty in models of hydrogen and helium burning on accreting neutron stars.

Intravascular ultrasound imaging for diagnosis and characterization of the popliteal compression syndrome

Objective

Functional popliteal artery entrapment syndrome (fPAES) is a rare form of nonatherosclerotic claudication most often seen in young athletic patients. Diagnosis remains challenging, with various imaging modalities showing equivocal or subtle findings that may be missed. We sought to critically examine and quantitate the utility of intravascular ultrasound (IVUS) imaging, a common diagnostic tool for vascular compression syndromes, in diagnosis and characterization of fPAES.

Methods

Patients presenting to a single tertiary care center between 2019 and 2022 with symptoms of PAES but without an anatomic etiology or equivocal workup were selected. Angiogram and IVUS with maneuvers were performed on affected extremities at rest, active plantarflexion/dorsiflexion, and plantarflexion/dorsiflexion against resistance. IVUS examination was recorded using a pull-back technique from the tibial vessels to the superficial femoral artery. The degree, length, and anatomic location of compression using the two imaging modalities were compared.

Results

Angiogram and IVUS with maneuvers were performed on 17 lower extremities (9 left, 8 right) in 15 patients (88% female; mean age, 21.2 years). Evidence of arterial compression on angiography was noted in 88.2% (n = 15) of limbs (66.7% complete contrast cessation and 20% popliteal artery tapering); 13.3% (n = 2) only demonstrated sluggish flow as possible evidence of compression. Arterial compression was seen on IVUS imaging in 15 of 17 limbs, and all completely compressed around the IVUS catheter. The IVUS-measured mean length of compression was 10.5 cm ± 4.2 (median, 11 cm; range, 4-23 cm). Compression involved only the popliteal vessels in 86.7% (n = 13); one patient had both popliteal and tibioperoneal trunk compression, whereas another had tibioperoneal trunk and peroneal artery compression. Popliteal vein compression was 100%. The contrast cessation point on angiography and the proximal point of compression on IVUS imaging differed in 80% of cases (P < .05). The distal extent of compression was unable to be determined by angiogram findings but was clearly delineated by IVUS imaging in all cases.

Conclusions

IVUS imaging is a more sensitive diagnostic and descriptive imaging modality compared with angiogram in patients with possible fPAES. IVUS and angiogram findings are greatly discordant; moreover, IVUS imaging can provide detailed information such as the precise extent and anatomic location of the arterial compression, which may be useful in aiding surgical planning. IVUS imaging should be considered the gold standard for diagnosing and characterizing fPAES before intervention planning.

Quenching of Single-Particle Strength in A=15 Nuclei

Absolute cross sections for the addition of s- and d-wave neutrons to ^{14}C and ^{14}N have been determined simultaneously via the (d,p) reaction at 10  MeV/u. The difference between the neutron and proton separation energies, ΔS, is around -20  MeV for the ^{14}C+n system and +8  MeV for ^{14}N+n. The population of the 1s_{1/2} and 0d_{5/2} orbitals for both systems is reduced by a factor of approximately 0.5 compared with the independent single-particle model, or about 0.6 when compared with the shell model. This finding strongly contrasts with results deduced from intermediate-energy knockout reactions between similar nuclei on targets of ^{9}Be and ^{12}C. The simultaneous technique used removes many systematic uncertainties.

Constraining the ^{30}P(p, γ)^{31}S Reaction Rate in ONe Novae via the Weak, Low-Energy, β-Delayed Proton Decay of ^{31}Cl

The ^{30}P(p,γ)^{31}S reaction plays an important role in understanding the nucleosynthesis of A≥30 nuclides in oxygen-neon novae. The Gaseous Detector with Germanium Tagging was used to measure ^{31}Cl β-delayed proton decay through the key J^{π}=3/2^{+}, 260-keV resonance. The intensity I_{βp}^{260}=8.3_{-0.9}^{+1.2}×10^{-6} represents the weakest β-delayed, charged-particle emission ever measured below 400 keV, resulting in a proton branching ratio of Γ_{p}/Γ=2.5_{-0.3}^{+0.4}×10^{-4}. By combining this measurement with shell-model calculations for Γ_{γ} and past work on other resonances, the total ^{30}P(p,γ)^{31}S rate has been determined with reduced uncertainty. The new rate has been used in hydrodynamic simulations to model the composition of nova ejecta, leading to a concrete prediction of ^{30}Si:^{28}Si excesses in presolar nova grains and the calibration of nuclear thermometers.

Ruptured Iliac Arteriovenous Fistula Presenting With Thigh Pain and Swelling: Case Report

The presentation of abdominal arteriovenous fistulas is classically described as a triad of a pulsatile abdominal mass with a bruit, high-output heart failure, and regional venous hypertension with primarily open operative therapy. In the following case, we present the treatment of a patient who arrived with acute right heart failure and renal failure due to an arteriovenous fistula and who was successfully treated with endovascular repair.

Syntheses and Structures of trans-bis(Alkenylacetylide) Ruthenium Complexes

A series of ruthenium alkenylacetylide complexes trans-[Ru{C≡CC(=CH₂ )R}Cl(dppe)₂ ] (R=Ph (1 a), ^c C₄ H₃ S (1 b), 4-MeS-C₆ H₄ (1 c), 3,3-dimethyl-2,3-dihydrobenzo[b]thiophene (DMBT) (1 d)) or trans-[Ru{C≡C-^c C₆ H₉ }Cl(dppe)₂ ] (1 e) were allowed to react with the corresponding propargylic alcohol HC≡CC(Me)R(OH) (R=Ph (A), ^c C₄ H₃ S (B), 4-MeS-C₆ H₄ (C), DMBT (D) or HC≡C-^c C₆ H₁₀ (OH) (E) in the presence of TlBF₄ and DBU to presumably give alkenylacetylide/allenylidene intermediates trans-[Ru{C≡CC(=CH₂ )R}{C=C=C(Me)}(dppe)₂ ]PF₆ ([2]PF₆ ). These complexes were not isolated but deprotonated to give the isolable bis(alkenylacetylide) complexes trans-[Ru{C≡CC(=CH₂ )R}₂ (dppe)₂ ] (R=Ph (3 a), ^c C₄ H₃ S (3 b), 4-MeS-C₆ H₄ (3 c), DMBT (3 d)) and trans-[Ru{C≡C-^c C₆ H₉ }₂ (dppe)₂ ] (3 e). Analogous reactions of trans-[Ru(CH₃ )₂ (dmpe)₂ ], featuring the more electron-donating 1,2-bis(dimethylphosphino)ethane (dmpe) ancillary ligands, with the propargylic alcohols A or C and NH₄ PF₆ in methanol allowed isolation of the intermediate mixed alkenylacetylide/allenylidene complexes trans-[Ru{C≡CC(=CH₂ )R}{C=C=C(Me)}(dmpe)₂ ]PF₆ (R=Ph ([4 a]PF₆ ), 4-MeS-C₆ H₄ ([4 c]PF₆ ). Deprotonation of [4 a]PF₆ or [4 c]PF₆ gave the symmetric bis(alkenylacetylide) complexes trans-[Ru{C≡CC(=CH₂ )R}₂ (dmpe)₂ ] (R=Ph (5 a), 4-MeS-C₆ H₄ (5 c)), the first of their kind containing the dmpe ancillary ligand sphere. Attempts to isolate bis(allenylidene) complexes [Ru{C=C=C(Me)R}₂ (PP)₂ ]²⁺ (PP=dppe, dmpe) from treatment of the bis(alkenylacetylide) species 3 or 5 with HBF₄  ⋅ Et₂ O were ultimately unsuccessful.

Multi-Level Lower Extremity Arterial Revascularization Via Retrograde Pedal Access Under Local Anesthesia in a Patient With Severe Cardiopulmonary Comorbidities: A Case Report

BACKGROUND

Chronic limb-threatening ischemia is a severe form of peripheral artery disease that leads to high rates of amputation and mortality if left untreated. Bypass surgery and antegrade endovascular revascularization through femoral artery access from either side are accepted as conventional treatment modalities for critical limb ischemia. The retrograde pedal access revascularization is an alternative treatment modality useful in specific clinical scenarios; however, these indications have not been well described in literature. This case report highlights the use of retrograde pedal access approach as primary treatment modality in a patient with an extensive comorbidities precluding general anesthesia nor supine positioning.

CASE PRESENTATION

The patient is a 60-year-old female with multiple severe cardiopulmonary comorbidities presenting with dry gangrene of the right great toe. Her comorbidities and inability to tolerate supine positioning precluded her from receiving open surgery, general anesthesia or monitored sedation, or percutaneous femoral access. Rather, the patient underwent ankle block and retrograde endovascular revascularization via dorsalis pedis artery access without post-operative complications.

DISCUSSION

The prevalence of comorbidities related to peripheral artery disease is increasing and with it the number of patients who are not optimal candidates for conventional treatment methods for critical limb ischemia. The retrograde pedal access revascularization as initial treatment modality offers these patients an alternative limb salvaging treatment option.

Exploiting Isospin Symmetry to Study the Role of Isomers in Stellar Environments

Proton capture on the excited isomeric state of ^{26}Al strongly influences the abundance of ^{26}Mg ejected in explosive astronomical events and, as such, plays a critical role in determining the initial content of radiogenic ^{26}Al in presolar grains. This reaction also affects the temperature range for thermal equilibrium between the ground and isomeric levels. We present a novel technique, which exploits the isospin symmetry of the nuclear force, to address the long-standing challenge of determining proton-capture rates on excited nuclear levels. Such a technique has in-built tests that strongly support its veracity and, for the first time, we have experimentally constrained the strengths of resonances that dominate the astrophysical ^{26m}Al(p,γ)^{27}Si reaction. These constraints demonstrate that the rate is at least a factor ∼8 lower than previously expected, indicating an increase in the stellar production of ^{26}Mg and a possible need to reinvestigate sensitivity studies involving the thermal equilibration of ^{26}Al.

A phase II randomised, placebo-controlled trial of low dose (metronomic) cyclophosphamide and nintedanib (BIBF1120) in advanced ovarian, fallopian tube or primary peritoneal cancer

BACKGROUND

We investigated the safety and efficacy of a combination of the oral tyrosine kinase inhibitor, nintedanib (BIBF 1120) with oral cyclophosphamide in patients with relapsed ovarian cancer.

PATIENTS AND METHODS

Patients with relapsed ovarian, fallopian tube or primary peritoneal cancer received oral cyclophosphamide (100 mg o.d.) and were randomised (1,1) to also have either oral nintedanib or placebo. The primary endpoint was overall survival (OS). Secondary endpoints included progression free survival (PFS), response rate, toxicity, and quality of life.

RESULTS

117 patients were randomised, 3 did not start trial treatment, median age 64 years. Forty-five (39%) had received ≥5 lines chemotherapy. 30% had received prior bevacizumab. The median OS was 6.8 (nintedanib) versus 6.4 (placebo) months (hazard ratio 1.08; 95% confidence interval 0.72-1.62; P = 0.72). The 6-month PFS rate was 29.6% versus 22.8% (P = 0.57). Grade 3/4 adverse events occurred in 64% (nintedanib) versus 54% (placebo) of patients (P = 0.28); the most frequent G3/4 toxicities were lymphopenia (18.6% nintedanib versus 16.4% placebo), diarrhoea (13.6% versus 0%), neutropenia (11.9% versus 0%), fatigue (10.2% versus 9.1%), and vomiting (10.2% versus 7.3%). Patients who had received prior bevacizumab treatment had 52 days less time on treatment (P < 0.01). 26 patients (23%) took oral cyclophosphamide for ≥6 months. There were no differences in quality of life between treatment arms.

CONCLUSIONS

This is the largest reported cohort of patients with relapsed ovarian cancer treated with oral cyclophosphamide. Nintedanib did not improve outcomes when added to oral cyclophosphamide. Although not significant, more patients than expected remained on treatment for ≥6 months. This may reflect a higher proportion of patients with more indolent disease or the higher dose of cyclophosphamide used.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.govNCT01610869.

Key ^{19}Ne States Identified Affecting γ-Ray Emission from ^{18}F in Novae

Detection of nuclear-decay γ rays provides a sensitive thermometer of nova nucleosynthesis. The most intense γ-ray flux is thought to be annihilation radiation from the β^{+} decay of ^{18}F, which is destroyed prior to decay by the ^{18}F(p,α)^{15}O reaction. Estimates of ^{18}F production had been uncertain, however, because key near-threshold levels in the compound nucleus, ^{19}Ne, had yet to be identified. We report the first measurement of the ^{19}F(^{3}He,tγ)^{19}Ne reaction, in which the placement of two long-sought 3/2^{+} levels is suggested via triton-γ-γ coincidences. The precise determination of their resonance energies reduces the upper limit of the rate by a factor of 1.5-17 at nova temperatures and reduces the average uncertainty on the nova detection probability by a factor of 2.1.

Differences in Small Molecule Neurotransmitter Profiles From the Crown-of-Thorns Seastar Radial Nerve Revealed Between Sexes and Following Food-Deprivation

Neurotransmitters serve as chemical mediators of cell communication, and are known to have important roles in regulating numerous physiological and metabolic events in eumetazoans. The Crown-of-Thorns Seastar (COTS) is an asteroid echinoderm that has been the focus of numerous ecological studies due to its negative impact on coral reefs when in large numbers. Research devoted to its neural signaling, from basic anatomy to the key small neurotransmitters, would expand our current understanding of neural-driven biological processes, such as growth and reproduction, and offers a new approach to exploring the propensity for COTS population explosions and subsequent collapse. In this study we investigated the metabolomic profiles of small molecule neurotransmitters in the COTS radial nerve cord. Multivariate analysis shows differential abundance of small molecule neurotransmitters in male and female COTS, and in food-deprived individuals with significant differences between sexes in gamma-aminobutyric acid (GABA), histamine and serotonin, and significant differences in histamine and serotonin between satiation states. Annotation established that the majority of biosynthesis enzyme genes are present in the COTS genome. The spatial distribution of GABA, histamine and serotonin in the radial nerve cord was subsequently confirmed by immunolocalization; serotonin is most prominent within the ectoneural regions, including unique neural bulbs, while GABA and histamine localize primarily within neuropil fibers. Glutamic acid, which was also found in high relative abundance and is a precursor of GABA, is known as a spawning inhibitor in seastars, and as such was tested for inhibition of ovulation ex-vivo which resulted in complete inhibition of oocyte maturation and ovulation induced by 1-Methyladenine. These findings not only advance our knowledge of echinoderm neural signaling processes but also identify potential targets for developing novel approaches for COTS biocontrol.

Assessing Interest and Barriers for Resident and Faculty Involvement in Global Surgery

BACKGROUND

Multiple institutions have developed international electives and sustainable global surgery initiatives to facilitate clinical, research, and outreach opportunities with hospitals in resource-poor areas. Despite increasing interest among programs, many institutions have not successfully reached potential involvement.

OBJECTIVE

This study evaluates the experiences of Yale residents and faculty, measures interest in the development of an international surgical elective, and enumerates barriers to developing or participating in these opportunities. This was performed to develop a formalized elective and assess interest and capacity for surgical global health initiatives, as a seemingly increasing number of trainee applicants and residents were expressing interest in working in resource-poor settings.

METHODS

Electronic survey of Yale Surgery residents and faculty analyzed using SPSS and Graphpad Prism.

RESULTS

Among residents, previous global experience correlates with current interest in international opportunities, with 100% remaining interested, and 78% of those without prior experience also expressing interest (p = 0.018). Barriers to pursuing these activities included the use of vacation time, funding, scheduling, family obligations, and concern for personal safety. Among faculty, 28% of respondents have been involved internationally, and most (86%) expressed interest in additional opportunities and all were willing to take residents. Barriers to faculty participation included funding, relative value unit target reduction, protected time, and the desire for institutional support for such activities.

CONCLUSIONS

A substantial proportion of residents and faculty have experience in global health and motivation to pursue additional opportunities. The main barriers to participation are not a lack of interest, but rather needs for funding support, protected time, and institutional recognition of academic contributions. These findings are being used to develop a global surgery elective and establish long-term partnerships with international colleagues.

Neuropeptides encoded within a neural transcriptome of the giant triton snail Charonia tritonis, a Crown-of-Thorns Starfish predator

Neuropeptides represent a diverse class of signaling molecules originating from neural tissues. These chemical modulators orchestrate complex physiological events including those associated with growth and reproduction. De novo transcriptome sequencing of a cerebral ganglion library of the endangered giant triton snail (Charonia tritonis) was undertaken in an effort to identify key neuropeptides that control or influence its physiology. The giant triton snail is considered a primary predator of the corallivore Acanthaster planci (Crown-of-Thorns Starfish) that is responsible for a significant loss in coral cover on reefs in the Indo-Pacific. The transcriptome library was assembled into contigs, and then bioinformatic analysis was used to identify a repertoire of 38 giant triton snail neuropeptide precursor genes, and various isoforms, that encode conserved molluscan neuropeptides. C. tritonis neuropeptides show overall precursor organisation consistent with those of other molluscs. These include those neuropeptides associated with mollusc reproduction such as the APGWamide, buccalin, conopressin, gonadotropin-releasing hormone (GnRH), NKY and egg-laying hormone. These data provide a foundation for further studies targeted towards the functional characterisation of neuropeptides to further understand aspects of the biology of the giant triton snail, such as elucidating its reproductive neuroendocrine pathway to allow the development of knowledge based captive breeding programs.

Multiomics analysis of the giant triton snail salivary gland, a crown-of-thorns starfish predator

The giant triton snail (Charonia tritonis) is one of the few natural predators of the adult Crown-of-Thorns starfish (COTS), a corallivore that has been damaging to many reefs in the Indo-Pacific. Charonia species have large salivary glands (SGs) that are suspected to produce either a venom and/or sulphuric acid which can immobilize their prey and neutralize the intrinsic toxic properties of COTS. To date, there is little information on the types of toxins produced by tritons. In this paper, the predatory behaviour of the C. tritonis is described. Then, the C. tritonis SG, which itself is made up of an anterior lobe (AL) and posterior lobe (PL), was analyzed using an integrated transcriptomics and proteomics approach, to identify putative toxin- and feeding-related proteins. A de novo transcriptome database and in silico protein analysis predicts that ~3800 proteins have features consistent with being secreted. A gland-specific proteomics analysis confirmed the presence of numerous SG-AL and SG-PL proteins, including those with similarity to cysteine-rich venom proteins. Sulfuric acid biosynthesis enzymes were identified, specific to the SG-PL. Our analysis of the C. tritonis SG (AL and PL) has provided a deeper insight into the biomolecular toolkit used for predation and feeding by C. tritonis.

The crown-of-thorns starfish genome as a guide for biocontrol of this coral reef pest

The crown-of-thorns starfish (COTS, the Acanthaster planci species group) is a highly fecund predator of reef-building corals throughout the Indo-Pacific region. COTS population outbreaks cause substantial loss of coral cover, diminishing the integrity and resilience of reef ecosystems. Here we sequenced genomes of COTS from the Great Barrier Reef, Australia and Okinawa, Japan to identify gene products that underlie species-specific communication and could potentially be used in biocontrol strategies. We focused on water-borne chemical plumes released from aggregating COTS, which make the normally sedentary starfish become highly active. Peptide sequences detected in these plumes by mass spectrometry are encoded in the COTS genome and expressed in external tissues. The exoproteome released by aggregating COTS consists largely of signalling factors and hydrolytic enzymes, and includes an expanded and rapidly evolving set of starfish-specific ependymin-related proteins. These secreted proteins may be detected by members of a large family of olfactory-receptor-like G-protein-coupled receptors that are expressed externally, sometimes in a sex-specific manner. This study provides insights into COTS-specific communication that may guide the generation of peptide mimetics for use on reefs with COTS outbreaks.

Identification of putative olfactory G-protein coupled receptors in Crown-of-Thorns starfish, Acanthaster planci

Background

In marine organisms, and in particular for benthic invertebrates including echinoderms, olfaction is a dominant sense with chemosensation being a critical signalling process. Until recently natural product chemistry was the primary investigative approach to elucidate the nature of chemical signals but advances in genomics and transcriptomics over the last decade have facilitated breakthroughs in understanding not only the chemistry but also the molecular mechanisms underpinning chemosensation in aquatic environments. Integration of these approaches has the potential to reveal the fundamental elements influencing community structure of benthic ecosystems as chemical signalling modulates intra- and inter-species interactions. Such knowledge also offers avenues for potential development of novel biological control methods for pest species such as the predatory Crown-of-Thorns starfish (COTS), Acanthaster planci which are the primary biological cause of coral cover loss in the Indo-Pacific.

Results

In this study, we have analysed the COTS sensory organs through histological and electron microscopy. We then investigated key elements of the COTS molecular olfactory toolkit, the putative olfactory rhodopsin-like G protein-protein receptors (GPCRs) within its genome and olfactory organ transcriptomes. Many of the identified Acanthaster planci olfactory receptors (ApORs) genes were found to cluster within the COTS genome, indicating rapid evolution and replication from an ancestral olfactory GPCR sequence. Tube feet and terminal sensory tentacles contain the highest proportion of ApORs. In situ hybridisation confirmed the presence of four ApORs, ApOR15, 18, 25 and 43 within COTS sensory organs, however expression of these genes was not specific to the adhesive epidermis, but also within the nerve plexus of tube feet stems and within the myomesothelium. G alpha subunit proteins were also identified in the sensory organs, and we report the spatial localisation of Gαi within the tube foot and sensory tentacle.

Conclusions

We have identified putative COTS olfactory receptors that localise to sensory organs. These results provide a basis for future studies that may enable the development of a biological control not only for COTS, but also other native pest or invasive starfish.

Electronic supplementary material

The online version of this article (doi:10.1186/s12864-017-3793-4) contains supplementary material, which is available to authorized users.

CD44 Promotes Inflammation and Extracellular Matrix Production During Arteriovenous Fistula Maturation

OBJECTIVE

Arteriovenous fistulae (AVF) remain the optimal conduit for hemodialysis access but continue to demonstrate poor patency and poor rates of maturation. We hypothesized that CD44, a widely expressed cellular adhesion molecule that serves as a major receptor for extracellular matrix components, promotes wall thickening and extracellular matrix deposition during AVF maturation.

APPROACH AND RESULTS

AVF were created via needle puncture in wild-type C57BL/6J and CD44 knockout mice. CD44 mRNA and protein expression was increased in wild-type AVF. CD44 knockout mice showed no increase in AVF wall thickness (8.9 versus 26.8 μm; P=0.0114), collagen density, and hyaluronic acid density, but similar elastin density when compared with control AVF. CD44 knockout mice also showed no increase in vascular cell adhesion molecule-1 expression, intercellular adhesion molecule-1 expression, and monocyte chemoattractant protein-1 expression in the AVF compared with controls; there were also no increased M2 macrophage markers (transglutaminase-2: 81.5-fold, P=0.0015; interleukin-10: 7.6-fold, P=0.0450) in CD44 knockout mice. Delivery of monocyte chemoattractant protein-1 to CD44 knockout mice rescued the phenotype with thicker AVF walls (27.2 versus 14.7 μm; P=0.0306), increased collagen density (2.4-fold; P=0.0432), and increased number of M2 macrophages (2.1-fold; P=0.0335).

CONCLUSIONS

CD44 promotes accumulation of M2 macrophages, extracellular matrix deposition, and wall thickening during AVF maturation. These data show the association of M2 macrophages with wall thickening during AVF maturation and suggest that enhancing CD44 activity may be a strategy to increase AVF maturation.

Increased Oxidative Stress and Hypoxia Inducible Factor-1 Expression during Arteriovenous Fistula Maturation

BACKGROUND

The poor clinical results that are frequently reported for arteriovenous fistulae (AVF) for hemodialysis are typically due to failure of AVF maturation. We hypothesized that early AVF maturation is associated with generation of reactive oxygen species and activation of the hypoxia-inducible factor-1 (HIF-1) pathway, potentially promoting neointimal hyperplasia. We tested this hypothesis using a previously reported mouse AVF model that recapitulates human AVF maturation.

METHODS

Aortocaval fistulae were created in C57Bl/6 mice and compared with sham-operated mice. AVFs or inferior vena cavas were analyzed using a microarray, Amplex Red for extracellular H₂O₂, quantitative polymerase chain reaction, immunohistochemistry, and immunoblotting for HIF-1α and immunofluorescence for NOX-2, nitrotyrosine, heme oxygenase-1 (HO-1), and vascular endothelial growth factor (VEGF)-A.

RESULTS

Oxidative stress was higher in AVF than that in control veins, with more H₂O₂ (P = 0.007) and enhanced nitrotyrosine immunostaining (P = 0.005). Immunohistochemistry and immunoblot showed increased HIF-1α immunoreactivity in the AVF endothelium; HIF-1 targets NOX-2, HO-1 and VEGF-A were overexpressed in the AVF (P < 0.01). AVF expressed increased numbers of HIF-1α (P < 0.0001) and HO-1 (P < 0.0001) messenger RNA transcripts.

CONCLUSIONS

Oxidative stress increases in mouse AVF during early maturation, with increased expression of HIF-1α and its target genes NOX-2, HO-1, and VEGF-A. These results suggest that clinical strategies to improve AVF maturation could target the HIF-1 pathway.

Crown-of-thorns starfish have true image forming vision

Background

Photoreceptors have evolved numerous times giving organisms the ability to detect light and respond to specific visual stimuli. Studies into the visual abilities of the Asteroidea (Echinodermata) have recently shown that species within this class have a more developed visual sense than previously thought and it has been demonstrated that starfish use visual information for orientation within their habitat. Whereas image forming eyes have been suggested for starfish, direct experimental proof of true spatial vision has not yet been obtained.

Results

The behavioural response of the coral reef inhabiting crown-of-thorns starfish (Acanthaster planci) was tested in controlled aquarium experiments using an array of stimuli to examine their visual performance. We presented starfish with various black-and-white shapes against a mid-intensity grey background, designed such that the animals would need to possess true spatial vision to detect these shapes. Starfish responded to black-and-white rectangles, but no directional response was found to black-and-white circles, despite equal areas of black and white. Additionally, we confirmed that starfish were attracted to black circles on a white background when the visual angle is larger than 14°. When changing the grey tone of the largest circle from black to white, we found responses to contrasts of 0.5 and up. The starfish were attracted to the dark area’s of the visual stimuli and were found to be both attracted and repelled by the visual targets.

Conclusions

For crown-of-thorns starfish, visual cues are essential for close range orientation towards objects, such as coral boulders, in the wild. These visually guided behaviours can be replicated in aquarium conditions. Our observation that crown-of-thorns starfish respond to black-and-white shapes on a mid-intensity grey background is the first direct proof of true spatial vision in starfish and in the phylum Echinodermata.

Electronic supplementary material

The online version of this article (doi:10.1186/s12983-016-0174-9) contains supplementary material, which is available to authorized users.

DNA barcoding the phyllosoma of Scyllarides squammosus (H. Milne Edwards, 1837) (Decapoda: Achelata: Scyllaridae)

Scyllarides has the largest number of species with commercial importance within the Scyllaridae family. As for other achelate lobsters, however, little is known of the unique long-lived planktonic phyllosoma stages of any of these tropical and temperate species. Recently, a large and diverse collection of Scyllaridae phyllosoma, compiled from cruises along the Coral Sea and spanning several years, has been analysed. Molecular evidence from DNA-barcoding and phylogenetic analyses is provided here on the identity of S. squammosus phyllosoma larvae, including stages that were previously undescribed or poorly known. As a consequence, the growth and morphological changes that occur during the mid- to late-stages of S. squammosus larval development is now well-documented. Furthermore, an additional collection of S. squammosus larvae, described by Alain Michel and thought to be no longer extant, were discovered in the crustacean collection of the Muséum national d'Histoire naturelle, Paris. This new molecular and morphological information is complemented by a review of the literature. As a result, descriptions of key larval characters by a number of authors were evaluated and appear to suggest the existence of distinct groups of larvae within Scyllarides. From a combination of adult and larval morphology, and molecular data, the results presented here revealed inconsistencies with regard to the affinities of species assigned to Scyllarides. This new evidence will contribute to future studies addressing the phylogenetic relationships within the genus.

Histochemical and Immunohistochemical Evidence of a Bacterium Associated with Lesions of Epizootic Bovine Abortion

Epizootic bovine abortion (EBA), a tick-transmitted disease of pregnant cattle grazing foothill pastures, is a major cause of reproductive failure in California and adjacent states. Affected fetuses develop a chronic disease, resulting in late-term abortion or premature calving. Despite investigations spanning 50 years, to the authors' knowledge, the etiologic agent of EBA has not yet been isolated from affected fetuses or the tick vector. The diagnosis of EBA is based on gross and microscopic lesions. Recently, documentation that the etiologic agent is susceptible to antibiotics and identification of a unique 16S deltaproteobacterial rDNA gene sequence in 90% of thymus tissues from aborted fetuses have supported the role of a bacterial infection as the cause of EBA. To determine whether bacteria could be detected in the tissues, histochemical staining and immunohistochemical procedures were used on formalin-fixed, paraffin-embedded tissues. Use of a modified Steiner silver stain revealed small numbers of intracytoplasmic bacterial rods in 37 of 42 thymic samples from EBA-affected fetuses. Improved detection was achieved by use of immunohistochemical staining with serum from EBA-affected fetuses that resulted in detection of numerous bacterial rods in the cytoplasm of histiocytic cells in the thymus from all 42 EBA-affected fetuses. Immunohistochemical examination of additional tissues from 21 field and experimental EBA cases revealed positively stained intracytoplasmic bacterial rods in many organs with inflammatory lesions. Use of the modified Steiner stain and immunohistochemical staining of tissues from negative-control fetuses failed to reveal organisms. To the authors' knowledge, this is the first report to document morphologic evidence of a bacterium associated with the lesions of EBA.

Statistics of highly heterogeneous flow fields confined to three-dimensional random porous media

We present a strong relationship between the microstructural characteristics of, and the fluid velocity fields confined to, three-dimensional random porous materials. The relationship is revealed through simultaneously extracting correlation functions R_{uu}(r) of the spatial (Eulerian) velocity fields and microstructural two-point correlation functions S_{2}(r) of the random porous heterogeneous materials. This demonstrates that the effective physical transport properties depend on the characteristics of complex pore structure owing to the relationship between R_{uu}(r) and S_{2}(r) revealed in this study. Further, the mean excess plot was used to investigate the right tail of the streamwise velocity component that was found to obey light-tail distributions. Based on the mean excess plot, a generalized Pareto distribution can be used to approximate the positive streamwise velocity distribution.

Diversity of Marine-Derived Fungal Cultures Exposed by DNA Barcodes: The Algorithm Matters

Marine fungi are an understudied group of eukaryotic microorganisms characterized by unresolved genealogies and unstable classification. Whereas DNA barcoding via the nuclear ribosomal internal transcribed spacer (ITS) provides a robust and rapid tool for fungal species delineation, accurate classification of fungi is often arduous given the large number of partial or unknown barcodes and misidentified isolates deposited in public databases. This situation is perpetuated by a paucity of cultivable fungal strains available for phylogenetic research linked to these data sets. We analyze ITS barcodes produced from a subsample (290) of 1781 cultured isolates of marine-derived fungi in the Bioresources Library located at the Australian Institute of Marine Science (AIMS). Our analysis revealed high levels of under-explored fungal diversity. The majority of isolates were ascomycetes including representatives of the subclasses Eurotiomycetidae, Hypocreomycetidae, Sordariomycetidae, Pleosporomycetidae, Dothideomycetidae, Xylariomycetidae and Saccharomycetidae. The phylum Basidiomycota was represented by isolates affiliated with the genera Tritirachium and Tilletiopsis. BLAST searches revealed 26 unknown OTUs and 50 isolates corresponding to previously uncultured, unidentified fungal clones. This study makes a significant addition to the availability of barcoded, culturable marine-derived fungi for detailed future genomic and physiological studies. We also demonstrate the influence of commonly used alignment algorithms and genetic distance measures on the accuracy and comparability of estimating Operational Taxonomic Units (OTUs) by the automatic barcode gap finder (ABGD) method. Large scale biodiversity screening programs that combine datasets using algorithmic OTU delineation pipelines need to ensure compatible algorithms have been used because the algorithm matters.

Disturbed shear stress reduces Klf2 expression in arterial-venous fistulae in vivo

Laminar shear stress (SS) induces an antiproliferative and anti-inflammatory endothelial phenotype and increases Klf2 expression. We altered the diameter of an arteriovenous fistula (AVF) in the mouse model to determine whether increased fistula diameter produces disturbed SS in vivo and if acutely increased disturbed SS results in decreased Klf2 expression. The mouse aortocaval fistula model was performed with 22, 25, or 28 gauge needles to puncture the aorta and the inferior vena cava. Duplex ultrasound was used to examine the AVF and its arterial inflow and venous outflow, and SS was calculated. Arterial samples were examined with western blot, immunohistochemistry, and immunofluorescence analysis for proteins and qPCR for RNA. Mice with larger diameter fistulae had diminished survival but increased AVF patency. Increased SS magnitudes and range of frequencies were directly proportional to the needle diameter in the arterial limb proximal to the fistula but not in the venous limb distal to the fistula, with 22-gauge needles producing the most disturbed SS in vivo. Klf2 mRNA and protein expression was diminished in the artery proximal to the fistula in proportion to increasing SS. Increased fistula diameter produces increased SS magnitude and frequency, consistent with disturbed SS in vivo. Disturbed SS is associated with decreased mRNA and protein expression of Klf2. Disturbed SS and reduced Klf2 expression near the fistula are potential therapeutic targets to improve AVF maturation.

Advanced age and disease predict lack of symptomatic improvement after endovascular iliac treatment in male veterans

BACKGROUND

Endovascular angioplasty and stent placement is currently the most frequent treatment for iliac artery occlusive disease. However, despite a successful endovascular procedure, some patients do not experience symptomatic improvement and satisfaction with their care. This study seeks to identify patient-related factors associated with lack of symptomatic improvement after endovascular iliac artery treatment in male veterans.

METHODS

Retrospective review of patients treated with endovascular methods for iliac artery occlusive disease between January 2008 and July 2012 at VA Connecticut Healthcare System. Symptomatic improvement on the first post-operative visit was evaluated, with bilateral treatments counted separately.

RESULTS

Sixty-two patients had 91 iliac arteries treated with angioplasty and stent placement. Forty-seven (52 percent) legs had critical limb ischemia, and 77 (85 percent) had at least two-vessel distal runoff. Angiographic success was 100 percent. Patient-reported symptomatic improvement at the first post-operative visit was 55 percent (50/91). Lack of symptomatic improvement correlated with older age (OR 1.09 [1.03-1.17], p = 0.008), presence of critical limb ischemia (OR 3.03 [1.09-8.65], p = 0.034), and need for additional surgical intervention (OR 5.61 [1.65-17.36], p = 0.006). Survival, primary and secondary patency, and freedom from restenosis were comparable between patients who reported symptomatic improvement and those who did not.

CONCLUSIONS

Despite angiographically successful revascularization, patients who are older or have critical limb ischemia who are treated with isolated endovascular iliac artery intervention are more likely to require additional interventions and less likely to experience symptomatic improvement. These patients may need more extensive infra-inguinal revascularization than isolated iliac angioplasty and stent placement, despite a preserved ankle-brachial index. Quality of life needs to be measured with formal instruments after iliac artery endovascular treatment, especially to determine long term outcomes.

Arterial shear stress reduces eph-b4 expression in adult human veins

Vein graft adaptation to the arterial environment is characterized by loss of venous identity, with reduced Ephrin type-B receptor 4 (Eph-B4) expression but without increased Ephrin-B2 expression. We examined changes of vessel identity of human saphenous veins in a flow circuit in which shear stress could be precisely controlled. Medium circulated at arterial or venous magnitudes of laminar shear stress for 24 hours; histologic, protein, and RNA analyses of vein segments were performed. Vein endothelium remained viable and functional, with platelet endothelial cell adhesion molecule (PECAM)-expressing cells on the luminal surface. Venous Eph-B4 expression diminished (p = .002), Ephrin-B2 expression was not induced (p = .268), and expression of osteopontin (p = .002) was increased with exposure to arterial magnitudes of shear stress. Similar changes were not found in veins placed under venous flow or static conditions. These data show that human saphenous veins remain viable during ex vivo application of shear stress in a bioreactor, without loss of the venous endothelium. Arterial magnitudes of shear stress cause loss of venous identity without gain of arterial identity in human veins perfused ex vivo. Shear stress alone, without immunologic or hormonal influence, is capable of inducing changes in vessel identity and, specifically, loss of venous identity.

Chronic kidney disease predicts long-term mortality after major lower extremity amputation

Background:

Despite low peri-operative mortality after major lower extremity amputation, long-term mortality remains substantial. Metabolic syndrome is increasing in incidence and prevalence at an alarming rate in the USA.

Aim:

This study was to determine whether metabolic syndrome predicts outcome after major lower extremity amputation.

Patients and Methods:

A retrospective review of charts between July 2005 and June 2010.

Results:

Fifty-four patients underwent a total of 60 major lower extremity amputations. Sixty percent underwent below-knee amputation and 40% underwent above-knee amputation. The 30-day mortality was 7% with no difference in level (below-knee amputation, 8%; above-knee amputation, 4%; P = 0.53). The mean follow-up time was 39.7 months. The 5-year survival was 54% in the whole group, and was independent of level of amputation (P = 0.24) or urgency of the procedure (P = 0.51). Survival was significantly decreased by the presence of underlying chronic kidney disease (P = 0.04) but not by other comorbidities (history of myocardial infarction, P = 0.79; metabolic syndrome, P = 0.64; diabetes mellitus, P = 0.56).

Conclusion:

Metabolic syndrome is not associated with increased risk of adverse outcomes after lower extremity amputation. However, patients with chronic kidney disease constitute a sub-group of patients at higher risk of postoperative long-term mortality and may be a group to target for intervention.

Vein graft adaptation and fistula maturation in the arterial environment

Veins are exposed to the arterial environment during two common surgical procedures, creation of vein grafts and arteriovenous fistulae (AVF). In both cases, veins adapt to the arterial environment that is characterized by different hemodynamic conditions and increased oxygen tension compared with the venous environment. Successful venous adaptation to the arterial environment is critical for long-term success of the vein graft or AVF and, in both cases, is generally characterized by venous dilation and wall thickening. However, AVF are exposed to a high flow, high shear stress, low-pressure arterial environment and adapt mainly via outward dilation with less intimal thickening. Vein grafts are exposed to a moderate flow, moderate shear stress, high-pressure arterial environment and adapt mainly via increased wall thickening with less outward dilation. We review the data that describe these differences, as well as the underlying molecular mechanisms that mediate these processes. Despite extensive research, there are few differences in the molecular pathways that regulate cell proliferation and migration or matrix synthesis, secretion, or degradation currently identified between vein graft adaptation and AVF maturation that account for the different types of venous adaptation to arterial environments.

Metabolic syndrome is associated with type II endoleak after endovascular abdominal aortic aneurysm repair

OBJECTIVE

Type II endoleak is usually a benign finding after endovascular abdominal aortic aneurysm repair (EVAR). In some patients, however, type II endoleak leads to aneurysm sac expansion and the need for further intervention. We examined which factors, in particular the components of metabolic syndrome (MetS), would lead to an increase risk of endoleak after EVAR.

METHODS

The medical records of all patients who underwent EVAR between 2002 and 2011 at the Veterans Affairs Connecticut Healthcare System were reviewed. MetS was defined as the presence of three or more of the following: hypertension (blood pressure ≥130 mm Hg/≥90 mm Hg), serum triglycerides ≥150 mg/dL, serum high-density lipoproteins ≤50 mg/dL for women and ≤40 mg/dL for men, body mass index ≥30 kg/m(2), and fasting blood glucose ≥110 mg/dL. Development of endoleak, including specific endoleak type, was determined by review of standard radiologic surveillance.

RESULTS

During a 9-year period, 79 male patients (mean age, 73.5 years), underwent EVAR for infrarenal abdominal aortic aneurysm (mean 6.2 cm maximal transverse diameter). MetS was present in 52 patients (66%). The distribution of MetS factors among all patients was hypertension in 86%, hypertriglyceridemia in 72%, decreased high-density lipoprotein in 68%, diabetes in 37%, and a body mass index of ≥30 kg/m(2) in 30%. No survival difference was found between the MetS and non-MetS groups (P = .66). There was no difference in perioperative myocardial infarction or visceral ischemia immediately postoperatively between the two groups. Patients with MetS had a significant increase in acute kidney injury (n = 7, P = .0128). Endoleaks of all types were detected in 26% (n = 20) of all patients; patients with MetS had more endoleaks than patients without MetS (35% vs 7.4%, P = .0039). Of the 19 type II endoleaks, 79% were present at the time of EVAR and only 21% developed during surveillance; 95% had MetS (P = .0007).

CONCLUSIONS

Type II endoleak after EVAR for abdominal aortic aneurysm is associated with MetS. Whether these patients are subject to more subsequent intervention due to sac expansion is unclear. MetS may be a factor to consider in the treatment of type II endoleak.

Metabolic syndrome is associated with type II endoleak after endovascular abdominal aortic aneurysm repair

OBJECTIVE

Type II endoleak is usually a benign finding after endovascular abdominal aortic aneurysm repair (EVAR). In some patients, however, type II endoleak leads to aneurysm sac expansion and the need for further intervention. We examined which factors, in particular the components of metabolic syndrome (MetS), would lead to an increase risk of endoleak after EVAR.

METHODS

The medical records of all patients who underwent EVAR between 2002 and 2011 at the Veterans Affairs Connecticut Healthcare System were reviewed. MetS was defined as the presence of three or more of the following: hypertension (blood pressure ≥130 mm Hg/≥90 mm Hg), serum triglycerides ≥150 mg/dL, serum high-density lipoproteins ≤50 mg/dL for women and ≤40 mg/dL for men, body mass index ≥30 kg/m(2), and fasting blood glucose ≥110 mg/dL. Development of endoleak, including specific endoleak type, was determined by review of standard radiologic surveillance.

RESULTS

During a 9-year period, 79 male patients (mean age, 73.5 years), underwent EVAR for infrarenal abdominal aortic aneurysm (mean 6.2 cm maximal transverse diameter). MetS was present in 52 patients (66%). The distribution of MetS factors among all patients was hypertension in 86%, hypertriglyceridemia in 72%, decreased high-density lipoprotein in 68%, diabetes in 37%, and a body mass index of ≥30 kg/m(2) in 30%. No survival difference was found between the MetS and non-MetS groups (P = .66). There was no difference in perioperative myocardial infarction or visceral ischemia immediately postoperatively between the two groups. Patients with MetS had a significant increase in acute kidney injury (n = 7, P = .0128). Endoleaks of all types were detected in 26% (n = 20) of all patients; patients with MetS had more endoleaks than patients without MetS (35% vs 7.4%, P = .0039). Of the 19 type II endoleaks, 79% were present at the time of EVAR and only 21% developed during surveillance; 95% had MetS (P = .0007).

CONCLUSIONS

Type II endoleak after EVAR for abdominal aortic aneurysm is associated with MetS. Whether these patients are subject to more subsequent intervention due to sac expansion is unclear. MetS may be a factor to consider in the treatment of type II endoleak.

The mouse aortocaval fistula recapitulates human arteriovenous fistula maturation

Several models of arteriovenous fistula (AVF) have excellent patency and help in understanding the mechanisms of venous adaptation to the arterial environment. However, these models fail to exhibit either maturation failure or fail to develop stenoses, both of which are critical modes of AVF failure in human patients. We used high-resolution Doppler ultrasound to serially follow mice with AVFs created by direct 25-gauge needle puncture. By day 21, 75% of AVFs dilate, thicken, and increase flow, i.e., mature, and 25% fail due to immediate thrombosis or maturation failure. Mature AVF thicken due to increased amounts of smooth muscle cells. By day 42, 67% of mature AVFs remain patent, but 33% of AVFs fail due to perianastomotic thickening. These results show that the mouse aortocaval model has an easily detectable maturation phase in the first 21 days followed by a potential failure phase in the subsequent 21 days. This model is the first animal model of AVF to show a course that recapitulates aspects of human AVF maturation.

Probiont niche specialization contributes to additive protection against Vibrio owensii in spiny lobster larvae

The development of efficient probiotic application protocols for use in marine larviculture relies on comprehensive understanding of pathogen-probiont-host interactions. The probiont combination of Pseudoalteromonas sp. PP107 and Vibrio sp. PP05 provides additive protection against vectored Vibrio owensii DY05 infection in larvae (phyllosomas) of ornate spiny lobster, Panulirus ornatus. Here, fluorescently tagged strains were used to demonstrate niche specialization of these probionts in both the live feed vector organism Artemia and in phyllosomas. The pathogen was vulnerable to direct interaction with PP05 in the bacterioplankton as well as in the Artemia gut and the phyllosoma foregut and midgut gland. In contrast, PP107 was localized on external surfaces of Artemia and phyllosomas, and direct interaction with the pathogen was limited to the bacterioplankton. While PP107 was the overall dominant ectobiont on the phyllosoma cephalothorax and inner leg segments, PP05 was the primary colonizer of outer leg segments, nutrient-rich locales that may promote ingestion during feeding. This study shows that niche specialization can contribute to the additive probiotic effect of a probiotic mixture and highlights that probiotic enrichment of Artemia cultures can intercept the infection cycle of V. owensii DY05 in early-stage P. ornatus phyllosomas.

Non-operative management of acute cholecystitis in the elderly

BACKGROUND

Although cholecystectomy is the standard therapy for acute cholecystitis (AC), operative morbidity in the elderly may be high owing to medical co-morbidities and decreased physiological reserve. Outcomes of AC in the elderly have not been fully defined with regard to operative and long-term non-operative management.

METHODS

Patients aged 65 years or over admitted to a tertiary care centre with a diagnosis of AC between January 2000 and December 2009 were reviewed retrospectively. Patient data, operative and postoperative details were obtained. To determine cholecystectomy rates in the non-operative group, medical records were reviewed, and patients and families were interviewed.

RESULTS

A total of 290 patients underwent cholecystectomy during the index admission, of whom 59 (20·3 per cent) required conversion to open operation. Fifty-eight of these patients experienced 98 complications, including acute respiratory failure (27), pneumonia (18), myocardial infarction (16) and sepsis (15). Some 185 patients had non-operative treatment, of whom 67 underwent percutaneous cholecystostomy. Forty-four patients subsequently had elective cholecystectomy, with a complication rate of 23 per cent. One hundred and twenty-six patients were discharged without a plan for cholecystectomy; the rate of recurrent AC was 4 per cent among the two-thirds of patients followed to within 15 months of death. No deaths or major complications occurred among those with recurrent AC.

CONCLUSION

Despite selection of the best elderly candidates for cholecystectomy, postoperative morbidity was significant. Medical management, with interval cholecystectomy only for recurrent AC, may be appropriate in selected patients.