Infrainguinal arterial reconstruction with non-reversed autologous vein after angioscopy guided valvulotomy ex situ

Aims:The advantages of in situ autologous vein grafts for long infrainguinal arterial reconstructions are the tapered conduit, minimising size mismatch at proximal and distal anastomoses, and the possibility of using small sized veins with good results. Unfortunately, in about 30% of legs the ipsilateral saphenous vein is inadequate rendering in situ bypass grafting impossible. To profit from a valveless autologous vein graft in these cases we routinely performed ex situ valvulotomy after harvesting the contralateral saphenous vein or good quality segments of the ipsilateral saphenous vein.Methods:The ex situ valvulotomy was performed under angioscopic guidance using a flushing-type Mill's valvulotome.Results:Fifty non reversed grafts in 46 patients entered a prospective surveillance program. Primary and primary-assisted patency rates at 2 years were 68% and 82% respectively, early graft thrombosis 2%, late stenosis 8% and major amputation rate with a patent graft 6%. No technique related problems were noticed.Conclusion:Angioscopy guided valvulotomy was safe and simple and allowed good quality control of the veins. The presented results in this study are comparable to other recently reported series of in situ bypass. The clinical use of small flexible endoscopes allows a safe and atraumatic valvulotomy and simultaneous quality control of autologous vein grafts

Gefäßchirurgische Ausbildung in endovaskulären Techniken am Universitären Gefäßzentrum Aarau-Basel

Zusammenfassung: Endovaskuläre Techniken gewinnen in der gefäßchirurgischen Praxis zunehmend an Bedeutung und müssen deshalb in die Ausbildung integriert werden. Die gefäßchirurgische Ausbildung in der Schweiz umfasst nach neuen Richtlinien das Beherrschen von endovaskulären Techniken und fordert die Durchführung von mindestens 50 Katheterisierungen/Angiographien und 25 interventionellen Eingriffen. An unserer Klinik stützt sich die interventionelle Ausbildung auf verschiedene Pfeiler. Wichtig ist eine gute interdisziplinäre Zusammenarbeit mit der Abteilung für interventionelle Radiologie, die konsequente Durchführung der Kontrollangiographie bei offenen Operationen und Virtual-Reality-Training. Unter diesen Bedingungen ist eine Ausbildung möglich, die den schweizerischen Richtlinien entspricht. Verbesserungspotenzial sehen wir v.a. in festen Kooperationsvereinbarungen mit der interventionellen Radiologi

Nierentransplantation: Was sollte der Gefäßchirurg wissen?

Zusammenfassung: Die Nierentransplantation ist die am häufigsten durchgeführte Organtransplantation und führt zu exzellenten Langzeitresultaten mit einem Fünfjahrestransplantatüberleben von bis zu 80%. Bei normaler Anatomie ist der Eingriff technisch verhältnismäßig einfach. Beim Vorliegen von multiplen Nierenarterien oder verkalkten und zur Dissektion neigenden Beckenarterien kann aber die Anastomose der Transplantatarterie an die Beckenarterie eine chirurgische Herausforderung darstellen und die verschiedensten gefäßchirurgischen Rekonstruktionstechniken erfordern. In diesen Situationen ist gefäßchirurgische Erfahrung unerlässlich, oder es kann sogar empfehlenswert sein, einen Gefäßchirurgen zur Transplantation hinzuzuziehen. Umgekehrt bedeutet dies, dass Gefäßchirurgen, die an Zentren arbeiten, wo Nieren transplantiert werden, sich mit der Nierentransplantation gut auskennen sollten. Offene Eingriffe an der abdominalen Aorta bei nierentransplantierten Patienten sind dadurch kompliziert, dass während des Abklemmens der Aorta eine längere Minderdurchblutung der Transplantatniere auftritt. Erstaunlicherweise wird dies aber gut toleriert, sodass Protektionsmaßnahmen wie die Anlage eines temporären aortofemoralen Bypass eher nicht empfohlen werden. Die endovaskuläre Versorgung eines abdominalen Aortenaneurysmas beim nierentransplantierten Patienten scheint in den meisten Fällen bedenkenlos möglich

Escape from NK cell tumor surveillance by NGFR-induced lipid remodeling in melanoma

Metastatic disease is a major cause of death for patients with melanoma. Melanoma cells can become metastatic not only due to cell-intrinsic plasticity but also due to cancer-induced protumorigenic remodeling of the immune microenvironment. Here, we report that innate immune surveillance by natural killer (NK) cells is bypassed by human melanoma cells expressing the stem cell marker NGFR. Using in vitro and in vivo cytotoxic assays, we show that NGFR protects melanoma cells from NK cell–mediated killing and, furthermore, boosts metastasis formation in a mouse model with adoptively transferred human NK cells. Mechanistically, NGFR leads to down-regulation of NK cell activating ligands and simultaneous up-regulation of the fatty acid stearoyl–coenzyme A desaturase (SCD) in melanoma cells. Notably, pharmacological and small interfering RNA–mediated inhibition of SCD reverted NGFR-induced NK cell evasion in vitro and in vivo. Hence, NGFR orchestrates immune control antagonizing pathways to protect melanoma cells from NK cell clearance, which ultimately favors metastatic disease

The extent, nature and distribution of child poverty in India

Despite a long history, research on poverty has only relatively recently examined the issue of child poverty as a distinct topic of concern. This article examines how child poverty and well-being are now conceptualized, defined and measured, and presents a portrait of child poverty in India by social and cultural groups, and by geographic area. In December 2006, the UN General Assembly adopted a definition of child poverty which noted that children living in poverty were deprived of (among other things) nutrition, water and sanitation facilities, access to basic health care services, shelter and education. The definition noted that while poverty hurts every human being ‘it is most threatening and harmful to children, leaving them unable to enjoy their rights, to reach their full potential and to participate as full members of the society’. Researchers have developed age-specific and gender-sensitive indicators of deprivation which conform to the UN definition of child poverty and which can be used to examine the extent and nature of child poverty in low and middle-income countries. These new methods have ‘transformed the way UNICEF and many of its partners both understood and measured the poverty suffered by children’ (UNICEF, 2009). This article uses these methods and presents results of child poverty in India based on nationally representative household survey data for India

Next generation transcriptomes for next generation genomes using est2assembly

<p>Abstract</p> <p>Background</p> <p>The decreasing costs of capillary-based Sanger sequencing and next generation technologies, such as 454 pyrosequencing, have prompted an explosion of transcriptome projects in non-model species, where even shallow sequencing of transcriptomes can now be used to examine a range of research questions. This rapid growth in data has outstripped the ability of researchers working on non-model species to analyze and mine transcriptome data efficiently.</p> <p>Results</p> <p>Here we present a semi-automated platform '<it>est2assembly</it>' that processes raw sequence data from Sanger or 454 sequencing into a hybrid <it>de-novo </it>assembly, annotates it and produces GMOD compatible output, including a SeqFeature database suitable for GBrowse. Users are able to parameterize assembler variables, judge assembly quality and determine the optimal assembly for their specific needs. We used <it>est2assembly </it>to process <it>Drosophila </it>and <it>Bicyclus </it>public Sanger EST data and then compared them to published 454 data as well as eight new insect transcriptome collections.</p> <p>Conclusions</p> <p>Analysis of such a wide variety of data allows us to understand how these new technologies can assist EST project design. We determine that assembler parameterization is as essential as standardized methods to judge the output of ESTs projects. Further, even shallow sequencing using 454 produces sufficient data to be of wide use to the community. <it>est2assembly </it>is an important tool to assist manual curation for gene models, an important resource in their own right but especially for species which are due to acquire a genome project using Next Generation Sequencing.</p

Status Update and Interim Results from the Asymptomatic Carotid Surgery Trial-2 (ACST-2)

Objectives: ACST-2 is currently the largest trial ever conducted to compare carotid artery stenting (CAS) with carotid endarterectomy (CEA) in patients with severe asymptomatic carotid stenosis requiring revascularization. Methods: Patients are entered into ACST-2 when revascularization is felt to be clearly indicated, when CEA and CAS are both possible, but where there is substantial uncertainty as to which is most appropriate. Trial surgeons and interventionalists are expected to use their usual techniques and CE-approved devices. We report baseline characteristics and blinded combined interim results for 30-day mortality and major morbidity for 986 patients in the ongoing trial up to September 2012. Results: A total of 986 patients (687 men, 299 women), mean age 68.7 years (SD ± 8.1) were randomized equally to CEA or CAS. Most (96%) had ipsilateral stenosis of 70-99% (median 80%) with contralateral stenoses of 50-99% in 30% and contralateral occlusion in 8%. Patients were on appropriate medical treatment. For 691 patients undergoing intervention with at least 1-month follow-up and Rankin scoring at 6 months for any stroke, the overall serious cardiovascular event rate of periprocedural (within 30 days) disabling stroke, fatal myocardial infarction, and death at 30 days was 1.0%. Conclusions: Early ACST-2 results suggest contemporary carotid intervention for asymptomatic stenosis has a low risk of serious morbidity and mortality, on par with other recent trials. The trial continues to recruit, to monitor periprocedural events and all types of stroke, aiming to randomize up to 5,000 patients to determine any differential outcomes between interventions. Clinical trial: ISRCTN21144362. © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved

Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86–1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91–1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. Funding: UK Medical Research Council and Health Technology Assessment Programme