The effect of cilostazol on late outcomes after endovascular treatment for occlusive femoropopliteal disease

OBJECTIVE

Restenosis and late occlusion remain a significant problem for endovascular treatment of peripheral artery disease. This meta-analysis aims to evaluate the effect of cilostazol on late outcomes after endovascular repair of occlusive femoropopliteal disease.

METHODS

A systematic literature review was conducted conforming to established criteria to identify articles published up to September 2023 evaluating late outcomes after endovascular treatment for atherosclerotic femoropopliteal disease. Eligible studies should compare outcomes between patients treated with cilostazol and patients not treated with cilostazol. Both prospective and retrospective studies were eligible. Late outcomes included primary patency (PP), restenosis, target lesion revascularization (TLR), and major amputation during follow-up.

RESULTS

Overall, 10 clinical studies were identified for analysis including 4721 patients (1831 with cilostazol vs 2890 without cilostazol) that were treated for 5703 lesions (2235 with cilostazol vs 3468 without cilostazol). All studies were performed in Japan. Mean follow-up was 24.1 ± 12.5 months. Cilostazol was associated with a lower risk for restenosis (pooled odds ratio [OR], 0.503; 95% confidence interval [CI], 0.383-0.660; P < .0001). However, no association was found between cilostazol and TLR (pooled OR, 0.918; 95% CI, 0.300-2.812; P = .881) as well as major amputation (pooled OR, 1.512; 95% CI, 0.734-3.116; P = .263). Regarding primary patency, cilostazol was associated with a higher 12-month PP (OR, 3.047; 95% CI, 1.168-7.946; P = .023), and a higher 36-month PP (OR, 1.616; 95% CI, 1.412-1.850; P < .0001). No association was found between cilostazol and mortality during follow-up (pooled OR, .755; 95% CI, 0.293-1.946; P = .561).

CONCLUSIONS

Cilostazol seems to have a positive effect on 1- to 3-year PP and restenosis rates among patients treated endovascularly for atherosclerotic femoropopliteal disease. A positive effect on TLR and amputation risk was not verified in this review.

Global taxonomic, functional, and phylogenetic diversity of bees in apple orchards

An essential prerequisite to safeguard pollinator species is characterisation of the multifaceted diversity of crop pollinators and identification of the drivers of pollinator community changes across biogeographical gradients. The extent to which intensive agriculture is associated with the homogenisation of biological communities at large spatial scales remains poorly understood. In this study, we investigated diversity drivers for 644 bee species/morphospecies in 177 commercial apple orchards across 33 countries and four global biogeographical biomes. Our findings reveal significant taxonomic dissimilarity among biogeographical zones. Interestingly, despite this dissimilarity, species from different zones share similar higher-level phylogenetic groups and similar ecological and behavioural traits (i.e. functional traits), likely due to habitat filtering caused by perennial monoculture systems managed intensively for crop production. Honey bee species dominated orchard communities, while other managed/manageable and wild species were collected in lower numbers. Moreover, the presence of herbaceous, uncultivated open areas and organic management practices were associated with increased wild bee diversity. Overall, our study sheds light on the importance of large-scale analyses contributing to the emerging fields of functional and phylogenetic diversity, which can be related to ecosystem function to promote biodiversity as a key asset in agroecosystems in the face of global change pressures.

Life-threatening urosepsis because of ureteral entrapment within a large inguinal hernia

Ureteral hernias are an uncommon entity that are usually incidentally discovered during inguinal hernia repair. However, when symptomatic, they could cause severe symptoms from the urinary system and even affect renal function. We aim to report a rare case of a 91-year-old male patient with urosepsis because of ureteral entrapment within an inguinal hernia, and further discuss proper management of such cases.

The effects of urbanization on pollinators and pollination: A meta-analysis

Urbanization is increasing worldwide, with major impacts on biodiversity, species interactions and ecosystem functioning. Pollination is an ecosystem function vital for terrestrial ecosystems and food security; however, the processes underlying the patterns of pollinator diversity and the ecosystem services they provide in cities have seldom been quantified. Here, we perform a comprehensive meta-analysis of 133 studies examining the effects of urbanization on pollinators and pollination. Our results confirm the widespread negative impacts of urbanization on pollinator richness and abundance, with Lepidoptera being the most affected group. Furthermore, pollinator responses were found to be trait-specific, with below-ground nesting and solitary Hymenoptera, and spring flyers more severely affected by urbanization. Meanwhile, cities promote non-native pollinators, which may exacerbate conservation risks to native species. Surprisingly, despite the negative effects of urbanization on pollinator diversity, pollination service measured as seed set is enhanced in non-tropical cities likely due to abundant generalists and managed pollinators therein. We emphasize that the richness of local flowering plants could mitigate the negative impacts of urbanization on pollinator diversity. Overall, the results demonstrate the varying magnitudes of multiple moderators on urban pollinators and pollination services and could help guide conservation actions for biodiversity and ecosystem function for a sustainable future.

Mason bees and honey bees synergistically enhance fruit set in sweet cherry orchards

Mason bees (Osmia spp.) are efficient fruit tree pollinators that can be encouraged to occupy and breed in artificial nesting material. In sweet cherry orchards, they are occasionally used as an alternative managed pollinator as a replacement for or in addition to honey bees (Apis mellifera). Yet, the lack of practical guidelines on management practices, for example optimal stocking rates, for both mason bee nesting material and honey bees might compromise pollination service provision. In this study, we assessed the relationship between stocking rates (honey bee hives and mason bee nesting material) and the abundance of honey bees and mason bees in 17 sweet cherry (Prunus avium) orchards in Central Germany. We furthermore performed a pollination experiment to explore the interactive effect of mason bees and honey bees on sweet cherry fruit set. In the orchards, both honey bee and mason bee abundance increased with increasing stocking rates of hives or nesting material, respectively. Honey bee abundance increased linearly with stocking rates. In contrast, mason bee abundance asymptoted at 2-3 nesting boxes per ha, beyond which more boxes resulted in little increase in visitation rate. Our pollination experiment demonstrated that orchards were pollen limited, with only 28% of insect-pollinated flowers setting fruit versus 39% of optimally hand-pollinated flowers. Honey bees and mason bees enhanced sweet cherry fruit set, but only when both were present and not when either was present alone in an orchard. Our findings demonstrate that offering nesting material for mason bees and employing honey bee hives can enhance bee abundance in sweet cherry orchards. By increasing honey bee abundance in combination with enhanced mason bee abundance, farmers can substantially boost fruit set and potentially sweet cherry yield. To enhance pollination services, farmers should consider the benefits of increasing pollinator biodiversity as an immediate benefit to improve crop yields.

When lizards try out a more plant-based lifestyle: The macroevolution of mutualistic lizard-plant-interactions (Squamata: Sauria/Lacertilia)

Pollination and seed dispersal of plants by animals are key mutualistic processes for the conservation of plant diversity and ecosystem functioning. Although different animals frequently act as pollinators or seed dispersers, some species can provide both functions, so-called 'double mutualists', suggesting that the evolution of pollination and seed dispersal may be linked. Here, we assess the macroevolution of mutualistic behaviours in lizards (Lacertilia) by applying comparative methods to a phylogeny comprising 2,838 species. We found that both flower visitation (potential pollination) (recorded in 64 species [2.3% of total] across 9 families) and seed dispersal (recorded in 382 species [13,5% of total] across 26 families) have evolved repeatedly in Lacertilia. Furthermore, we found that seed dispersal activity pre-dated flower visitation and that the evolution of seed dispersal activity and flower visitation was correlated, illustrating a potential evolutionary mechanism behind the emergence of double mutualisms. Finally, we provide evidence that lineages with flower visitation or seed dispersal activity have higher diversification rates than lineages lacking these behaviours. Our study illustrates the repeated innovation of (double) mutualisms across Lacertilia and we argue that island settings may provide the ecological conditions under which (double) mutualisms persist over macroevolutionary timescales.

Interdisciplinary Collaboration and Communication Among Doctors and Nurses in ICUs During the COVID-19 Pandemic and Their Importance in Professional Life Quality Improvement

To investigate interdisciplinary cooperation and communication among doctors and nurses along with its role in improving the quality of their professional life, a cross-sectional survey was designed. The study was carried out from February to April 2021 through the application of an anonymous, structured, self-completed, closed-ended questionnaire in a convenience sample consisting of 110 healthcare professionals currently working in the intensive care units (ICUs) of three distinct hospitals (response rate: 76.4%). It was observed that medical personnel manifested a more positive stance toward interdisciplinary collaboration than nursing while women seemed to believe more than men that nurses' administrative skills are not valued enough by doctors. Nurses with limited work experience reported that doctors show scarce respect to nurses in the presence of patients' parents and companions while male nurses acknowledged more the provision of multidimensional care given to patients. Occupational stress, professional satisfaction, and burnout levels were mainly moderate across study participants.

Job Satisfaction and Burnout Levels of the Human Resources of a Public Oncology Hospital During the COVID-19 Pandemic

To investigate job satisfaction and burnout levels among the personnel of a public oncology hospital amid the COVID-19 pandemic, a cross-sectional survey was designed. The study was carried out from December 2021 to January 2022 through the application of an anonymous, structured, self-completed, closed-ended questionnaire, consisting of the Job Satisfaction Survey (JSS) and the Copenhagen Burnout Inventory (CBI) in a convenience sample comprised by 117 employees of "Agioi Anargyroi" General Oncology Hospital (response rate: 98%). It was observed that while overall job satisfaction was reduced, several of its determining dimensions like supervision, relationship with co-workers, or work nature were increased. Also, an average overall burnout of 49% was observed across all participants, with women, nurses, and those with a lower educational level experiencing it more intensely. The COVID-19 pandemic outbreak affected negatively healthcare professionals who experienced significant personal and occupational burnout, consequently reducing their job satisfaction.

Investigating Mobbing Syndrome's Incidence in the Working Environment of a Public and a Private Greek Hospital

To investigate the phenomenon of moral harassment (mobbing) as well as the effect of demographic and occupational characteristics of healthcare professionals working in a public provincial general hospital and a private hospital in Athens a cross-sectional survey was designed. The study was conducted from November to December 2021 through the application of the Leymann Inventory of Psychological Terror (LIPT) a widely recognized research tool for the quantitative investigation of ethical harassment in the workplace. 264 fully completed questionnaires were collected out of the 300 that were distributed in both hospitals (response rates: 92% for the public hospital and 83.3% for the private). It was observed that private hospital's employees were morally harassed to a greater extent and for a longer time than the employees of a public hospital. The levels of moral harassment were quite high, indicating the necessity of thorough audit by the management in both hospitals.

The Impact of Smokers' Information-Seeking Behavior on Smoking Cessation

INTRODUCTION

Smoking has a harmful effect on human body and is rated to be the primary cause of preventable premature disease and death worldwide, while it is responsible for at least 25 life-threatening diseases.

METHODS

An empirical investigation has been carried out through the development and distribution of a structured questionnaire. The sample of empirical investigation consisted of 150 smokers aged over 18 years (response rate 85.7%).

ANALYSIS

Descriptive analysis and correlation control of questionnaire variables are used to report the findings of the study.

RESULTS

Information about passive smoking, smoking consequences, and current therapies in quitting smoking were rated highest among smoke-related information needs. The main sources of information were family/relatives/friends/colleagues and Internet and less important factors were formal sources like medical staff, health professionals, and primary health care services. Ε-health literacy is correlated with higher self-efficacy, positive intention to quit smoking, and better educational level while is negatively correlated with increasing age.

CONCLUSIONS

The creation of specialized programs and upgraded information services is fundamental for successful smoking cessation. These programs and services should be addressed to all socioeconomic groups and combined with the improvement in smokers' e-health literacy will contribute to a higher self-efficacy and finally drive them to quit smoking.

Anthropogenic effects on the body size of two neotropical orchid bees

To accommodate an ever-increasing human population, agriculture is rapidly intensifying at the expense of natural habitat, with negative and widely reported effects on biodiversity in general and on wild bee abundance and diversity in particular. Cities are similarly increasing in area, though the impact of urbanisation on wild bees is more equivocal and potentially positive in northern temperate regions. Yet agriculture and urbanisation both lead to the loss and alteration of natural habitat, its fragmentation, a potential reduction in floral availability, and warmer temperatures, factors thought to be drivers of wild bee decline. They have also been shown to be factors to which wild bee populations respond through morphological change. Body size is one such trait that, because of its relation to individual fitness, has received growing attention as a morphological feature that responds to human induced modification in land use. Here, we investigated the change in body size of two sympatric orchid bee species on the Yucatan Peninsula of Mexico in response to urbanization and agricultural intensification. By measuring 540 male individuals sampled from overall 24 sites, we found that Euglossa dilemma and Euglossa viridissima were on average smaller in urban and agricultural habitats than in natural ones. We discuss the potential role of reduced availability of resources in driving the observed body size shifts. Agricultural and urban land management in tropical regions might benefit wild bees if it encompassed the planting of flowering herbs and trees to enhance their conservation.

The effects of urbanisation on ecological interactions

Cities are expanding worldwide and urbanisation is considered a global threat to biodiversity. Urban ecology has provided important insights on how urban environmental changes might affect individuals, populations, and species; however, we know little about how the ecological impacts of urbanisation alter species interactions. Species interactions are the backbone of ecological communities and play a crucial role in population and community dynamics and in the generation, maintenance and structure of biodiversity. Here, I review urban ecological studies to identify key mechanistic pathways through which urban environmental processes could alter antagonistic and mutualistic interactions among species. More specifically, I focus on insect predation, parasitoidism and herbivory, competition, insect host-pathogen interactions, and pollination. I furthermore identify important knowledge gaps that require additional research attention and I suggest future research directions that may help to shed light on the mechanisms that affect species interactions and structure insect communities and will thus aid conservation management in cities.

The Dimensionality of the Multidimensional Fatigue Inventory (MFI-20) Derived From Healthy Adults and Patient Subpopulations: A Challenge for Clinicians

Introduction: Fatigue is associated with various diseases of different origins extending from immune disorders to cancer. The purpose of this study was to explore the psychometric properties/dimensionality of the Multidimensional Fatigue Inventory (MFI-20) questionnaire in samples of healthy adults and patient subgroups in Greece.

Methods: This was a multicenter cross-sectional study that included 80 women with breast cancer, 108 patients with multiple sclerosis (MS), 100 people with thalassemia diagnosis, and 185 healthy adults, aged 18-45 years. All patients were adults. Patients were recruited from a breast surgery clinic, a neurological clinic, and a thalassemia unit, while healthy adults were recruited from the University of West Attica students and personnel. The MFI-20, the modified fatigue impact scale (MFIS), the fatigue severity scale (FSS), and the Hamilton anxiety-depression scale (HANDS) were used. Internal consistency, repeatability, test-retest reliability, construct, and convergent validity were investigated.

Results: MFI-20 exhibited excellent reliability properties (internal consistency: Cronbach’s alpha MFI-20 subscales ranged from 0.83 to 0.94; repeatability: Pearson’s r = 0.335 [p < 0.001]). Significant correlations were found between MFI-20 and MFIS: Pearson’s r = 0.870, FSS: Pearson’s r = 0.582 - 0.335, and HANDS: Pearson’s r = 0.734 - 0.442 (all p-values < 0.0001) on all subsamples. However, its dimensionality is questionable depending on the subpopulation tested, and the one-dimension perspective is possible. MS patients exhibited the highest total score (55.26 ± 16.53), while thalassemia patients exhibited the lowest score (45.09 ± 13.54). In all subscales, thalassemia patients differed statistically significantly from the MS patients (p < 0.01), while in the reduced activity subscale, thalassemia patients differed significantly from all other groups (p < 0.01).

Conclusions: As strict fatigue subscale classification is questionable, the use of MFI-20 total score is suggested for the assessment of fatigue in clinical populations. As MFI-20 is a very useful research tool for studying fatigue, the use of the total and/or partial scores depends on the clinical population. Total score instead of (or additionally) partial scores is suggested in clinical practice.

Global urban environmental change drives adaptation in white clover

Urbanization transforms environments in ways that alter biological evolution. We examined whether urban environmental change drives parallel evolution by sampling 110,019 white clover plants from 6169 populations in 160 cities globally. Plants were assayed for a Mendelian antiherbivore defense that also affects tolerance to abiotic stressors. Urban-rural gradients were associated with the evolution of clines in defense in 47% of cities throughout the world. Variation in the strength of clines was explained by environmental changes in drought stress and vegetation cover that varied among cities. Sequencing 2074 genomes from 26 cities revealed that the evolution of urban-rural clines was best explained by adaptive evolution, but the degree of parallel adaptation varied among cities. Our results demonstrate that urbanization leads to adaptation at a global scale.

Honey bees increase social distancing when facing the ectoparasite Varroa destructor

Social distancing in response to infectious diseases is a strategy exhibited by human and nonhuman animals to counteract the spread of pathogens and/or parasites. Honey bee (Apis mellifera) colonies are ideal models to study this behavior because of the compartmentalized structure of these societies, evolved under exposure to parasite pressure and the need to ensure efficient functioning. Here, by using a combination of spatial and behavioral approaches, we investigated whether the presence of the ectoparasite mite Varroa destructor induces changes in the social organization of A. mellifera colonies that could reduce the spread of the parasite. Our results demonstrated that honey bees react to the intrusion of V. destructor by modifying space use and social interactions to increase the social distancing between young (nurses) and old (foragers) cohorts of bees. These findings strongly suggest a behavioral strategy not previously reported in honey bees to limit the intracolony parasite transmission.

A brief history and popularity of methods and tools used to estimate micro-evolutionary forces

Population genetics is a field of research that predates the current generations of sequencing technology. Those approaches, that were established before massively parallel sequencing methods, have been adapted to these new marker systems (in some cases involving the development of new methods) that allow genome-wide estimates of the four major micro-evolutionary forces-mutation, gene flow, genetic drift, and selection. Nevertheless, classic population genetic markers are still commonly used and a plethora of analysis methods and programs is available for these and high-throughput sequencing (HTS) data. These methods employ various and diverse theoretical and statistical frameworks, to varying degrees of success, to estimate similar evolutionary parameters making it difficult to get a concise overview across the available approaches. Presently, reviews on this topic generally focus on a particular class of methods to estimate one or two evolutionary parameters. Here, we provide a brief history of methods and a comprehensive list of available programs for estimating micro-evolutionary forces. We furthermore analyzed their usage within the research community based on popularity (citation bias) and discuss the implications of this bias for the software community. We found that a few programs received the majority of citations, with program success being independent of both the parameters estimated and the computing platform. The only deviation from a model of exponential growth in the number of citations was found for the presence of a graphical user interface (GUI). Interestingly, no relationship was found for the impact factor of the journals, when the tools were published, suggesting accessibility might be more important than visibility.

Urbanization is associated with shifts in bumblebee body size, with cascading effects on pollination

Urbanization is a global phenomenon with major effects on species, the structure of community functional traits and ecological interactions. Body size is a key species trait linked to metabolism, life-history and dispersal as well as a major determinant of ecological networks. Here, using a well-replicated urban-rural sampling design in Central Europe, we investigate the direction of change of body size in response to urbanization in three common bumblebee species, Bombus lapidarius, Bombus pascuorum and Bombus terrestris, and potential knock-on effects on pollination service provision. We found foragers of B. terrestris to be larger in cities and the body size of all species to be positively correlated with road density (albeit at different, species-specific scales); these are expected consequences of habitat fragmentation resulting from urbanization. High ambient temperature at sampling was associated with both a small body size and an increase in variation of body size in all three species. At the community level, the community-weighted mean body size and its variation increased with urbanization. Urbanization had an indirect positive effect on pollination services through its effects not only on flower visitation rate but also on community-weighted mean body size and its variation. We discuss the eco-evolutionary implications of the effect of urbanization on body size, and the relevance of these findings for the key ecosystem service of pollination.

Urban fragmentation leads to lower floral diversity, with knock-on impacts on bee biodiversity

Bees and flowering plants are two closely interacting groups of organisms. Habitat loss and fragmentation associated with urbanisation are major threats to both partners. Yet how and why bee and floral richness and diversity co-vary within the urban landscape remain unclear. Here, we sampled bees and flowering plants in urban green spaces to investigate how bee and flowering plant species richness, their phylogenetic diversity and pollination-relevant functional trait diversity influence each other in response to urban fragmentation. As expected, bee abundance and richness were positively related to flowering plant richness, with bee body size (but not bee richness and diversity) increasing with nectar-holder depth of flowering plants. Causal modelling indicated that bottom-up effects dictated patterns of bee-flower relationships, with urban fragmentation diminishing flowering plants richness and thereby indirectly reducing bee species richness and abundance. The close relationship between bees and flowering plants highlights the risks of their parallel declines in response to land-use change within the urban landscape.

Disentangling the effects of local resources, landscape heterogeneity and climatic seasonality on bee diversity and plant-pollinator networks in tropical highlands

Land-use alteration and climate seasonality have profound effects on bee species diversity by influencing the availability of nesting and floral resources. Here, using twelve sites embedded in an agriculture-forest mosaic in the tropical highlands of Guatemala, we investigated the relative effects of climate seasonality and landscape heterogeneity on bee and floral-resource community structure and on their mutualistic network architecture. We found that climate seasonality affected bee diversity, which was higher in the wet season and associated positively with the availability of floral resources across both seasons. Bee community composition also differed between seasons and it was mainly driven by floral-resource richness and the proportion of agricultural, semi-natural and forest cover. In addition to the effects on bee diversity, climate seasonality also affected flower-bee visitation networks. We documented higher relative (null model corrected) nestedness in the dry season compared to the wet season. Niche partitioning as a result of competition for scarce resources in the dry season could be the process driving the differences in the network structure between seasons. Furthermore, relative nestedness was consistently smaller than zero, and relative modularity and specialization were consistently larger than zero in both seasons, suggesting the existence of isolated groups of interacting partners in all our flower-bee visitation networks. Our results highlight the effect of climatic seasonality and the importance of preserving local floral resources and natural heterogeneous habitats for the conservation of bee communities and their pollination services in tropical highlands.

A cross-sectional survey interconnecting health information seeking behavior with clinical data of type 2 diabetes mellitus patients

Purpose

The purpose of this paper is the investigation of type 2 diabetes patients' information seeking behavior in terms of their information needs, sources and barriers faced by patients when seeking information. The information seeking behavior is associated with clinical patient data.

Design/methodology/approach

The relevant literature is reviewed, and the results of a cross-sectional survey informed by Wilson's macro-model of information seeking behavior are reported. The survey includes 106 outpatients from the diabetes clinic of a Greek major university hospital and includes information seeking behaviors and patient's clinical evidence.

Findings

The most important health information needs are related to the complications, symptoms and causes of diabetes, to the proper diet for diabetics and the measures adopted to avoid foot complications. Furthermore, the most important information resources were physicians, ophthalmologists, books, broadcast media and family members. Obstacles encountered during information seeking include the complicated nature of health information, which involves scientific terms as well as psychological issues. The diabetes stage is correlated with information needs for diabetes medication, while the years from the first diagnosis are negatively correlated with the use of informal sources.

Research limitations/implications

The information needs and sources of diabetic patients, as well as the main obstacles to this pursuit, could potentially have important implications in designing a future information campaign and information services for diabetes patients.

Originality/value

The Wilson's macro-model of information seeking has been applied to the diabetic patients' information seeking behavior; while information needs, information sources and information obstacles are correlated with clinical evidence from patients’ hospital records.

Propolis Consumption Reduces Nosema ceranae Infection of European Honey Bees (Apis mellifera)

Nosema ceranae is a widespread obligate intracellular parasite of the ventriculus of many species of honey bee (Apis), including the Western honey bee Apis mellifera, in which it may lead to colony death. It can be controlled in A. mellifera by feeding the antibiotic fumagillin to a colony, though this product is toxic to humans and its use has now been banned in many countries, so in beekeeping, there exists a need for alternative and safe products effective against N. ceranae. Honeybees produce propolis from resinous substances collected from plants and use it to protect their nest from parasites and pathogens; propolis is thought to decrease the microbial load of the hive. We hypothesized that propolis might also reduce N. ceranae infection of individual bees and that they might consume propolis as a form of self-medication. To test these hypotheses, we evaluated the effects of an ethanolic extract of propolis administered orally on the longevity and spore load of experimentally N. ceranae-infected worker bees and also tested whether infected bees were more attracted to, and consumed a greater proportion of, a diet containing propolis in comparison to uninfected bees. Propolis extracts and ethanol (solvent control) increased the lifespan of N. ceranae-infected bees, but only propolis extract significantly reduced spore load. Our propolis extract primarily contained derivatives of caffeic acid, ferulic acid, ellagic acid and quercetin. Choice, scan sampling and food consumption tests did not reveal any preference of N. ceranae-infected bees for commercial candy containing propolis. Our research supports the hypothesis that propolis represents an effective and safe product to control N. ceranae but worker bees seem not to use it to self-medicate when infected with this pathogen.

Population genetics of the European rabbit along a rural-to-urban gradient

The European rabbit (Oryctolagus cuniculus) is declining in large parts of Europe but populations in some German cities remained so far unaffected by this decline. The question arises of how urbanization affects patterns of population genetic variation and differentiation in German rabbit populations, as urban habitat fragmentation may result in altered meta-population dynamics. To address this question, we used microsatellite markers to genotype rabbit populations occurring along a rural-to-urban gradient in and around the city of Frankfurt, Germany. We found no effect of urbanization on allelic richness. However, the observed heterozygosity was significantly higher in urban than rural populations and also the inbreeding coefficients were lower, most likely reflecting the small population sizes and possibly on-going loss of genetic diversity in structurally impoverished rural areas. Global FST and G'ST-values suggest moderate but significant differentiation between populations. Multiple matrix regression with randomization ascribed this differentiation to isolation-by-environment rather than isolation-by-distance. Analyses of migration rates revealed asymmetrical gene flow, which was higher from rural into urban populations than vice versa and may again reflect intensified agricultural land-use practices in rural areas. We discuss that populations inhabiting urban areas will likely play an important role in the future distribution of European rabbits.

Resin foraging dynamics in Varroa destructor-infested hives: a case of medication of kin?

Social insects have evolved colony behavioral, physiological, and organizational adaptations (social immunity) to reduce the risks of parasitization and/or disease transmission. The collection of resin from various plants and its use in the hive as propolis is a clear example of behavioral defense. For Apis mellifera, an increased propolis content in the hive may correspond to variations in the microbial load of the colony and to a downregulation of an individual bee's immune response. However, many aspects of such antimicrobial mechanism still need to be clarified. Assuming that bacterial and fungal infection mechanisms differ from the action of a parasite, we studied the resin collection dynamics in Varroa destructor-infested honeybee colonies. Comparative experiments involving hives with different mite infestation levels were conducted in order to assess the amount of resin collected and propolis quality within the hive, over a 2-year period (2014 and 2015). Our study demonstrates that when A. mellifera colonies are under stress because of Varroa infestation, an increase in the number of resin foragers is recorded, even if a general intensification of the foraging activity is not observed. A reduction in the total polyphenolic content in propolis produced in infested versus uninfested hives was also noticed. Considering that different propolis types show varying levels of inhibition against a variety of honey bee pathogens in vitro, it would be very important to study the effects against Varroa of two diverse types of propolis: from Varroa-free and from Varroa-infested hives.

A roadmap for urban evolutionary ecology

Urban ecosystems are rapidly expanding throughout the world, but how urban growth affects the evolutionary ecology of species living in urban areas remains largely unknown. Urban ecology has advanced our understanding of how the development of cities and towns change environmental conditions and alter ecological processes and patterns. However, despite decades of research in urban ecology, the extent to which urbanization influences evolutionary and eco-evolutionary change has received little attention. The nascent field of urban evolutionary ecology seeks to understand how urbanization affects the evolution of populations, and how those evolutionary changes in turn influence the ecological dynamics of populations, communities, and ecosystems. Following a brief history of this emerging field, this Perspective article provides a research agenda and roadmap for future research aimed at advancing our understanding of the interplay between ecology and evolution of urban-dwelling organisms. We identify six key questions that, if addressed, would significantly increase our understanding of how urbanization influences evolutionary processes. These questions consider how urbanization affects nonadaptive evolution, natural selection, and convergent evolution, in addition to the role of urban environmental heterogeneity on species evolution, and the roles of phenotypic plasticity versus adaptation on species' abundance in cities. Our final question examines the impact of urbanization on evolutionary diversification. For each of these six questions, we suggest avenues for future research that will help advance the field of urban evolutionary ecology. Lastly, we highlight the importance of integrating urban evolutionary ecology into urban planning, conservation practice, pest management, and public engagement.

The Two Prevalent Genotypes of an Emerging Infectious Disease, Deformed Wing Virus, Cause Equally Low Pupal Mortality and Equally High Wing Deformities in Host Honey Bees

Deformed wing virus (DWV) is an emerging infectious disease of the honey bee (Apis mellifera) that is considered a major cause of elevated losses of honey bee colonies. DWV comprises two widespread genotypes: the originally described genotype A, and genotype B. In adult honey bees, DWV-B has been shown to be more virulent than DWV-A. However, their comparative effects on earlier host developmental stages are unknown. Here, we experimentally inoculated honey bee pupae and tested for the relative impact of DWV-A versus DWV-B on mortality and wing deformities in eclosing adults. DWV-A and DWV-B caused similar, and only slightly elevated, pupal mortality (mean 18% greater mortality than control). Both genotypes caused similarly high wing deformities in eclosing adults (mean 60% greater wing deformities than control). Viral titer was high in all of the experimentally inoculated eclosing adults, and was independent of wing deformities, suggesting that the phenotype 'deformed wings' is not directly related to viral titer or viral genotype. These viral traits favor the emergence of both genotypes of DWV by not limiting the reproduction of its vector, the ectoparasitic Varroa destructor mite, in infected pupae, and thereby facilitating the spread of DWV in honey bees infested by the mite.

Small and genetically highly structured populations in a long-legged bee, Rediviva longimanus, as inferred by pooled RAD-seq

Adaptation to local host plants may impact a pollinator's population genetic structure by reducing gene flow and driving population genetic differentiation, representing an early stage of ecological speciation. South African Rediviva longimanus bees exhibit elongated forelegs, a bizarre adaptation for collecting oil from floral spurs of their Diascia hosts. Furthermore, R. longimanus foreleg length (FLL) differs significantly among populations, which has been hypothesised to result from selection imposed by inter-population variation in Diascia floral spur length. Here, we used a pooled restriction site-associated DNA sequencing (pooled RAD-seq) approach to investigate the population genetic structure of R. longimanus and to test if phenotypic differences in FLL translate into increased genetic differentiation (i) between R. longimanus populations and (ii) between phenotypes across populations. We also inferred the effects of demographic processes on population genetic structure and tested for genetic markers underpinning local adaptation. RESULTS: Populations showed marked genetic differentiation (average FST = 0.165), though differentiation was not statistically associated with differences between populations in FLL. All populations exhibited very low genetic diversity and were inferred to have gone through recent bottleneck events, suggesting extremely low effective population sizes. Genetic differentiation between samples pooled by leg length (short versus long) rather than by population of origin was even higher (FST = 0.260) than between populations, suggesting reduced interbreeding between long and short-legged individuals. Signatures of selection were detected in 1119 (3.8%) of a total of 29,721 SNP markers, CONCLUSIONS: Populations of R. longimanus appear to be small, bottlenecked and isolated. Though we could not detect the effect of local adaptation (FLL in response to floral spurs of host plants) on population genetic differentiation, short and long legged bees appeared to be partially differentiated, suggesting incipient ecological speciation. To test this hypothesis, greater resolution through the use of individual-based whole-genome analyses is now needed to quantify the degree of reproductive isolation between long and short legged bees between and even within populations.

Genome-wide single nucleotide polymorphism scan suggests adaptation to urbanization in an important pollinator, the red-tailed bumblebee (Bombus lapidarius L.)

Urbanization is considered a global threat to biodiversity; the growth of cities results in an increase in impervious surfaces, soil and air pollution, fragmentation of natural vegetation and invasion of non-native species, along with numerous environmental changes, including the heat island phenomenon. The combination of these effects constitutes a challenge for both the survival and persistence of many native species, while also imposing altered selective regimes. Here, using 110 314 single nucleotide polymorphisms generated by restriction-site-associated DNA sequencing, we investigated the genome-wide effects of urbanization on putative neutral and adaptive genomic diversity in a major insect pollinator, Bombus lapidarius, collected from nine German cities and nine paired rural sites. Overall, genetic differentiation among sites was low and there was no obvious genome-wide genetic structuring, suggesting the absence of strong effects of urbanization on gene flow. We nevertheless identified several loci under directional selection, a subset of which was associated with urban land use, including the percentage of impervious surface surrounding each sampling site. Overall, our results provide evidence of local adaptation to urbanization in the face of gene flow in a highly mobile insect pollinator.

Pollination services enhanced with urbanization despite increasing pollinator parasitism

Animal-mediated pollination is required for the reproduction of the majority of angiosperms, and pollinators are therefore essential for ecosystem functioning and the economy. Two major threats to insect pollinators are anthropogenic land-use change and the spread of pathogens, whose effects may interact to impact pollination. Here, we investigated the relative effects on the ecosystem service of pollination of (i) land-use change brought on by agriculture and urbanization as well as (ii) the prevalence of pollinator parasites, using experimental insect pollinator-dependent plant species in natural pollinator communities. We found that pollinator habitat (i.e. availability of nesting resources for ground-nesting bees and local flower richness) was strongly related to flower visitation rates at the local scale and indirectly influenced plant pollination success. At the landscape scale, pollination was positively related to urbanization, both directly and indirectly via elevated visitation rates. Bumblebees were the most abundant pollinator group visiting experimental flowers. Prevalence of trypanosomatids, such as the common bumblebee parasite Crithidia bombi, was higher in urban compared with agricultural areas, a relationship which was mediated through higher Bombus abundance. Yet, we did not find any top-down, negative effects of bumblebee parasitism on pollination. We conclude that urban areas can be places of high transmission of both pollen and pathogens.

Sweat bees on hot chillies: provision of pollination services by native bees in traditional slash-and-burn agriculture in the Yucatán Peninsula of tropical Mexico

Traditional tropical agriculture often entails a form of slash-and-burn land management that may adversely affect ecosystem services such as pollination, which are required for successful crop yields. The Yucatán Peninsula of Mexico has a >4000 year history of traditional slash-and-burn agriculture, termed 'milpa'. Hot 'Habanero' chilli is a major pollinator-dependent crop that nowadays is often grown in monoculture within the milpa system.We studied 37 local farmers' chilli fields (sites) to evaluate the effects of landscape composition on bee communities. At 11 of these sites, we undertook experimental pollination treatments to quantify the pollination of chilli. We further explored the relationships between landscape composition, bee communities and pollination service provision to chilli.Bee species richness, particularly species of the family Apidae, was positively related to the amount of forest cover. Species diversity decreased with increasing proportion of crop land surrounding each sampling site. Sweat bees of the genus Lasioglossum were the most abundant bee taxon in chilli fields and, in contrast to other bee species, increased in abundance with the proportion of fallow land, gardens and pastures which are an integral part of the milpa system.There was an average pollination shortfall of 21% for chilli across all sites; yet the shortfall was unrelated to the proportion of land covered by crops. Rather, chilli pollination was positively related to the abundance of Lasioglossum bees, probably an important pollinator of chilli, as well indirectly to the proportion of fallow land, gardens and pastures that promote Lasioglossum abundance. Synthesis and applications. Current, low-intensity traditional slash-and-burn (milpa) agriculture provides Lasioglossum spp. pollinators for successful chilli production; fallow land, gardens and pasture therefore need to be valued as important habitats for these and related ground-nesting bee species. However, the negative impact of agriculture on total bee species diversity highlights how agricultural intensification is likely to reduce pollination services to crops, including chilli. Indeed, natural forest cover is vital in tropical Yucatán to maintain a rich assemblage of bee species and the provision of pollination services for diverse crops and wild flowers.

Replication of honey bee-associated RNA viruses across multiple bee species in apple orchards of Georgia, Germany and Kyrgyzstan

The essential ecosystem service of pollination is provided largely by insects, which are considered threatened by diverse biotic and abiotic global change pressures. RNA viruses are one such pressure, and have risen in prominence as a major threat for honey bees (Apis mellifera) and global apiculture, as well as a risk factor for other bee species through pathogen spill-over between managed honey bees and sympatric wild pollinator communities. Yet despite their potential role in global bee decline, the prevalence of honey bee-associated RNA viruses in wild bees is poorly known from both geographic and taxonomic perspectives. We screened members of pollinator communities (honey bees, bumble bees and other wild bees belonging to four families) collected from apple orchards in Georgia, Germany and Kyrgyzstan for six common honey bee-associated RNA virus complexes encompassing nine virus targets. The Deformed wing virus complex (DWV genotypes A and B) had the highest prevalence across all localities and host species and was the only virus complex found in wild bee species belonging to all four studied families. Based on amplification of negative-strand viral RNA, we found evidence for viral replication in wild bee species of DWV-A/DWV-B (hosts: Andrena haemorrhoa and several Bombus spp.) and Black queen cell virus (hosts: Anthophora plumipes, several Bombus spp., Osmia bicornis and Xylocopa spp.). Viral amplicon sequences revealed that DWV-A and DWV-B are regionally distinct but identical in two or more bee species at any one site, suggesting virus is shared amongst sympatric bee taxa. This study demonstrates that honey bee associated RNA viruses are geographically and taxonomically widespread, likely infective in wild bee species, and shared across bee taxa.

A sting in the spit: widespread cross-infection of multiple RNA viruses across wild and managed bees

Declining populations of bee pollinators are a cause of concern, with major repercussions for biodiversity loss and food security. RNA viruses associated with honeybees represent a potential threat to other insect pollinators, but the extent of this threat is poorly understood.

This study aims to attain a detailed understanding of the current and ongoing risk of emerging infectious disease (EID) transmission between managed and wild pollinator species across a wide range of RNA viruses.

Within a structured large‐scale national survey across 26 independent sites, we quantify the prevalence and pathogen loads of multiple RNA viruses in co‐occurring managed honeybee (Apis mellifera) and wild bumblebee (Bombus spp.) populations. We then construct models that compare virus prevalence between wild and managed pollinators.

Multiple RNA viruses associated with honeybees are widespread in sympatric wild bumblebee populations. Virus prevalence in honeybees is a significant predictor of virus prevalence in bumblebees, but we remain cautious in speculating over the principle direction of pathogen transmission. We demonstrate species‐specific differences in prevalence, indicating significant variation in disease susceptibility or tolerance. Pathogen loads within individual bumblebees may be high and in the case of at least one RNA virus, prevalence is higher in wild bumblebees than in managed honeybee populations.

Our findings indicate widespread transmission of RNA viruses between managed and wild bee pollinators, pointing to an interconnected network of potential disease pressures within and among pollinator species. In the context of the biodiversity crisis, our study emphasizes the importance of targeting a wide range of pathogens and defining host associations when considering potential drivers of population decline.

Transanal endoscopic microsurgery (TEM) facilitated by video-assistance and anal insertion of a single-incision laparoscopic surgery (SILS(®))-port: preliminary experience

OBJECTIVE

Transanal endoscopic microsurgery (TEM) is an established method for the resection of benign and early malignant rectal lesions. Very recently, TEM via an anally inserted single incision laparoscopic surgery (SILS(®))-port has been proposed to overcome remaining obstacles of the classical TEM equipment.

METHODS

Nine patients with a total of 12 benign or early stage malignant rectal polyps were operated using the SILS(®)-port for TEM. Patients' and polyps' characteristics, perioperative and postoperative complications, as well as operating and hospitalization time were recorded.

RESULTS

All 12 polyps (ten low-grade adenoma, one high-grade adenoma, one pT2 carcinoma [preoperatively staged as T1]) were resected. Local full-thickness bowel wall resection was performed for three lesions and submucosal resection for nine lesions. Median operating time was 64 (range 30-180) min. No conversion to laparoscopic or open techniques was necessary. The median maximum diameter of the specimen was 25 (range 3-60) mm, fragmentation of polyps was avoidable in 11 of 12 (92 %) lesions, and resection margins were histologically clear in 11 of 12 (92 %) polyps. Only one patient, in whom three lesions were resected, experienced a complication as postoperative hemorrhage. No mortality occurred. Median hospitalization time was four (range 1-14) days.

CONCLUSIONS

SILS(®)-TEM is a feasible and safe method, providing numerous advantages in application, handling, and economy compared with the classical TEM technique. SILS(®)-TEM might become a promising alternative to classical TEM. Randomized, controlled trials comparing safety and efficacy of both instrumental settings will be needed in the future.

Adipose-derived stem cells and keratinocytes in a chronic wound cell culture model: the role of hydroxyectoine

Chronic wounds represent a major socio-economic problem in developed countries today. Wound healing is a complex biological process. It requires a well-orchestrated interaction of mediators, resident cells and infiltrating cells. In this context, mesenchymal stem cells and keratinocytes play a crucial role in tissue regeneration. In chronic wounds these processes are disturbed and cell viability is reduced. Hydroxyectoine (HyEc) is a membrane protecting osmolyte with protein and macromolecule stabilising properties. Adipose-derived stem cells (ASC) and keratinocytes were cultured with chronic wound fluid (CWF) and treated with HyEc. Proliferation was investigated using MTT test and migration was examined with transwell-migration assay and scratch assay. Gene expression changes of basic fibroblast growth factor (b-FGF), vascular endothelial growth factor (VEGF), matrix metalloproteinases-2 (MMP-2) and MMP-9 were analysed by quantitative real-time polymerase chain reaction (qRT-PCR). CWF significantly inhibited proliferation and migration of keratinocytes. Addition of HyEc did not affect these results. Proliferation capacity of ASC was not influenced by CWF whereas migration was significantly enhanced. HyEc significantly reduced ASC migration. Expression of b-FGF, VEGF, MMP-2 and MMP-9 in ASC, and b-FGF, VEGF and MMP-9 in keratinocytes was strongly induced by chronic wound fluid. HyEc enhanced CWF induced gene expression of VEGF in ASC and MMP-9 in keratinocytes. CWF negatively impaired keratinocyte function, which was not influenced by HyEc. ASC migration was stimulated by CWF, whereas HyEc significantly inhibited migration of ASC. CWF induced gene expression of VEGF in ASC and MMP-9 in keratinocytes was enhanced by HyEc, which might partly be explained by an RNA stabilising effect of HyEc.

Habitat complexity affects how young of the year Atlantic cod Gadus morhua perceive predation threat from older conspecifics

The response of age 0+ year juvenile Atlantic cod Gadus morhua to the presence of age 1+ and age 3+ year conspecifics was measured with and without cover available. Juveniles reacted by aggregating more closely and maintaining distance from older conspecifics in an experimental setting without cover but only to age 3+ year conspecifics when cover was available. The results indicate that prior residence of older juveniles can affect age 0+ year juveniles during benthic settlement and highlights the conservation value of structurally complex nursery habitats.

Early single-shot intravenous steroids do not affect pulmonary complications and mortality in burned or scalded patients

BACKGROUND AND OBJECTIVES

Inhalation injury, especially in combination with cutaneous burns, is the major cause of morbidity and mortality in patients admitted to burn care centers. Either with or without the presence of a cutaneous burn, inhalation injury contributes to high risk for developing severe pulmonary complications. Steroids may reduce a prolonged and destructive inflammatory response to toxic or allergic substances. The objective of this study was to evaluate the effect of early single-shot intravenous steroids on pulmonary complications and mortality in burned or scalded patients with or without inhalation injury.

METHODS

Retrospective analysis of a prospective single center database of patients registered between 1989 and 2011 who were admitted to the intensive care unit of our burn care center after burn or scald injury. Uni-variate statistical analysis was performed comparing two groups (steroid treated vs. non steroid treated patients) with regard to clinical outcome. Main parameters were sepsis, mortality and pulmonary complications such as pneumonia, ALI and ARDS. Multi-variate analysis was used by logistic regression with mortality and pulmonary complications as the dependent variables to identify independent risk factors after burn or scald injuries.

RESULTS

A total of 1637 patients with complete data were included in the present analysis. 199 (12.2%) received single-shot intravenous steroids during the prehospital phase of care. In 133 (66.8%) of these patients, inhalation injury was diagnosed via bronchoscopy. Steroid treated patients had sustained a significantly higher severity of burn than non-steroid treated patients (Abbreviated Burn Severity Index 7.1±3 vs. 6.0±2.9; p<0.001). In a multivariate analysis using a logistic regression model early intravenous steroid treatment had no significant effect on pulmonary complications and mortality.

CONCLUSIONS

In our single center cohort of burned and scalded patients single-shot intravenous steroids during the pre-hospital phase of care was not associated with pulmonary complications or mortality.

Clinical profile of assault burned victims: a 16-year review

OBJECTIVE

Assaults by burning occur infrequently and are related to the social circumstances and demographics of each population. We aimed to explore the mechanisms, complications, morbidity and mortality associated with assault burn injuries admitted to the Burns Intensive Care Unit of Merheim University Hospital in Cologne.

METHODS

A retrospective data analysis of a consecutive series of 1 243 burn patients between 1989 and 2004. The cohort was divided into two groups: AG (assault group) and CG (control group). Analyses were controlled for clinical data, treatment and outcome of all patients involved.

RESULTS

Forty-one patients with assault burn injuries were identified during the study period. Compared with the general burn population (CG), the AG had a significantly larger size of third-degree burns (p=0.047), a higher incidence of inhalation injury (p<0.001) and a longer intubation period (p=0.047). Patients in the AG were also more likely to undergo escharotomy (p=0.013) and to receive antibiotics on admission (p=0.016). The mortality rate was higher in the AG than in the CG (26.8% v. 19.9%), but this difference was not significant.

CONCLUSIONS

Burned patients who were victims of assault tend to have more severe injuries than the general burn population. These injuries are not only physical, and their management requires a multidisciplinary approach to improve outcome.

Quality of life measurement in patients with hypertension in Cyprus

INTRODUCTION

Cardiovascular diseases and hypertension may have a significant impact on the quality of life of those who suffer from these conditions. The aim of the present study was to measure health-related quality of life among Cypriot patients suffering from hypertension and/or dyslipidaemia, as well as to investigate any temporal changes in their quality of life at 3 and 6 months from the initial visit.

METHODS

A stratified random sampling method was used in this follow-up multi-centre study to select a representative sample of physicians who treat patients with hypertension in both public and private sector outpatient hospital clinics and physician offices. The participants were diagnosed by the physician according to the 2007 European guidelines for the management of arterial hypertension. The EQ-5D questionnaire was employed to measure self-assessed quality of life among these patients. Six hundred and fifty-four patients were recruited by physicians and agreed to participate, while 528 of them successfully completed EQ-5D at baseline and two subsequent phases (at 3 and 6 months), representing a response rate of 80.7%.

RESULTS

A total of 39.6% of the respondents reported problems in one or more of the EQ-5D dimensions. This was more apparent in the case of anxiety and depression. There appeared to be statistically significant improvements with regard to mobility, usual activities, pain/discomfort and anxiety/depression dimensions between the initial visit and on first follow up, as well as subsequently. Median (interquartile range) EQ-5D index scores were 0.97 (0.19), 0.97 (0.19) and 0.97 (0.17) at first visit, first follow-up and second followup respectively (p<0.001). Also, median EQ-5D VAS scores were 80 (20), 85 (10) and 90 (15) at the initial, first follow-up and second follow-up visit respectively (p<0.001). Median EQ-5D VAS scores increased over time amongst all socio-demographic and risk groups of participants.

CONCLUSION

Hypertension had little association with mobility and physical activities, indicating that performing physical activities was not limited by hypertension. However, hypertension seems to be more strongly related to anxiety and depression.

Suicide by burning: epidemiological and clinical profiles

Self-immolation constitutes a rare form of suicide in developed countries, though it accounts for unique injury characteristics in the burn intensive care unit. The aim of this study was to present the epidemiological and clinical features of patients burned during a suicidal attempt seen in a North Rhine-Westphalia burn intensive care unit (BICU). To address this aim, we undertook a 21-year retrospective study involving patients with thermal injuries admitted to the largest burn unit in Germany. A total of 125 suicide-related burn victims were identified in the study period (9.4%). Comparing the self-immolation group with the rest burn patient cohort, suicide victims were more likely to be single and to act under the influence of alcohol. The suicidal group had a larger extent of burns, higher incidence of inhalation injury, required more surgical procedures, catecholamines, blood transfusions, and a longer BICU stay. Their clinical course was complicated by prolonged intubation period, higher rate of multiple drug-resistant bacteria acquisition and sepsis, leading to a higher mortality rate. Although the proportion of self-immolation victims among all burned patients is not high, the markedly higher severity of their burns and their poorer quality of outcomes makes them an important clinical subgroup for further study.

Combined latissimus dorsi and serratus anterior flaps for pelvic reconstruction

In recurrent pressure sores, adjacent tissue has already been consumed by multiple surgeries. Additional problems are several co-morbidities of patients. Especially, severe atherosclerosis would be a contraindication for using free flaps. However, microsurgical techniques allow circumventing these limitations and preparing even severely atherosclerotic vessels. We performed a total of eight sacral pressure sore coverage in our standardized fashion, using the free combined latissimus dorsi and serratus anterior free flaps. All patients had severe atherosclerosis and needed large soft tissue coverage of the sacral defects. Five patients presented after bowel resection, three with recurrent sacral pressure sores. The average follow-up was 12 months. Postoperatively, all patients were allowed to be prone on the operated area. One minor wound dehiscence was sutured in local anesthesia. CT imaging analysis of the pelvis showed complete void space coverage. The combined latissimus dorsi and serratus anterior flaps are a valuable tool for pelvic reconstruction in our hands. In addition, severe atherosclerosis should not be considered an obstacle to microsurgery and the use of free flaps.