Comparison of Cycle Threshold and Clinical Status Among Different Age Groups of COVID-19 Cases

Purpose

Aim of the study was to compare the viral load and clinical status among different age groups with COVID-19 infection

Methods & Materials

A retrospective cross-sectional study was carried out to analyse the Ct values of positive samples reported during April 2020 till May 2021. Result of 13,820 number of RT-PCR positive samples were included for analysis of Ct values. Ct values of confirmatory genes were taken into consideration and Ct values below 25, >25 to 30 and >30 was categorized as high, moderate and low viral load respectively. Age group was stratified into ≤18 years, 18-60 and >60 years as young, adult and elderly respectively. The data was analysed using SPSS windows version 25.0.

Results

The Mean Ct value was 27.9, 26, and 26.2 in young, adult and elderly age group respectively. Mean Ct value of young patients were significantly higher as compared to adult and elderly patients (p<0.05). The percentage of high viral load (Ct<25) was found to be significantly higher in adults and elderly (44.6% & 43.7%) as compared to young (32.2%) (p<0.001). Majority of the covid 19 positive cases belonging to <18 years age (75.9%) were asymptomatic as compared to 64.5% and 59.7% in adult and elderly age groups respectively.

Conclusion

Present study observed a significantly high proportion of viral load in the adult and elderly population which plays a substantial contribution to SARS CoV-2 transmission, whereas the majority of the young population being asymptomatic play major role as silent transmitters. The study reemphasizes the need for strict adherence to COVID appropriate behaviours.

OP0108 LORECIVIVINT (SM04690), AN INTRA-ARTICULAR, SMALL-MOLECULE CLK2/DYRK1A INHIBITOR THAT MODULATES THE WNT PATHWAY, PROVIDED CARTILAGE-PROTECTIVE EFFECTS IN AN ANIMAL MODEL OF POST-TRAUMATIC OA

Background:

Osteoarthritis (OA) is characterized by increased cartilage thinning, bone remodeling, and inflammation. Post-traumatic OA, which develops after acute direct trauma to the joints, accounts for approximately 12% of all OA cases.1 Current therapeutic options focus on alleviating symptoms and pain rather than disease modification. Lorecivivint (LOR; SM04690), an intra-articular (IA), small-molecule CLK2/DYRK1A inhibitor that modulates the Wnt pathway, has been shown in animal studies to induce chondrogenesis, protect cartilage, and reduce inflammation and, thereby, improve joint health.2

Objectives:

A single IA LOR injection was evaluated in a rat model of knee instability to determine its protective and regenerative effects when injected at different timepoints after induction of post-traumatic OA.

Methods:

Knee instability/post-traumatic OA was surgically induced in rats by combining anterior cruciate ligament transection with partial medial meniscus transection (ACLT+pMMx). LOR (0.3 ug) or vehicle was injected into the IA space of the damaged knee at 2, 3, or 4 weeks after induction of OA. OA-induced (n=10/group) or sham-operated (surgery without ACLT+pMMx; n=5/group) rats were sacrificed at the injection timepoint (baseline) or 12 weeks following LOR/vehicle injection (study conclusion). Histological grades were evaluated using the summed OARSI scores (stage and grade of cartilage damage)3 of the anterior and posterior medial femoral condyle (MFC) and medial tibial plateau (MTP). Weight distribution analysis was performed using an incapacitance meter at several timepoints. Statistical analysis was performed using one-way ANOVA with Dunnett’s multiple comparison test.

Results:

ACLT+pMMx surgeries led to increased OARSI scores in rats compared with sham surgeries by 2 weeks. LOR treatment at Weeks 2, 3, and 4 led to significant decreases (P<0.05) in total joint OARSI scores (Table 1) at the end of the study compared with vehicle treatment. Rats treated with LOR for 12 weeks and rats at injection baseline had similar OARSI scores, suggesting that LOR treatment arrested the progression of cartilage damage. Significant improvements (P<0.05) were also observed in the weight distribution of LOR-treated rats in the 3- and 4-week groups at 6 and 12 weeks after their respective IA injections compared with vehicle-treated rats.

Table 1.

OARSI scores

Week-2 injectionSham-operated(14 weeks after surgery)Baseline (BL)(2 weeks after surgery)Vehicle(12 weeks after injection)LOR(12 weeks after injection)Total score5.9919.1731.3619.19SEM1.071.552.481.81P value versus BL0.9999P value versus vehicle0.0004Week-3 injectionSham-operated(15 weeks after surgery)Baseline (BL)(3 weeks after surgery)Vehicle(12 weeks after injection)LOR(12 weeks after injection)Total score6.0923.1730.4521.20SEM1.251.361.421.00P value versus BL0.4522P value versus vehicle0.0001Week-4 injectionSham-operated(16 weeks after surgery)Baseline (BL)(4 weeks after surgery)Vehicle(12 weeks after injection)LOR(12 weeks after injection)Total score6.9716.8824.9518.63SEM1.321.041.741.61P value versus BL0.6257P value versus vehicle0.0111

Conclusion:

LOR exhibited cartilage-protective effects and slowed disease progression in the ACLT+pMMx model in vivo and, therefore, has potential as a structure-modifying treatment for OA.

References:

[1]Brown TD, et al. J Orthop Trauma. 2006.

[2]Deshmukh V, et al. Osteoarthr Cartil. 2019.

[3]Pritzker KPH, et al. Osteoarthr Cartil. 2006.

Disclosure of Interests:

Tim Seo Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Vishal Deshmukh Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Yusuf Yazici Shareholder of: Samumed, LLC, Employee of: Samumed, LLC

POS0372 LORECIVIVINT (SM04690), AN INTRA-ARTICULAR, SMALL-MOLECULE CLK2/DYRK1A INHIBITOR THAT MODULATES THE WNT PATHWAY, AS A POTENTIAL TREATMENT FOR MENISCAL INJURIES

Background:

Meniscal injuries are the most common pathology of the knee and are associated with pain, stiffness, and localized swelling. Meniscal damage is a frequent finding on MRI images of knee osteoarthritis (OA).1 Efforts to repair meniscal damage have been largely unsuccessful and do not prevent the progression of degenerative changes that lead to knee OA.2 The Wnt signaling pathway has been shown to be regulated during meniscal development,3 suggesting that manipulation of this pathway may influence the regenerative capacity of the meniscus. Lorecivivint (LOR; SM04690) is an intra-articular (IA), small-molecule CLK2/DYRK1A inhibitor that modulates the Wnt pathway.4

Objectives:

LOR was evaluated in preclinical studies to determine its protective and anabolic effects in ex vivo explants and in a rat model of chemically induced inflammatory meniscal degeneration.

Methods:

Effects of LOR (30 nM) on matrix metalloproteinase (MMP) expression in cultured rat menisci treated with IL-1B were measured by qRT-PCR. In vivo, LOR activity was evaluated in a rat model of monosodium iodoacetate (MIA) injection-induced inflammatory meniscal degeneration. A single IA injection of MIA was immediately followed by a single IA injection of LOR (0.3 ug) or vehicle. Knees were harvested on Days 1, 4, and 11 and menisci were isolated. Anti-inflammatory effects were evaluated by qRT-PCR for TNFA and IL6 expression. Meniscal protection was evaluated by qRT-PCR for MMPs and aggrecanase. Anabolic effects were evaluated by qRT-PCR for collagens.

Results:

In ex vivo meniscal explants, LOR inhibited expression of MMP1, MMP3, and MMP13 compared with DMSO (P<0.01). In vivo, LOR significantly decreased expression of MMPs and aggrecanase (P<0.05) and reduced expression of inflammatory cytokines TNFA and IL6 compared with vehicle in the rat model of inflammatory meniscal degeneration at Day 4 after MIA injection. Additionally, LOR increased expression of collagen types I, II, and III at Day 11 after MIA injection (Figure 1).

Conclusion:

LOR exhibited protective effects in the meniscus ex vivo and in vivo by reducing catabolic enzyme expression compared with control. Anti-inflammatory effects of LOR were demonstrated by inhibition of inflammatory cytokine expression. Compared with vehicle, LOR increased collagen expression in vivo, indicating potential meniscal anabolic effects. These data support further investigation of LOR as a potential structure-modifying treatment for meniscal injuries.

References:

[1]Englund M, et al. Rheum Dis Clin North Am. 2009.

[2]Collins JE, et al. Arthritis Care Res (Hoboken). 2019.

[3]Pazin DE, et al. Dev Dyn. 2012.

[4]Deshmukh V, et al. Osteoarthr Cartil. 2019.

Disclosure of Interests:

Tim Seo Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Vishal Deshmukh Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Yusuf Yazici Shareholder of: Samumed, LLC, Employee of: Samumed, LLC

Fixed-dose combination in management of type 2 diabetes mellitus: Expert opinion from an international panel

Type 2 diabetes mellitus (T2DM) is a progressive disease with multifactorial etiology. The first-line therapy includes monotherapy (with metformin), which often fails to provide effective glycemic control, necessitating the addition of add-on therapy. In this regard, multiple single-dose agents formulated as a single-dose form called fixed-dose combinations (FDCs) have been evaluated for their safety, efficacy, and tolerability. The primary objective of this review is to develop practice-based expert group opinion on the current status and the causes of concern regarding the irrational use of FDCs, in Indian settings. After due discussions, the expert group analyzed the results from several clinical evidence in which various fixed combinations were used in T2DM management. The panel opined that FDCs (double or triple) improve patient adherence, reduce cost, and provide effective glycemic control and, thereby, play an important role in the management of T2DM. The expert group strongly recommended that the irrational metformin FDC's, banned by Indian government, should be stopped and could be achieved through active participation from the government, regulatory bodies, and health ministry, and through continuous education of primary care physicians and pharmacists. In T2DM management, FDCs play a crucial role in achieving glycemic targets effectively. However, understanding the difference between rational and irrational FDC combinations is necessary from the safety, efficacy, and tolerability perspective. In this regard, primary care physicians will have to use a multistep approach so that they can take informed decisions.

COVID-19: a conundrum to decipher

OBJECTIVE

Recent worldwide outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of respiratory coronavirus disease 2019 (COVID-19), is a current, ongoing life-threatening crisis, and international public health emergency. The early diagnosis and management of the disease remains a major challenge. In this review, we aim to summarize the updated epidemiology, causes, clinical manifestation and diagnosis, as well as prevention and control of the novel coronavirus SARS-CoV-2.

MATERIALS AND METHODS

A broad search of the literature was performed in "PubMed" "Medline" "Web of Science", "Google Scholar" and "World Health Organization-WHO" using the keywords "severe acute respiratory syndrome coronavirus", "2019-nCoV", "COVID-19, "SARS", "SARS-CoV-2" "Epidemiology" "Transmission" "Pathogenesis" "Clinical Characteristics". We reviewed and documented the information obtained from literature on epidemiology, pathogenesis and clinical appearances of SARS-CoV-2 infection.

RESULTS

The global cases of COVID-19 as of April 2, 2020, have risen to more than 900,000 and morbidity has reached more than 47,000. The incidence rate for COVID-19 has been predicted to be higher than the previous outbreaks of other coronavirus family members, including those of SARS-CoV and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV). The main clinical presentation of SARS-CoV-2 infection ranges from asymptomatic stages to severe lower respiratory infection in the form of pneumonia. Most of the patients also presented with fever, cough, sore throat, headache, fatigue, myalgia and breathlessness. Individuals at higher risk for severe illness include elderly people and patients with a weakened immune system or that are suffering from an underlying chronic medical condition like hypertension, diabetes mellitus, cancer, respiratory illness or cardiovascular diseases.

CONCLUSIONS

SARS-Cov-2 has emerged as a worldwide threat, currently affecting 170 countries and territories across the globe. There is still much to be understood regarding SARS-CoV-2 about its virology, epidemiology and clinical management strategies; this knowledge will be essential to both manage the current pandemic and to conceive comprehensive measures to prevent such outbreaks in the future.

THU0056 SM04755, A POTENTIAL DISEASE-MODIFYING TREATMENT FOR TENDINOPATHY, MODULATES THE WNT PATHWAY VIA INHIBITION OF CLKS AND DYRK1A

Background:

Tendinopathy is an inflammatory and degenerative disorder of tendons caused by injuries and/or overuse. Left untreated, tendinopathy can lead to pain and rupture. Current therapeutic options only treat symptoms. Stem cell- and growth factor-based treatments are under investigation but have not established safety or efficacy, leaving considerable unmet need. The Wnt pathway is upregulated in chronic tendinopathy, affecting inflammation and tenocyte differentiation. SM04755, a novel, topical, small-molecule Wnt pathway inhibitor, has previously been shown to inhibit inflammation, protect tenocytes, and increase tenocyte differentiation in nonclinical models.1

Objectives:

To identify molecular targets of SM04755 and its associated mechanism of action.

Methods:

Wnt pathway inhibition was measured using a cell-based luciferase reporter assay controlled by a β-catenin/TCF-responsive promoter in SW480 colon cancer cells. A kinome screen (318 kinases) and kinase assays were performed. Effects of SM04755 on phosphorylation of proteins, including serine/arginine-rich splicing factor (SRSF) proteins in rat tendon-derived stem cells (rTDSCs) and peripheral blood mononuclear cells (PBMCs), were measured using western blot. SiRNA-mediated knockdown of CDC-like kinases (CLKs) and dual-specificity tyrosine kinase (DYRK1A) were performed in human mesenchymal stem cells (hMSCs), rTDSCs, and rat tenocytes. Effects of SM04755 and siRNA knockdowns on Wnt pathway gene expression and catabolic enzymes (MMPs) were measured using qPCR. SM04755 and siRNA effects on tenocyte marker expression were assessed by qPCR and immunostaining. Effects of SM04755 on LPS-induced expression of inflammatory cytokines in PBMCs were measured by MSD-based ELISA. Statistical analyses used one-way ANOVA for multiple group comparisons and t-tests for comparison between two groups.

Results:

SM04755 was a potent inhibitor (EC50=156 nM) of Wnt signaling. Biochemical assays identified CLKs and DYRK1A as molecular targets of SM04755. SM04755 potently inhibited CLK-mediated phosphorylation of SRSF proteins compared with DMSO controls. Knockdowns of CLKs and DYRK1A led to inhibition of Wnt pathway genes (AXIN2,LEF1,TCF4,TCF7, etc.) compared with siRNA controls (siCtrl). CLK1, 2, and 4 and DYRK1A knockdowns also induced expression of tenocyte markers in rTDSCs and inhibited IL-1β-induced expression of catabolic enzymes (MMP1, 3, 9, 13) in tenocytes compared with siCtrl. SM04755 treatment of LPS-stimulated PBMCs resulted in reduced phosphorylation of NF-kB and STAT3 and inhibited production of inflammatory cytokines compared with DMSO.

Conclusion:

SM04755 inhibited CLKs and DYRK1A, which led to Wnt pathway modulation. Knockdowns of CLKs and DYRK1A, compared with control siRNA, induced tenocyte differentiation and reduced tendon-destroying proteases in tenocytes. This supports the potential disease modification of tendinopathy with SM04755. Furthermore, the anti-inflammatory effects of SM04755 are mechanistically supported by the decreased phosphorylation of STAT3 and NF-kB. These data support that SM04755, as a single agent, may potentially improve symptoms and provide disease modification in tendinopathy. Human tendinopathy trials are planned.

References:

[1]Deshmukh et al.Arthritis and Rheum. 2016

Acknowledgments:

Brian Hofilena for chemistry, Josh Stewart for pharmacokinetics, and Luis Dellamary for formulation.

Disclosure of Interests:

Vishal Deshmukh Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Alyssa O’Green Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Tim Seo Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Yusuf Yazici Shareholder of: Samumed, LLC, Grant/research support from: Bristol-Myers Squibb, Celgene, and Genentech, Consultant of: Celgene and Sanofi, Employee of: Samumed, LLC

AB0069 LORECIVIVINT (SM04690), AN INTRA-ARTICULAR, SMALL-MOLECULE CLK/DYRK1A INHIBITOR THAT MODULATES THE WNT PATHWAY, AS A POTENTIAL TREATMENT FOR MENISCAL INJURIES

Background:

Meniscal injuries, associated with pain, stiffness, and localized swelling, are the most common pathology of the knee with a prevalence of 61 per 100,000.1Meniscal damage is a frequent finding on MRI images of knee osteoarthritis (OA)2; while a meniscal tear can lead to knee OA, knee OA can also lead to a spontaneous meniscal tear.3Efforts to repair meniscal damage have been largely unsuccessful and do not prevent the progression of degenerative changes that lead to knee OA.4The Wnt signaling pathway has been shown to be regulated during meniscal development,5,6suggesting that manipulation of this pathway may influence the regenerative capacity of the meniscus. Lorecivivint (LOR; SM04690) is an intra-articular (IA), small-molecule CLK/DYRK1A inhibitor that modulates the Wnt pathway.

Objectives:

LOR was evaluated in preclinical studies to determine its protective and anabolic effects in ex vivo explants and in a rat model of chemically induced inflammatory meniscus degeneration.

Methods:

Effects of LOR (30 nM) on expression of matrix metalloproteinases (MMPs) in cultured rat menisci treated with IL-1B were measured by qPCR. In vivo, LOR activity was evaluated in a rat model of monosodium iodoacetate (MIA) injection-induced inflammatory meniscus degeneration. A single IA injection of MIA was immediately followed by a single IA injection of LOR (0.3 ug) or vehicle. Knees were harvested on Days 1, 4, and 11 and menisci were isolated. Anti-inflammatory effects were evaluated by measuringTNFAandIL6expression by qPCR. Meniscus protection was evaluated by qPCR for MMPs and aggrecanase and anabolic effects by qPCR for collagens.

Results:

In ex vivo meniscal explants, LOR inhibited expression ofMMP1,MMP3, andMMP13compared to DMSO (P<0.01). In vivo, LOR significantly decreased expression of these MMPs and aggrecanase (P<0.05) compared to vehicle in the rat model of inflammatory meniscus degeneration at Day 4 after MIA injection. In addition, LOR reduced expression of inflammatory cytokinesTNFAandIL6at Day 4 compared to vehicle. Finally, LOR increased expression of collagen types I, II, and III at Day 11 after MIA injection.

Conclusion:

LOR exhibited protective effects in the meniscus ex vivo and in vivo by reducing the expression of catabolic enzymes compared to control. Anti-inflammatory effects of LOR were demonstrated by inhibition of inflammatory cytokine expression. Compared to vehicle, LOR increased expression of collagens in vivo, indicating potential meniscal anabolic effects. These data support further investigation of LOR as a potential disease-modifying therapy for meniscal injuries.

References:

[1]Logerstedt D and Snyder-Mackler L.J Orthop Sports Phys Ther. 2010

[2]Englund M, et al.Rheum Dis Clin North Am. 2009

[3]Englund M, et al.Radiol Clin North Am. 2009

[4]von Lewinski, et al.Knee Surg Sports Traumatol Arthrosc. 2007

[5]Pazin DE, et al.ORS 2012 Annual Meeting. Paper No. 0221

[6]Pazin DE, et al.Dev Dyn. 2012

Disclosure of Interests:

Tim Seo Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Vishal Deshmukh Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Yusuf Yazici Shareholder of: Samumed, LLC, Grant/research support from: Bristol-Myers Squibb, Celgene, and Genentech, Consultant of: Celgene and Sanofi, Employee of: Samumed, LLC

AB0070 LORECIVIVINT (SM04690), A POTENTIAL DISEASE-MODIFYING TREATMENT FOR KNEE OSTEOARTHRITIS, DEMONSTRATED CARTILAGE-PROTECTIVE EFFECTS ON HUMAN OSTEOARTHRITIC EXPLANTS

Background:

Wnt pathway upregulation contributes to knee osteoarthritis (OA) through osteocyte differentiation, cartilage thinning, and inflammation. Lorecivivint (LOR; SM04690), a novel, small-molecule CLK/DYRK1A inhibitor that modulates the Wnt pathway, demonstrated disease-modifying potential for knee OA in preclinical studies.1However, the specific mechanisms by which LOR protects cartilage in knee OA are unclear.

Objectives:

To evaluate the cartilage-protective effects of LOR on human OA explants from total knee replacement (TKR) donors.

Methods:

Knee joint tissue from 22 TKR donors was obtained. IRB approval was obtained from Scripps Health. Cartilage was scored using the Outerbridge classification system based on gross appearance (grade 1=least-damaged tissue, grade 4=most-damaged tissue). Cartilage explants (4 mm in diameter) with Outerbridge grades 2–3 were harvested and cultured for 48 hours to reach metabolic stability. They were then treated with LOR (10 nM, 30 nM) or DMSO and stimulated with either IL-1β (10 ng/ml) or TNF-α (20 ng/ml)+oncostatin M (OM) (10 ng/ml) or left unstimulated. After 72 hours, supernatants and explants were collected. Gene expression of matrix metalloproteinases (MMPs) 1, 3, and 13 was measured by qPCR and protein levels of MMP-1, MMP-3, MMP-13, and thrombospondin-motif-containing disintegrins/metalloproteinases ADAMTS-4 and ADAMTS-5 were measured in supernatants by ELISA. Glycosaminoglycan (GAG) and nitric oxide (NO) levels were measured in supernatants using the dimethylmethylene blue assay and Griess assay, respectively. One-way ANOVA was used for multiple group comparisons.

Results:

Treatment with IL-1β or TNF-α+OM led to statistically significant increases in gene expression ofMMP1,MMP3, andMMP13and increased secretion of GAG, MMP-1, MMP-3, MMP-13, ADAMTS-4, ADAMTS-5, and NO in supernatants compared to unstimulated control. Treatment with LOR decreased both IL-1β-stimulated and TNF-α+OM-stimulated gene expression ofMMP1,MMP3, andMMP13and secretion of GAG, MMP-1, MMP-3, MMP-13, ADAMTS-4, ADAMTS-5, and NO in supernatants compared to treatment with DMSO.

Conclusion:

LOR demonstrated potent inhibition of cartilage catabolism enzyme production in human OA explants compared to controls. These cartilage-protective effects support the development of LOR as a potential disease-modifying treatment for knee OA. Human trials are ongoing.

References:

[1]Deshmukh V, et al.Osteoarthr Cartil. 2019.

Disclosure of Interests:

Vishal Deshmukh Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Shawn Grogan: None declared, Tim Seo Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, Deepti Bhat Shareholder of: Samumed, LLC, Employee of: Samumed, LLC, William Bugbee: None declared, Darryl D’Lima: None declared, Yusuf Yazici Shareholder of: Samumed, LLC, Grant/research support from: Bristol-Myers Squibb, Celgene, and Genentech, Consultant of: Celgene and Sanofi, Employee of: Samumed, LLC

Unravelling the utility of modern sulfonylureas from cardiovascular outcome trials and landmark trials: expert opinion from an international panel

AIM

The primary objective of this review is to develop practice-based expert group opinions on the cardiovascular (CV) safety and utility of modern sulfonylureas (SUs) in cardiovascular outcome trials (CVOTs).

BACKGROUND

The United States Food and Drug Administration issued new guidance to the pharmaceutical industry in 2008 regarding the development of new antihyperglycemic drugs. The guidance expanded the scope for the approval of novel antihyperglycemic drugs by mandating CVOTs for safety. A few long-term CVOTs on dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors have been completed, while others are ongoing. SUs, which constitute one of the key antihyperglycemic agents used for the management of type 2 diabetes mellitus (T2DM), have been used as comparator agents in several CVOTs. However, the need for CVOTs on modern SUs remains debatable. In this context, a multinational group of endocrinologists convened for a meeting and discussed the need for CVOTs of modern SUs to evaluate their utility in the management of patients with T2DM. At the meeting, CVOTs of modern SUs conducted to date and the hypotheses derived from the results of these trials were discussed.

REVIEW RESULTS

The expert group analyzed the key trials emphasizing the CV safety of modern SUs and also reviewed the results of various CVOTs in which modern SUs were used as comparators. Based on literature evidence and individual clinical insights, the expert group opined that modern SUs are cardiosafe and that since they have been used as comparators in other CVOTs, CVOTs of SUs are not required.

CONCLUSION

Modern SUs can be considered a cardiosafe option for the management of patients with diabetes mellitus and CV disease; thus CVOTs among individuals with T2DM are not required.

Modulation of the Wnt pathway through inhibition of CLK2 and DYRK1A by lorecivivint as a novel, potentially disease-modifying approach for knee osteoarthritis treatment

OBJECTIVES

Wnt pathway upregulation contributes to knee osteoarthritis (OA) through osteoblast differentiation, increased catabolic enzymes, and inflammation. The small-molecule Wnt pathway inhibitor, lorecivivint (SM04690), which previously demonstrated chondrogenesis and cartilage protection in an animal OA model, was evaluated to elucidate its mechanism of action.

DESIGN

Biochemical assays measured kinase activity. Western blots measured protein phosphorylation in human mesenchymal stem cells (hMSCs), chondrocytes, and synovial fibroblasts. siRNA knockdown effects in hMSCs and BEAS-2B cells on Wnt pathway, chondrogenic genes, and LPS-induced inflammatory cytokines was measured by qPCR. In vivo anti-inflammation, pain, and function were evaluated following single intra-articular (IA) lorecivivint or vehicle injection in the monosodium iodoacetate (MIA)-induced rat OA model.

RESULTS

Lorecivivint inhibited intranuclear kinases CDC-like kinase 2 (CLK2) and dual-specificity tyrosine phosphorylation-regulated kinase 1A (DYRK1A). Lorecivivint inhibited CLK2-mediated phosphorylation of serine/arginine-rich (SR) splicing factors and DYRK1A-mediated phosphorylation of SIRT1 and FOXO1. siRNA knockdowns identified a role for CLK2 and DYRK1A in Wnt pathway modulation without affecting β-catenin with CLK2 inhibition inducing early chondrogenesis and DYRK1A inhibition enhancing mature chondrocyte function. NF-κB and STAT3 inhibition by lorecivivint reduced inflammation. DYRK1A knockdown was sufficient for anti-inflammatory effects, while combined DYRK1A/CLK2 knockdown enhanced this effect. In the MIA model, lorecivivint inhibited production of inflammatory cytokines and cartilage degradative enzymes, resulting in increased joint cartilage, decreased pain, and improved weight-bearing function.

CONCLUSIONS

Lorecivivint inhibition of CLK2 and DYRK1A suggested a novel mechanism for Wnt pathway inhibition, enhancing chondrogenesis, chondrocyte function, and anti-inflammation. Lorecivivint shows potential to modify structure and improve symptoms of knee OA.

Intraoperative Image Guidance during Endoscopic Sinus Surgery

Endoscopic sinus surgery (ESS) is one of the most commonly performed procedures in otorhinolaryngology and is associated with a definite risk for both intraoperative and postoperative complications. Intraoperative image guidance is expected to have a major effect on procedures such as ESS by allowing the clinician to more efficiently remove pathology and by improving surgeon confidence and knowledge of anatomy, particularly in revision procedures or in patients with altered anatomy. As a consequence, complications during these pro-’ cedures will decrease and patient safety will increase. Several guidance modalities are available including computed tomography (CT), magnetic resonance imaging (MRI), and fluoroscopy. This article will describe current applications of each of these three techniques with respect to ESS while focusing on innovative techniques that use MRI and CT to provide intraoperative guidance with unmatched convenience, reliability, and utility.

A small-molecule inhibitor of the Wnt pathway (SM04690) as a potential disease modifying agent for the treatment of osteoarthritis of the knee

OBJECTIVES

Osteoarthritis (OA) is a degenerative disease characterized by loss of cartilage and increased subchondral bone within synovial joints. Wnt signaling affects the pathogenesis of OA as this pathway modulates both the differentiation of osteoblasts and chondrocytes, and production of catabolic proteases. A novel small-molecule Wnt pathway inhibitor, SM04690, was evaluated in a series of in vitro and in vivo animal studies to determine its effects on chondrogenesis, cartilage protection and synovial-lined joint pathology.

DESIGN

A high-throughput screen was performed using a cell-based reporter assay for Wnt pathway activity to develop a small molecule designated SM04690. Its properties were evaluated in bone-marrow-derived human mesenchymal stem cells (hMSCs) to assess chondrocyte differentiation and effects on cartilage catabolism by immunocytochemistry and gene expression, and glycosaminoglycan breakdown. In vivo effects of SM04690 on Wnt signaling, cartilage regeneration and protection were measured using biochemical and histopathological techniques in a rodent acute cruciate ligament tear and partial medial meniscectomy (ACLT + pMMx) OA model.

RESULTS

SM04690 induced hMSC differentiation into mature, functional chondrocytes and decreased cartilage catabolic marker levels compared to vehicle. A single SM04690 intra-articular (IA) injection was efficacious in a rodent OA model, with increased cartilage thickness, evidence for cartilage regeneration, and protection from cartilage catabolism observed, resulting in significantly improved Osteoarthritis Research Society International (OARSI) histology scores and biomarkers, compared to vehicle.

CONCLUSIONS

SM04690 induced chondrogenesis and appeared to inhibit joint destruction in a rat OA model, and is a candidate for a potential disease modifying therapy for OA.

Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke)

Supplemental Digital Content is available in the text.

Background:

Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation.

Methods:

STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass.

Results:

A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier.

Conclusions:

In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.

Time-constrained mother and expanding market: emerging model of under-nutrition in India

Background

Persistent high levels of under-nutrition in India despite economic growth continue to challenge political leadership and policy makers at the highest level. The present inductive enquiry was conducted to map the perceptions of mothers and other key stakeholders, to identify emerging drivers of childhood under-nutrition.

Methods

We conducted a multi-centric qualitative investigation in six empowered action group states of India. The study sample included 509 in-depth interviews with mothers of undernourished and normal nourished children, policy makers, district level managers, implementer and facilitators. Sixty six focus group discussions and 72 non-formal interactions were conducted in two rounds with primary caretakers of undernourished children, Anganwadi Workers and Auxiliary Nurse Midwives.

Results

Based on the perceptions of the mothers and other key stakeholders, a model evolved inductively showing core themes as drivers of under-nutrition. The most forceful emerging themes were: multitasking, time constrained mother with dwindling family support; fragile food security or seasonal food paucity; child targeted market with wide availability and consumption of ready-to-eat market food items; rising non-food expenditure, in the context of rising food prices; inadequate and inappropriate feeding; delayed recognition of under-nutrition and delayed care seeking; and inadequate responsiveness of health care system and Integrated Child Development Services (ICDS). The study emphasized that the persistence of child malnutrition in India is also tied closely to the high workload and consequent time constraint of mothers who are increasingly pursuing income generating activities and enrolled in paid labour force, without robust institutional support for childcare.

Conclusion

The emerging framework needs to be further tested through mixed and multiple method research approaches to quantify the contribution of time limitation of the mother on the current burden of child under-nutrition.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3189-4) contains supplementary material, which is available to authorized users.

Effectiveness of Er:YAG and CO2 lasers in the management of gingival melanin hyperpigmentation

BACKGROUND

Although clinical melanin pigmentation does not present itself as a medical problem or a disease entity, "black gums" is a major esthetic complaint for many people, who often requests cosmetic corrections. Gingival depigmentation can be carried out using many procedures; lasers of various types being a new addition. This study was undertaken to evaluate and compare the effectiveness of CO2 and Er:YAG lasers for the treatment of gingival melanin hyper pigmentation.

MATERIALS & METHODS

Twenty young age and gender matched subjects were selected for a randomized split mouth depigmentation procedure using Er:YAG (Group A) and CO2 laser (Group B). Parameters evaluated were: Dummet index, Hedin melanin Index, Gingival and Plaque Index, time taken for the procedure, bleeding during the procedure, VAS scale for pain perception and wound healing and patient preference for the procedure. Wilcoxon signed rank test, Chi-square test, paired t test were used to analyze statistical significance between different variables.

RESULTS

CO2 laser treatment caused increased pain and delayed wound healing when compared to Er:YAG laser treatment.

CONCLUSION

Although both treatment modalities are highly effective depigmentation procedures, giving excellent esthetics results; when pain, wound healing and patient preferences were considered Er:YAG outscored CO2 Laser.

SUMMARY

The effectiveness of the Er:YAG and CO2 laser for the treatment of gingival melanin depigmentation was evaluated clinically and histologically, although both treatment modalities are highly effective, giving excellent esthetics results, however, when pain and wound healing were considered Er:YAG was better than CO2 laser.

Interdistrict variations in child health status and health services utilization: lessons for health sector priority setting and planning from a cross-sectional survey in rural India

BACKGROUND

There are limited data on interdistrict variations in child health status and health services utilization within the states of India. We conducted this study to identify and understand district-wise variations in child morbidity, mortality, healthcare seeking, and the status of health facilities in India.

METHODS

A cross-sectional population-based cluster survey was conducted from April to July 2007 in 16 districts of eight states in India. Two districts with similar demographic profile and health criteria were selected from each study state.

RESULTS

A total of 216 794 households and 24 812 under-5 children were surveyed. There were wide interdistrict variations in the health status of children within the same state and between different states across India. Interdistrict difference of >5 points/1000 live-births was found for infant mortality rate and under-5 mortality rate in all eight study states, while in six out of eight states this difference was >10 points/1000 live-births. Four states had a difference of >10 points/1000 live-births between respective districts for neonatal mortality rate. The interdistrict differences were also noted in childhood morbidity and health-seeking behaviour. Analysis of proportion of health facilities conforming to Indian public health standards revealed that the difference was m10% for availability of vaccines in five states, emergency services in three, laboratory services and logistics in four each, and referral facility in three of the eight study states.

CONCLUSION

This study underscores an important information gap in the country where planners seem to rely heavily on a few selected national-level databases that may not be adequate at the micro level. The current process of sporadic health surveys also appears inadequate and inappropriate. There is a need for district-specific data for planning, improving quality of service and generating demand for health service utilization to improve child survival in India. The findings of this study may prove useful for child health programme planning in India.

Excess fibrinogen adsorption to monolayers of mixed lipids

Adsorption of fibrinogen to the monolayers of mixed lipids, dipalmitoyl phosphatidyl choline (DPPC) and eicosylamine (EA) was measured at a surface pressure of 20 mN/m by an in situ surface plasmon resonance technique. Pressure-area isotherms of DPPC+EA mixtures on water and buffer subphases indicated good lipid miscibility and some contraction of the monolayers at intermediate and higher surface pressures. Surface electric potential of the DPPC+EA monolayers showed excess values for intermediate DPPC:EA ratios. Fibrinogen adsorption and its adsorption rates from a dilute solution (0.03 mg/ml) were proportional to the fraction of EA in the monolayer indicating that protein binding was primarily driven by electrostatic interactions between positive EA charges in the monolayer and a net negative protein charge. At a higher protein concentration (0.06 mg/ml) both the fibrinogen adsorbed amount and its maximum adsorption rate showed excess values relative to the pure EA for 1:1, 2:1 and 3:1 DPPC+EA monolayers. This excess adsorption could be explained, in part, by the contraction of the monolayers with intermediate DPPC:EA ratios which resulted in an excess surface electric potential.

Cruciate paralysis secondary to traumatic atlantooccipital dislocation

Cruciate paralysis is a clinical phenomenon thought to result from injury to decussating pyramidal tract fibers at the cervicomedullary junction, producing clinical findings of upper-extremity weakness out of proportion to the lower extremities. The authors present, to their knowledge, the first reported case of cruciate paralysis resulting from atlantooccipital dislocation.

Bilateral vision, hearing impairment, and decreased level of consciousness in a patient hospitalized for new-onset seizure

Middle-aged patients who present with new-onset visual loss, hearing impairment, or decreased level of consciousness usually represent a broad differential diagnosis. We present a 57-year-old man who developed all these symptoms a few days after hospitalization for new-onset seizures.

Anatomy of the mastoid emissary vein and venous system of the posterior neck region: neurosurgical implications

OBJECTIVE

The superficial venous system of the posterior neck (suboccipital venous plexus) is a potential source of complications from bleeding and air embolism. Because there is little information available about this in the literature, an anatomic study of the superficial posterior neck venous system and a morphometric analysis of the mastoid emissary vein (MEV) complex were undertaken. Both surgical and endovascular implications were considered.

METHODS

The posterior craniocervical regions of 15 silicon-injected human cadaveric specimens were dissected. The patterns and variances of venous anatomy were observed. Distances between fixed bony landmarks were measured with a caliper.

RESULTS

The suboccipital venous plexus, which forms a complex venous network located between the posterior muscular layers of the neck, drains to the anterior vertebral vein and deep cervical vein. The MEV connects this plexus to the sigmoid sinus. Its average diameter was 2.15 mm, and it was located a mean of 21.14 mm from the asterion and a mean of 33.65 mm from the mastoid tip. However, the size of the MEV complex varied considerably.

CONCLUSION

The suboccipital venous plexus in the posterior neck region may be very large. The size of the veins in the plexus varies, but the drainage pattern remains consistent. The plexus is a potential source of intense bleeding and air embolism during posterior fossa approaches. The risks are greatest for lateral surgical approaches, as a result of the anatomic position of the venous system. The described measurements can be used to approach the MEV in endovascular procedures that involve the sigmoid sinus.

An anatomical evaluation of the mini-supraorbital approach and comparison with standard craniotomies

OBJECTIVE

To compare anatomically the surgical exposure provided by pterional (PT), orbitozygomatic (OZ), and minisupraorbital (SO) craniotomies.

METHODS

Seven sides of six fixed cadaver heads injected with silicone were used. The mini-SO craniotomy followed by the PT and OZ approaches were performed sequentially. The bony flaps were attached with miniplates and screws, allowing easy conversion between the approaches. A frameless stereotactic device was used to calculate an area of surgical exposure and the angles of approach for six different anatomic targets. An image guidance system was used to demonstrate the limits of the surgical exposure for each technique.

RESULTS

No significant differences were observed in the total area of surgical exposure when comparing the mini-SO (A = 1831.2 +/- 415.3 mm), PT (A = 1860.0 +/- 617.2 mm), and OZ approaches (A = 1843.3 +/- 358.1 mm; P > 0.05). Angular exposure was greater for the OZ and PT approaches than for the mini-SO approach, either in the vertical and horizontal axes, considering all of the six targets studied (P < 0.05). Except for the distal segment of the ipsilateral sylvian fissure, no practical differences in the limits of the exposure were detected.

CONCLUSION

The mini-SO approach may offer a similar surgical working area compared with that provided by standard craniotomies and constitutes an excellent alternative to the OZ and PT craniotomies in selected patients. Selection should not be based primarily on the area to be exposed, but rather on the working angles that are anticipated to be required. The key point is to use the most adequate technique for a particular patient, rather than using a one-size-fits-all approach for all patients.

Synchronous endoscopy and microsurgery: a novel strategy to approach complex ventricular lesions. Report of three cases

Simultaneous endoscopic and microsurgical (synchronous) approaches represent a new paradigm in the treatment of complex ventricular lesions. This technique is well suited for lesions that involve multiple ventricular or cisternal compartments, have a nonlinear axis, or adhere to critical anatomical or neurovascular structures. Two distinct operative corridors, one endoscopic and the other microsurgical, are used during synchronous approaches to address such lesions, increasing the likelihood of a safe and complete resection. The authors present the cases of two children and an adult treated via synchronous approaches. All patients had multi-compartmental lesions involving the ventricles and/or cisterns. One patient presented with a suprasellar Rathke cyst with a significant third ventricular component, one with a hypothalamic hamartoma having a substantial cisternal component, and the remaining patient with a choroid plexus papilloma in the left lateral ventricle that extended from midbody to the temporal horn. In the cases of the Rathke cyst and the hamartoma, debulking in the third ventricle and controlled detachment of the lesion from the hypothalamus were undertaken using endoscopy, and simultaneous resection of the suprasellar component was performed through a subfrontal craniotomy. In the case of the choroid plexus papilloma, selective cautery of the choroidal feeding vessels and detachment from the temporal tela choroidea were performed using endoscopy, and the tumor from the ventricular body to the atrium was resected via a craniotomy. In each case the resection concluded with the intersection of endoscopic and microsurgical fields. All three patients had good outcomes. Endoscopic and microsurgical approaches can be used concurrently to treat multicompartment ventricular and/or cisternal lesions with good results. The probable advantages of this method are more complete resection and improved safety.

Biomechanical analysis of a resorbable anterior cervical graft containment plate

STUDY DESIGN

A series of in vitro experiments were performed in human cadaveric cervical spines in the normal condition, after discectomy and graft, and instrumented with MacroPore resorbable anterior plates (MacroPore, San Diego, CA). Flexibility, graft containment, and load-to-failure were studied.

OBJECTIVE

To assess the stability, strength, and resistance to graft extrusion provided by the resorbable plate after discectomy and grafting.

SUMMARY OF BACKGROUND DATA

Metallic plates are known to improve stability after discectomy and graft. Resorbable plates have not been evaluated regarding stability offered or ability to contain the graft.

METHODS

Specimens were loaded using nonconstraining, nondestructive torques to induce flexion, extension, lateral bending, and axial rotation. One and 2-level specimens were studied: (1) normal, (2) after discectomy and graft, (3) after resorbable plating with 2 screws per vertebra, and (4) after resorbable plating with 3 screws per vertebra. All specimens were loaded to failure after completing nondestructive tests. Additional 1-level specimens with and without resorbable plate were tested for graft containment using anterior shear force directly on the graft.

RESULTS

The 1-level resorbable plate did not limit motion significantly better than grafted but unplated specimens. However, 2-level resorbable plates allowed significantly less motion than grafted but unplated specimens during all loading modes (P < 0.05). Specimens with resorbable plates resisted graft extrusion significantly better than unplated specimens. With 1-level resorbable plates, 2 or 3 screws per vertebra provided equivalent stability; in 2-level plates, 3 screws provided significantly better stability. Comparison to previous 1-level metallic plate data revealed a significant difference in motion only during flexion.

CONCLUSIONS

The 1-level resorbable plate does not increase stability compared to grafted but unplated specimens and provides less stability than a metal plate, especially during flexion. However, the resorbable plate substantially improves resistance to graft extrusion. The 2-level resorbable plate significantly reduces motion compared to grafted but unplated specimens. When applying a 2-level plate, 3 screws per vertebra are recommended. In a 1-level plate, 2 or 3 screws per vertebra are equivalent.

Biomechanical evaluation of a bioresorbable odontoid screw

Object.The authors tested the ability of a resorbable cannulated lag screw composed of a polylactide copolymer to repair Type II odontoid fractures. The resorbable screw was evaluated for its ability to restore strength and stiffness to the fractured odontoid process compared with traditional titanium screws.

Methods.Type II odontoid fractures were created in 14 human cadaveric C-2 vertebrae by applying a posterolaterally directed load and piston displacement was measured. Seven of these specimens were repaired using metal screws and seven were repaired using resorbable screws. Specimens were reinjured using the same mechanism as the initial fracture. Values of ultimate strength and stiffness during failure were statistically compared between metal and resorbable screws and between initial fracture and reinjury.

Conclusions.The stiffness and ultimate strength during initial fracture were significantly greater than those during reinjury in specimens repaired using resorbable screws or titanium screws (p < 0.001). The resorbable and titanium screws both restored 31% of the initial ultimate strength of the intact specimen (p = 0.95). The stiffness of the fractured odontoid process was restored to 15 and 23% of its initial value by repair with resorbable and metal screws, respectively (p = 0.07). The mode of failure in resorbable screws was usually breakage or bending, whereas that in metal screws was consistently cutout of the proximal shaft of the screw through the anterior C-2 vertebral body.

Cerebral revascularization performed using posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass. Report of four cases and literature review

Cerebral revascularization is often required for the surgical treatment of complex intracranial aneurysms. In certain anatomical locations, vascular anatomy and redundancy make in situ bypass possible. The authors present four patients who underwent revascularization performed using the rarely reported posterior inferior cerebellar artery (PICA)-PICA in situ bypass after their aneurysms had been trapped. At Barrow Neurological Institute, between 1991 and the present, four male patients underwent PICA-PICA by-passes to treat aneurysms involving the vertebral artery, the PICA, or both. The mean age of these patients was 34 years (range 5-49 years). Follow-up studies revealed patent bypasses and no evidence of infarction. Patient outcomes were excellent or good. Multiple surgical techniques have been described for revascularization of at-risk cerebral territories. Often, the blood supply must be derived from extracranial sources through a mobilized pedicle or interposited graft. Certain anatomical locations such as the vertebrobasilar junction, the anterior circle of Willis, and the middle cerebral artery bifurcation are amenable to in situ bypass because there is vessel redundancy or proximity to the contralateral analogous vessel. The advantages of an in situ bypass include one suture line, a short bypass distance, and a close match with the caliber of the recipient graft. Although technically challenging, this technique can be successful and should be considered for appropriate candidates.

Cerebral revascularization performed using posterior inferior cerebellar artery-posterior inferior cerebellar artery bypass. Report of four cases and literature review

Cerebral revascularization is often required for the surgical treatment of complex intracranial aneurysms. In certain anatomical locations, vascular anatomy and redundancy make in situ bypass possible. The authors present four patients who underwent revascularization performed using the rarely reported posterior inferior cerebellar artery (PICA)-PICA in situ bypass after their aneurysms had been trapped. At Barrow Neurological Institute, between 1991 and the present, four male patients underwent PICA-PICA by-passes to treat aneurysms involving the vertebral artery, the PICA, or both. The mean age of these patients was 34 years (range 5-49 years). Follow-up studies revealed patent bypasses and no evidence of infarction. Patient outcomes were excellent or good. Multiple surgical techniques have been described for revascularization of at-risk cerebral territories. Often, the blood supply must be derived from extracranial sources through a mobilized pedicle or interposited graft. Certain anatomical locations such as the vertebrobasilar junction, the anterior circle of Willis, and the middle cerebral artery bifurcation are amenable to in situ bypass because there is vessel redundancy or proximity to the contralateral analogous vessel. The advantages of an in situ bypass include one suture line, a short bypass distance, and a close match with the caliber of the recipient graft. Although technically challenging, this technique can be successful and should be considered for appropriate candidates.