Reinforcing the pulmonary artery autograft in the aortic position with a textile mesh: a histological evaluation

OBJECTIVES The Ross procedure involves replacing a patient’s diseased aortic valve with their own pulmonary valve. The most common failure mode is dilatation of the autograft. Various strategies to reinforce the autograft have been proposed. Personalized external aortic root support has been shown to be effective in stabilizing the aortic root in Marfan patients. In this study, the use of a similar external mesh to support a pulmonary artery autograft was evaluated. METHODS The pulmonary artery was translocated as an interposition autograft in the descending thoracic aortas of 10 sheep. The autograft was reinforced with a polyethylene terephthalate mesh (n = 7) or left unreinforced (n = 3). After 6 months, a computed tomography scan was taken, and the descending aorta was excised and histologically examined using the haematoxylin–eosin and Elastica van Gieson stains. RESULTS The autograft/aortic diameter ratio was 1.59 in the unreinforced group but much less in the reinforced group (1.11) (P < 0.05). A fibrotic sheet, variable in thickness and containing fibroblasts, neovessels and foreign body giant cells, was incorporated in the mesh. Histological examination of the reinforced autograft and the adjacent aorta revealed thinning of the vessel wall due to atrophy of the smooth muscle cells. Potential spaces between the vessel wall and the mesh were filled with oedema. CONCLUSIONS Reinforcing an interposition pulmonary autograft in the descending aorta with a macroporous mesh showed promising results in limiting autograft dilatation in this sheep model. Histological evaluation revealed atrophy of the smooth muscle cell and consequently thinning of the vessel wall within the mesh support

Biomechanical evaluation of a personalized external aortic root support applied in the Ross procedure

A commonly heard concern in the Ross procedure, where a diseased aortic valve is replaced by the patient's own pulmonary valve, is the possibility of pulmonary autograft dilatation. We performed a biomechanical investigation of the use of a personalized external aortic root support or exostent as a possibility for supporting the autograft. In ten sheep a short length of pulmonary artery was interposed in the descending aorta, serving as a simplified version of the Ross procedure. In seven of these cases, the autograft was supported by an external mesh or so-called exostent. Three sheep served as control, of which one was excluded from the mechanical testing. The sheep were sacrificed six months after the procedure. Samples of the relevant tissues were obtained for subsequent mechanical testing: normal aorta, normal pulmonary artery, aorta with exostent, pulmonary artery with exostent, and pulmonary artery in aortic position for six months. After mechanical testing, the material parameters of the Gasser-Ogden-Holzapfel model were determined for the different tissue types. Stress-strain curves of the different tissue types show significantly different mechanical behavior. At baseline, stress-strain curves of the pulmonary artery are lower than aortic stress-strain curves, but at the strain levels at which the collagen fibers are recruited, the pulmonary artery behaves stiffer than the aorta. After being in aortic position for six months, the pulmonary artery tends towards aorta-like behavior, indicating that growth and remodeling processes have taken place. When adding an exostent around the pulmonary autograft, the mechanical behavior of the composite artery (exostent + artery) differs from the artery alone, the non-linearity being more evident in the former

Appendicular intussusception with lymphoid hyperplasia

A 4-year-old boy is sent to paediatric consultation for nightrecurring abdominal pain of 3 weeks duration

Past abrupt changes, tipping points and cascading impacts in the Earth system

The geological record shows that abrupt changes in the Earth system can occur on timescales short enough to challenge the capacity of human societies to adapt to environmental pressures. In many cases, abrupt changes arise from slow changes in one component of the Earth system that eventually pass a critical threshold, or tipping point, after which impacts cascade through coupled climate–ecological–social systems. The chance of detecting abrupt changes and tipping points increases with the length of observations. The geological record provides the only long-term information we have on the conditions and processes that can drive physical, ecological and social systems into new states or organizational structures that may be irreversible within human time frames. Here, we use well-documented abrupt changes of the past 30 kyr to illustrate how their impacts cascade through the Earth system. We review useful indicators of upcoming abrupt changes, or early warning signals, and provide a perspective on the contributions of palaeoclimate science to the understanding of abrupt changes in the Earth system

The EUFOREA pocket guide for chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS

The EUFOREA pocket guide for chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is known to affect around 5 % of the total population, with major impact on the quality of life of those severely affected (1). Despite a substantial burden on individuals, society and health economies, CRS often remains underdiagnosed, under-estimated and under-treated (2). International guidelines like the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) (3) and the International Consensus statement on Allergy and Rhinology: Rhinosinusitis 2021 (ICAR) (4) offer physicians insight into the recommended treatment options for CRS, with an overview of effective strategies and guidance of diagnosis and care throughout the disease journey of CRS

Reporting and Interpreting Intentions in Defamation Law

The interpretation and the indirect reporting of a speaker’s communicative intentions lie at the crossroad between pragmatics, argumentation theory, and forensic linguistics. Since the leading case Masson v. New Yorker Magazine, Inc., in the United States the legal problem of determining the truth of a quotation is essentially equated with the correctness of its indirect reporting, i.e. the representation of the speaker’s intentions. For this reason, indirect reports are treated as interpretations of what the speaker intends to communicate. Theoretical considerations, aimed at establishing the pragmatic meaning of an utterance and differentiating between presumptive and non-presumptive interpretation, are thus interwoven with the practical legal need of distinguishing a correct indirect report from an indirect one or a misquotation. An incorrect report or a misquotation has the dialectical effect of attributing to the misquoted party commitments that he never held, which the latter needs to rebut. This shifting of the burden of persuasion can be increased by using strategically the conflict between the presumptive interpretation of an utterance and the non-presumptive one, i.e. the different types of pragmatic ambiguity. When an interpreter is confronted with an utterance taken out of its dialogical context, his interpretative process is not guided by the actual context or intention, but rather the most frequent or prototypical dialogical setting or the most typical individual purpose that it could have served to achieve. This presumptive reconstruction can be used to provide a prima facie case that the other party needs to reject. The stronger the interpretative presumptions a speaker needs to rebut, the more effective the misquotation strategy. The conflict between the systematic and the presumptive process of interpretation can be represented as an argumentative mechanism of reconstruction of the individual intention, which allows one to assess the reasonableness of the interpretative reasoning