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Objective: Sudden gains (SGs) are rapid symptom improvements between two consecutive therapy sessions that predict treatment outcomes. This study investigated SGs in posttraumatic stress disorder (PTSD) symptoms, interpersonal relationship functioning, and social role functioning in Cognitive Processing Therapy (CPT)., Method: Participants were 121 patients and 81 therapists involved in a parent randomized controlled hybrid implementation-effectiveness trial of CPT. Descriptive analyses examined the frequency and timing of different forms of SGs. Multilevel modeling examined the impact of the three SGs on outcomes., Results: PTSD SGs occurred more often and at different sessions than SGs in facets of social functioning. Most individuals experienced only one form of SG and there were no significant clinical or demographic differences in those who had PTSD only SGs, social functioning only SGs, or both SGs. PTSD SGs and interpersonal relationship functioning SGs both predicted changes in PTSD symptoms and interpersonal difficulties over time, but not changes in social role functioning. SGs in social role functioning predicted all three forms of outcomes., Conclusions: The findings suggest that there are multiple forms of SGs in CPT beyond primary symptom changes that are predictive of patient outcomes. Clinicians should highlight various SGs that patients experience to further enhance outcomes.

Background/Objectives : The suprascapular nerve is most vulnerable to entrapment at the suprascapular and spinoglenoid notches, causing neuropathy. Numerous studies have examined the suprascapular notch and ligament and its relationship with suprascapular nerve entrapment, but few have examined the spinoglenoid notch and the inferior transverse scapular ligament (ITSL). This study summarizes all existing ITSL morphology studies and presents a simple and comprehensive classification system for different ITSL subtypes. Methods: A systematic review of the literature was conducted according to the PRISMA guidelines, searching the online databases PubMed and Embase. The references of each relevant article were further screened to find more eligible studies. The Anatomical Quality Assessment tool was used in order to further evaluate the quality of the records extracted. STATA MP 14 was used for the analysis in this study. Results : In total, 14 studies (995 scapulae; minimum: 1 and maximum: 268) were included in the present study. The overall ITSL prevalence was 5.8 (95% CI: 4.5-7.1) and the estimated odds for ligamentous vs. membranous type was 0.5 (95% CI: 0.3-0.7). The basic different morphological subtypes of the ITSL reported in the included studies are the band-like ligament, the fan-shaped ligament, the membranous ITSL, and the perforated membranous types. Conclusions: The ITSL represents an anatomical structure of mostly ligamentous nature. A single ITSL definition and standardization of its basic morphological subtypes along with an easy-to-remember and thus widely used classification system could greatly facilitate the comprehensive description, identification, and proper handling of this element across many surgical procedures.

Glioblastoma (GBM) constitutes the most common primary brain tumor in adults. The challenges in GBM therapeutics have shed light on zebrafish used as a promising animal model for preclinical GBM xenograft studies without a standardized methodology. This systematic review aims to summarize the advances in zebrafish GBM xenografting, compare research protocols to pinpoint advantages and underlying limitations, and designate the predominant xenografting parameters. Based on the PRISMA checklist, we systematically searched PubMed, Scopus, and ZFIN using the keywords "glioblastoma," "xenotransplantation," and "zebrafish" for papers published from 2005 to 2022, available in English. 46 articles meeting the review criteria were examined for the zebrafish strain, cancer cell line, cell labeling technique, injected cell number, time and site of injection, and maintenance temperature. Our review designated that AB wild-type zebrafish, Casper transparent mutants, transgenic Tg(fli1:EGFP), or crossbreeding of these predominate among the zebrafish strains. Orthotopic transplantation is more commonly employed. A number of 50-100 cells injected at 48 h post-fertilization in high density and low infusion volume is considered as an effective xenografting approach. U87 cells are used for GBM angiogenesis studies, U251 for GBM proliferation studies, and patient-derived xenograft (PDX) to achieve clinical relevance. Gradual acclimatization to 32-33 °C can partly address the temperature differential between the zebrafish and the GBM cells. Zebrafish xenograft models constitute valuable tools for preclinical studies with clinical relevance regarding PDX. The GBM xenografting research requires modification based on the objective of each research team. Automation and further optimization of the protocol parameters could scale up the anticancer drug trials., (© 2023. The Author(s).)

The hypothenar muscle with the greatest frequency of variations is the abductor digiti minimi manus. Except for morphological variations of this muscle, have also been reported cases of an extra wrist muscle, the accessory abductor digiti minimi manus muscle. This case report presents a rare case of an accessory abductor digiti minimi muscle characterized by an unusual origin from the tendons of the flexor digitorum superficialis. This anatomical variation was identified on a formalin - fixed male cadaver of Greek origin during routine dissection. This anatomical variation, which may result in Guyon's canal syndrome or complicate common wrist and hand surgical procedures such as the carpal tunnel release, should be known to orthopaedic surgeons and hand surgeons in particular.

Surgical training is a long process that requires a lot of commitment and effort. Basic surgical techniques are the foundation of every procedure, with suturing being one of them. Hence, it is of great importance for aspiring young surgeons to practice and develop their suturing skills. Quite many kinds of suturing training models have been used and proposed worldwide, ranging from commercial silicone pads to meat leftovers and various fruits. We have developed our own, simplified, and low-cost suturing training pad that consists of three layers and is based on the combined use of silicone sponge sheet and polyurethane foam. It is quite durable and elastic and has been applied in three suturing training workshops so far. For this reason, we would like to present our experience of a low-cost but effective way of promoting and achieving further surgical excellence., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Antonopoulos et al.)

Purpose: Several studies have examined gender-equality challenges and ways to improve women's representation and management. Orthopaedic surgeons and patients are less gender equitable than them of other surgical disciplines. This systematic review summarizes these findings and highlights orthopaedic surgery gender inequality., Methods: Search of the PubMed, Embase, and Cochrane databases was carried out to extract human studies investigating the gender gap in orthopaedics, trying to highlight the equality challenges orthopaedic surgery faces. Studies incorporating patients with comorbidities in which gender is a proven risk factor, and pregnant women were excluded., Results: This systematic review included 59 studies involving 692,435 people (mean females/males ratio: 4.44), spanning the years 1987-2023. Regarding the targeted population, 35 (59.32%) studies focused on patients, while 24 (40.68%) on physicians. Orthopaedic surgery is described as an unfriendly career field for women as surgeons or sports leading physicians while women are generally under represented in the academic field of orthopaedics. Regarding patients, female gender consists both a risk and prognostic factor influencing the prevalence of degenerative disease and the outcome of the operative treatment in reconstructive orthopaedics. Female gender is a risk factor for multiple sports injuries and influences the pathogenetic mechanisms resulting in ACL reconstruction. Regarding spine surgery, women are less likely to have surgery suggested, and such suggestion underlines severe disease's progression., Conclusions: Gender differences affect orthopaedic patient-physician-healthcare system interactions. Recognizing biases and their patterns is useful to improve the actual situation. By preventing those an unbiased, tolerant, and egalitarian workplace for physicians and a healthcare system that provides the best treatment to patients could be created., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Objective: The objective of the current study was the examination of possible variants of the celiac trunk., Methods: An advanced review of the literature search was undertaken by means of the PubMed database and Google Scholar, searching for new studies published up to October 2022. Additional articles provided useful information in relation to the aim of this review. Hence, articles that met the inclusion criteria were included in this review and the collected data were organized into a table., Results: The search of the literature retrieved 10 articles that referred to the anatomical variations of the celiac trunk. According to the available literature, the most common anatomical variations are: hepatosplenic trunk where the left gastric artery originates from the abdominal aorta, hepatosplenic trunk, where the left gastric artery originates from the splenic artery, and hepatogastric trunk and splenic artery origin from the superior mesenteric artery. Many other anatomical variations of the celiac trunk may exist, such as tetrafurcation, pentafurcation and hexafurcation, that refer to the division of the celiac trunk into four, five or six branches, respectively, and should be reported as they can affect surgical approaches and the development of the appropriate treatment strategy in patients., Conclusion: Every visceral surgeon, interventional radiologist and abdominal imager should be familiar with these variants., (Copyright © 2023 Vougadiotis et al. This article is available under a Creative Commons License (Attribution 4.0 International).)

Objective: The aim of this study is to present a relatively rare case of the coexistence of an incomplete superficial palmar arch and a Berrettini anastomosis, identified in a cadaveric specimen, and further discuss the potential clinical implications of such anatomical variations., Case Report: The variation was found in the left hand of a formalin-fixed male cadaver of Greek origin, that was dissected under an operating microscope (×4, ×10 magnification) in our Anatomy Department. In the specimen, we found an incomplete superficial palmar arch, formed only by the superficial branch of the ulnar artery, and a Type 1 Berrettini Anastomosis, originating from the ulnar nerve and joining a branch of the median nerve., Conclusion: To avoid iatrogenic damage and permanent loss of sensation, hand surgeons and microsurgeons should be aware of the presence of a BA, and the potential coexistence of this variation with vascular abnormalities in the hand that may complicate surgical procedures., (Copyright © 2023 Antonopoulos et al. This article is available under a Creative Commons License (Attribution 4.0 International).)

Rheumatoid arthritis (RA) and affective disorders (anxiety/depression) constitute important pathologies in the elderly population, and their coexistence creates synergistically increased problems in functional ability and quality of life of the patients., Purpose: Evaluation of anxiety, distress, and depression in elderly (≥65 years old) patients with RA., Patients – Methods: 114 patients from the cities of Patras, Arta and Ioannina (all located in Western Greece) were included. Demographics and medical information regarding RA were recorded, including disease duration, medication, previous treatments, disease activity measures, comorbidities etc. Patients answered the State-Trait Anxiety Inventory (STAI), General Health Questionnaire-28 (GHQ28) and Health Assessment Questionnaire -Disability Index (HAQ-DI) questionnaires, for evaluation of anxiety, general health and functional ability, respectively. Statistical analysis was made by using STATA., Results: 88 women (78.07%) and 25 men (21.93%) with median age 70 years and median disease duration 10 years were studied. Female patients, with longer disease duration and higher disease activity, had statistically significant higher levels of anxiety, worse general health and decreased functional ability. A strongly significant association was found between the levels of anxiety and distress, with disease activity and functional inability., Conclusions: Levels of anxiety and distress are strongly associated with disease activity and functional inability in elderly patients with RA. Women with longer disease have higher levels of anxiety and distress. Controlling disease activity is of upmost importance for improvement of anxiety and distress and functional ability. Larger studies are needed for evaluation of anxiety and distress in elderly patients with RA., Competing Interests: The authors declare no conflict of interest., (© 2022 The Mediterranean Journal of Rheumatology (MJR).)

Purpose: New training methods sprung up using communication technologies after the suspension imposed on Greek Universities due to restrictive measures against the COVID-19 pandemic. The current questionnaire-based study evaluates the efficacy and utility of the interactive online anatomy labs (ONALs) in assisting the assimilation of anatomy and substituting dissection labs during the pandemic., Methods: ONALs consisting of video recorded demonstrations of dissected cadavers were developed so that real-time dialogue and interaction between tutor and students was feasible. First- and second-year medical students who were taught neuroanatomy and splanchnology and first-year dental students who were taught head and neck anatomy evaluated the ONALs., Results: One hundred and sixty students participated. The 61 students (38.13%) attended the splanchnology, 58 (36.25%) the neuroanatomy, and 41 (25.63%) the head and neck anatomy course. 86.9% of the participants found the ONALs beneficial for their study. The 75.5% with previous experience of a "face-to-face" dissection replied that the ONALs cannot substitute satisfactorily "face-to-face" dissections. 63.8% replied positively to the ONALs maintenance after the pandemic., Conclusions: The study's novelty is based on the maintenance of the greater possible interaction between tutors and students during the ONALs, in contrast to the previously described usage of dissection educational videos in anatomy. Our findings reinforce the established statement that "a teaching dissection is an irreplaceable tool in anatomy education". However, the ONALs were well-received by the students and can be kept on as a supplementary teaching modality and can be proven quite useful in Medical Schools that lack cadavers., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: To estimate the prevalence of the left-sided aortic arch (LSAA) variants, and the effect of possible moderators on variants' detection., Methods: A systematic online literature search was conducted. The pooled prevalence with 95% confidence intervals was estimated for the typical and atypical branching patterns to compare the overall proportions of different variants. Meta-regression analyses were performed to investigate the effect of the subjects' gender and geographical region, and the multidetector computed tomography (MDCT) scanner's technology on the estimated prevalence., Results: In total, 18,075 cases from 23 imaging studies were included and 33 different LSAA variants were detected. The estimated heterogeneity was statistically significant. Based on the estimated prevalence, approximately 77% of the population is expected to have the typical branching anatomy with sequence brachiocephalic trunk-left common carotid artery-left subclavian artery, and 23% variant branching patterns. Approximately 71%, 23%, 2%, and 0.1% of the atypical populations are expected to have two, four, three, and five emerging branches, respectively. The meta-regression analyses showed that the number of detector rows of the MDCT scanner, and the subjects' geographical region are statistically significant moderators of the estimated prevalence., Conclusion: The current findings indicate that the prevalence of the LSAA variant branching anatomy is significantly affected by the subjects' geographical region and the MDCT scanner's technological improvement, with the advanced scanners to facilitate the detection of the aortic arch variants. However, due to the heterogeneity among studies, further research is required., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

The anterior cerebral artery (ACA) branching pattern may be particularly complex and variant including bifurcations, trifurcations or quadrifurcations, thus leading to typical or atypical vessels. The bihemispheric ACA (BhACA) variant crosses the midline to supply the contralateral hemisphere. The current case highlights a left-sided ACA trifurcation into a bihemispheric pericallosal artery, and two ipsilateral atypical arteries: a callosomarginal artery of short course and a left-sided pericallosal artery of an aberrant course into the cingulate sulcus. The depicted trifurcation was characterized as a distal ACA tripod. The bihemispheric branch supplied the contralateral pericallosal area and coursed into the cingulate sulcus. Deviations from the typical ACA pattern, especially when they coexist are quite rare and may complicate neurosurgical approaches or raise diagnostic difficulties. The BhACA may be implicated in aneurysm formation and bilateral ischemia after its occlusion. Knowledge of such variants, as well as awareness of the complications they may be related to, is of great significance., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: The splenic artery (SA) is the largest and most tortuous branch of the celiac trunk with a wide spectrum of variants, particularly in its terminal branches., Methods: The current study presents a systematic review of the English literature on the SA variations, with emphasis on its terminal branching patterns., Results: Thirty cadaveric studies (3132 specimens) were included in the analysis. The SA originated from the celiac trunk in 97.2%, from the abdominal aorta in 2.1% and from the superior mesenteric or the common hepatic artery in 0.7% of cases. A suprapancreatic course was observed in 77.4%, retropancreatic course in 17.8%, anteropancreatic course in 3.4% and intrapancreatic course in 1.3%. In the majority of cases, the SA bifurcated into superior and inferior lobar arteries (83.4%), with trifurcation and quadrifurcation in 11.3% and 2.7%, respectively. Five or more lobar branches (1.4%) and a single lobar artery (1.2%) were rarely identified. The distributed branching pattern was found in 72.7%, whereas the magistral pattern in 26.9%. The inferior and superior polar arteries (IPA and SPA) were found in 47.7% and 41.7% of cases, respectively, while polar artery agenesis was recorded in 28.2%. The SPA usually originated from the SA main trunk (53.6%) or from the superior lobar artery (33.1%). The IPA emanated mainly from the left gastroepiploic artery (53%), from the SA (23.5%) or the inferior lobar artery (21.9%). Intersegmental anastomoses between adjacent arterial segments were identified in 14.2%., Conclusion: Knowledge of the SA aberrations is important for surgeons and radiologists involved in angiographic interventions., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS part of Springer Nature.)

Background  The suprascapular notch (SN) represents the point along the route of the suprascapular nerve (SSN) with the greatest potential risk for injury and compression. Thus, factors reducing the area of the notch have been postulated for suprascapular neuropathy development. Methods  Thirty-one fresh-frozen shoulders were dissected. The contents of the SN were described according to four types as classified by Polguj et al and the middle-transverse diameter of the notch was measured. Also, the presence of an ossified superior transverse scapular ligament (STSL) was identified. Results  The ligament was partially ossified in 8 specimens (25.8%), fully ossified in 6 (19.35%), and not ossified in the remaining 17 (54.85%). The mean middle-transverse diameter of the SN was 9.06 mm (standard deviation [SD] = 3.45). The corresponding for type-I notches was 8.64 mm (SD = 3.34), 8.86 mm (SD = 3.12) was for type-II, and 14.5 mm (SD = 1.02) was for type III. Middle-transverse diameter was shorter when an ossified ligament was present (mean = 5.10 mm, SD = 0.88 mm), comparing with a partially ossified ligament (mean =7.67 mm, SD = 2.24 mm) and a nonossified one (mean = 11.12 mm, SD = 2.92 mm). No statistically significant evidence was found that the middle-transverse diameter depends on the number of the elements, passing below the STSL. Conclusion  Our results suggest that SSN compression could be more likely to occur when both suprascapular vessels pass through the notch. Compression of the nerve may also occur when an ossified transverse scapular ligament is present, resulting to significant reduction of the notch's area., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. ( https://creativecommons.org/licenses/by/4.0/ ).)

Increasing plastic waste recycling is a milestone of European environmental policy to reduce environmental impacts and dependency on foreign resources. This is particularly challenging for plastic packaging waste, consisting of very heterogeneous fractions and typically rather contaminated. In this study, we collected primary data from plants sorting and recycling plastic packaging waste to illustrate process efficiencies, material flows, and barriers. We observed that significant losses of target materials occurred both at sorting and recycling stages. These were higher for polymers such as films, polypropylene and polystyrene, and lower for polyethylene terephthalate and high-density polyethylene. Applying material flow analysis, we estimated an overall end-of-life recycling rate for post-consumer plastic packaging waste in EU27 in 2017 of 14% (not considering waste exported as recycled; 25% otherwise). An improved scenario for 2030 showed that achieving an overall end-of-life recycling rate of about 49% was possible when best available practices and technologies were implemented. To fulfil the ambitious recycling targets set at EU27 level (55% overall recycling rate), substantial improvements are necessary at the plants, product design, collection system, and market level. Our findings further indicate that films and other problematic contaminants in the input-waste considerably hamper the recovery rates, thus the improvement of the efficiency of the collection systems is imperative. In parallel, the development of markets for lower value fractions, e.g. polypropylene, could be a way forward to increase recycling, while improvements in the product design will considerably reduce the presence of impurities and contaminants in the input-waste., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction The brachiocephalic artery (BCA) is the largest branch that arises from the aortic arch, which varies in length. The present study focuses on BCA length and its probable correlation with height and torso length. Methods The BCA length (from the artery's origin to the arcus aortae), the length of the torso, and height were measured in 76 embalmed adult human cadavers of Caucasian (Hellenic) origin. Results A total of 74 arteries were measured (36 females and 38 males). The mean length was found to be 3.82 cm (SD=±0.947, SE=0.110). In male cadavers, the mean BCA length was 3.94 cm (SD=±0.980, SE=0.159) and in females, it was found to be 3.69 cm (SD=±0.905, SE=0.151). No statistically significant difference was found (p=0.248, p>0.05) The mean torso length was 62.27 cm (SD=±4.325, SE=0.496) and the mean height was 155.3 cm (SD=±10.124, SE=1.161). The BCA length was correlated with body height and torso length in both sexes. A statistically significant correlation was found only between BCA length and body height in male cadavers (r=0.267, p=0.021). Conclusion The morphometric characteristics of the BCA are of great importance in a number of surgical procedures, such as stenting and catheterization in cases of aneurysms. One statistically significant correlation was observed in our study, which could be considered an important finding, as it could lead to the plausible assumption that greater height leads to the formation of larger arteries., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Panagouli et al.)

Objective: The aim of our paper is to depict an anatomical variation of the brachial plexus, concerning a communicating branch between the median and the musculocutaneous nerve and its clinical significance. Anatomical variations of the brachial plexus and especially those of the musculocutaneous nerve are quite common. Awareness of these variations is of paramount importance in clinical practice, mainly in achieving best results in minimal invasive or surgical procedures., Case Report: After dissection in upper extremities in a 89-year-old male cadaver, a communicating branch between the median and the musculocutaneous nerve was found. This communicating branch was formed before the musculocutaneous nerve perforated the coracobrachialis muscle. It also derived from the level of the ansa medianis and its course was of an approximately 2cm length., Conclusion: The clinical significance of our study is the entrapment of the musculocutaneous nerve that may cause clinical findings similar to those of the carpal tunnel syndrome., (Copyright © 2020 by Academy of Sciences and Arts of Bosnia and Herzegovina.)

The purpose of the present systematic review is to summarize the available evidence concerning the impact of investigated intervals of treatment (diagnosis to surgery and surgical treatment to adjuvant therapy) on survival outcomes of endometrial cancer patients. We searched Medline, Scopus, Clinicaltrials.gov, EMBASE, and Google Scholar databases from inception until July 31st 2019. All observational studies were considered eligible for inclusion. Investigated outcomes were retrieved and analyzed as well as factors that influenced the extent of wait intervals. Overall, 12 articles were included that investigated the influence of wait intervals on survival outcomes of 773,185 patients. We observed that the proposed cut-off values for interval periods, the reported survival outcomes as well as the tumor characteristics of included patients varied significantly among the studies that were included. Given these differences, meta-analysis of survival outcomes was not possible. The most common cut-off for the time to surgery interval was 6 weeks and for the time to adjuvant treatment 9 weeks. The percentage of patients that was treated within this limit ranged between 24 and 74 %. Given this information we believe that the optimal interval between diagnosis and surgical treatment of endometrial cancer patients should not exceed eight weeks (keeping in mind that surgery within the first two weeks may be a negative prognostic factor), whereas between surgery and adjuvant therapy should be limited to a maximum of nine weeks. Future studies should evaluate factors that seem to influence the extent of waiting intervals to help determine the limitations of healthcare systems., Competing Interests: Declaration of Competing Interest The authors report that they have no conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Recent data suggests that rituximab may favorably affect skin fibrosis and lung function in patients with systemic sclerosis. Based on experimental data suggesting a key role of B and T cells in scleroderma we aimed to explore the effect(s) of rituximab treatment on T cell subpopulations. Fifteen patients with scleroderma who received rituximab treatment and six who received standard treatment alone were recruited. Peripheral CD4+IL4+, CD4+INFγ+, CD4+IL17+ and CD4+CD40L+ T cells were assessed using flow cytometry. Using ELISA, serum levels of IL4 were assessed. Skin CD4+IL4+ T cells were assessed with confocal microscopy from skin biopsies. Following rituximab treatment skin CD4+IL4+ T cells obviously decreased as seen with confocal microscopy. Moreover, peripheral CD4+IL4+ T cells decreased significantly compared to those from patients who received standard treatment alone: median (IQR): 14.9 (22.63-12.88) vs 7.87 (12.81-4.9)%, p = 0.005 and 9.43 (19.53-7.50)% vs 14.86 (21.96-6.75)%, p = NS at baseline and 6 months later respectively, whereas there was no difference in serum IL4 levels. Peripheral CD4+CD40L+ T cells also decreased significantly following rituximab treatment compared to those from patients who received standard treatment alone: median (IQR): 17.78 (25.64-14.44)% vs 8.15 (22.85-3.08)%, p = 0.04 and 22.13 (58.77-8.20)% vs 72.11 (73.05-20.45)%, p = NS at baseline and 6 months later respectively. Furthermore, peripheral CD4+INFγ+ and CD4+IL17+ T cells revealed no differences following rituximab treatment. Our study demonstrates a link between rituximab treatment and CD4+IL4+ T cell decrease both in the skin and peripheral blood of patients with SSc.

Objectives: The activity of the Wnt pathway, a critical mediator of fibrosis, is regulated by Dickkopf-1 (Dkk-1). Dkk-1 is absent from scleroderma skin in contrast to skin from healthy subjects where it is clearly expressed. There are no data on circulating levels and function of Dkk-1 in patients with systemic sclerosis (SSc). Our objectives are to assess: i) circulating and functional levels of Dkk-1 in patients with SSc and ii) whether the striking lack of Dkk-1 skin expression is also evident in a) clinically uninvolved skin from patients with SSc and b) very early disease prior to skin thickening., Methods: Circulating Dkk-1 levels were measured in 50 patients with SSc and 50 controls. Skin biopsies were obtained from SSc patients from a) clinically involved skin b) clinically uninvolved skin, c) oedematous skin prior to skin thickening., Results: Circulating and functional Dkk-1 levels were similar in patients with SSc and controls. Healthy skin displayed a high Dkk-1 immuno-expression in the epidermis and dermal fibroblasts in contrast to clinically involved scleroderma skin where Dkk-1 was totally absent. In all biopsies of clinically uninvolved skin Dkk-1 was only moderately expressed whereas skin from very early disease displayed only a weak Dkk-1 immunoreactivity., Conclusions: The downregulation of Dkk-1 at the oedematous phase of the disease indicates that the Wnt pathway is involved early in the disease process and may play a role in driving fibrosis. The decrease in Dkk-1 expression in clinically uninvolved scleroderma skin indicates that skin in SSc is universally affected.

Objectives The purpose of the present study was to describe histologically the gastro-oesophageal junction in the cat and interrelationships of this region. Our hypothesis was that cats are devoid of abdominal oesophagus. Methods Three centimetres of the terminal oesophagus, the phreno-oesophageal membrane with 1-2 cm margins of the diaphragmatic crural muscle and the proximal 3 cm of the gastric cardia were obtained from nine domestic shorthair cats and one domestic longhair cat that were euthanased for reasons other than digestive tract pathology. Longitudinal samples were examined histologically. Evaluated parameters included the location of the phreno-oesophageal membrane with reference to the transition between the oesophageal and gastric mucosa, the thickness of the circumferential smooth muscle of the muscular layer of the distal oesophagus at points 3 mm and 6 mm cranial to the mucosa transition, and the thickness of the circumferential smooth muscle layer at the mucosa transition level. Median differences in the thickness of the smooth muscle layer were compared by performing non-parametric statistical analysis using the Mann-Whitney U-test. Results The transition of the oesophageal to gastric mucosa was abrupt and corresponded to the point of insertion of the phreno-oesophageal membrane at the diaphragm level in all cats. The mean thickness of the circumferential smooth muscle layer at the point of oesophageal to gastric mucosa transition was significantly greater than the mean thickness of the oesophageal circumferential smooth muscle layer at 3 mm and 6 mm cranial to the mucosa transition ( P ⩽0.05). The increased muscle thickness at the gastro-oesophageal junction correlates with the accepted location of the high-pressure zone, reflecting the caudal oesophageal sphincter. It seems that the whole oesophagus was situated within the thoracic rather than the abdominal cavity. Conclusions and relevance No distinct abdominal oesophagus was observed in nine domestic shorthair cats and one domestic longhair cat. These findings might have implications for the pathophysiology of hiatal hernia in cats.

Objectives: Rituximab (RTX) may favorably affect lung function and skin fibrosis in patients with systemic sclerosis (SSc). We aimed to assess long-term efficacy and safety of RTX in SSc compared to standard treatment., Methods: A total of 51 patients with SSc-associated interstitial lung disease were recruited and treated with RTX (n = 33) or conventional treatment (n = 18). Median follow-up was 4 years (range: 1-7). Conventional treatment consisted of azathioprine (n = 2), methotrexate (n = 6), and mycophenolate mofetil (n = 10)., Results: Patients in the RTX group showed an increase in FVC at 2 years (mean ± SD of FVC: 80.60 ± 21.21 vs 86.90 ± 20.56 at baseline vs 2 years, respectively, p = 0.041 compared to baseline). In sharp contrast, patients in the control group had no change in FVC during the first 2 years of follow-up. At the 7 year time point the remaining patients in the RTX group (n = 5) had higher FVC compared to baseline (mean ± SD of FVC: 91.60 ± 14.81, p = 0.158 compared to baseline) in contrast to patients in the control group (n = 9) where FVC deteriorated (p < 0.01, compared to baseline). Direct comparison between the 2 groups showed a significant benefit for the RTX group in FVC (p = 0.013). Improvement of skin thickening was found in both the RTX and the standard treatment group; however, direct comparison between groups strongly favored RTX at all-time points. Adverse events were comparable between groups., Conclusions: Our data indicate that RTX has a beneficial effect on lung function and skin fibrosis in patients with SSc. Randomized controlled studies are highly needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)