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Intra-articular distal radius fractures with significant articular step-off and gapping are associated with high risk of developing symptomatic arthritis and poor functional outcome. The use of arthroscopy for distal radius fixation had been well published in the literature. It allows the surgeon to fine-tune intra-articular fragments to achieve articular congruency, address ligamentous disruption, and check for screw penetration within the joint. Various techniques have been reported, including volar locking plate presetting to aid in arthroscopic reduction. Here, we demonstrate our arthroscopic-assisted distal radius fixation technique using a 1.9-mm miniature scope NanoScope (Arthrex, Naples, FL).

(1) Background: Although Physaloptera retusa is one of the most widespread species infecting reptiles in the Americas, numerous taxonomic problems and little genetic data are associated with it. To clarify the taxonomy of this species, we used an integrative approach. (2) Methods: Physaloptera retusa-infecting Erythrolamprus typhlus (snake) from the Pantanal wetlands, Brazil, was morphologically and genetically characterised (18S and 28S rDNA; COI mtDNA) and compared with conspecific sequences available in GenBank, from parasites of Tupinambis teguixin (lizard), using species delimitation methods. Type specimens of P. liophis were re-evaluated given its morphological similarities with P. retusa. (3) Results: The morphology of the present specimens was equal to that of P. retusa, in which the only difference from P. liophis was the relative position of the vulva. Species delimitation methods were more accurate for the COI dataset; all of them (except ABGD) indicated interspecificity among P. retusa sequences. However, a lack of morphological data or voucher material, associated with the deposited sequences, prevented more assertive conclusions. (4) Conclusions: The present results highlight the importance of a clear association between genetic data and morphology of the isolation source, or at least its adequate vouchering. Moreover, P. retusa may represent a species complex in cryptic speciation, since it is widespread and has low hosts specificity.

Polyarteritis nodosa (PAN) is a rare form of vasculitis. Acute limb ischemia is a rare presentation and complication of PAN. Plain old balloon angioplasty (POBA) is one of the treatment strategies for addressing PAN-related critical limb threatening ischemia (CLTI). However, recurrence of stenosis and occlusion is frequent, making POBA a poor treatment choice, as evidenced in our described clinical case. Consequently, with consideration of sirolimus's anti-inflammatory and immunosuppressive properties, we used a sirolimus-coated balloon in the treatment of PAN-induced CLTI. A 37-year-old woman first presented with acute limb ischemia as her initial symptom. Diagnostic angiography demonstrated occlusion of her tibial vessels, and POBA was performed to restore perfusion. Later in the course of her illness, she developed foot gangrene despite multiple courses of immunosuppressive drugs and several attempts with POBA to achieve limb salvage. Because of her disease trajectory, a MagicTouch (Concept Medical) sirolimus-coated balloon was deployed to her anterior tibial artery during her third angioplasty. At 17 months after her last angioplasty, she remained ulcer free, and surveillance scans demonstrated occlusion-free tibial vessels. The use of sirolimus-coated balloon angioplasty is a promising treatment approach for successful limb salvage in patients with PAN vasculitis and CLTI.

Background: Diabetic foot ulcers (DFUs) are debilitating to the patient and costly for the healthcare system. We set up the Diabetic Rapid Evaluation and lower limb Amputation Management (DREAM) clinic with the aim of providing early directed specialist care to patients with DFUs. With early management, we hope to treat DFUs in its early stages, reducing the need for and associated morbidity of major and minor lower limb amputations. Objectives: We evaluated the outcomes of the fast-access DREAM clinic with multi-disciplinary evaluation for patients with DFUs. Outcomes include time from the point of referral to DREAM clinic evaluation, amputation rates and wound healing rates. Design; Patients presenting with DFU to the DREAM clinic were enrolled. A podiatrist made the first assessment, followed by immediate specialist consultation with Endocrinologists, Vascular surgeons or Orthopaedic surgeons as required. Methods: Data on baseline demographics and DFU characteristics were collected. Outcomes evaluated were wound healing at 12 weeks, wound salvage rates, time to DREAM clinic access and time to specialist referral. Results: Sixty-eight patients were enrolled, with 57.3% males, and mean age of 63 ± 13.0 years. Majority of ulcers were classified as neuropathic (41.3%) and located at the digits (40%). At 12-weeks follow-up, 1 had undergone major amputation, 9 minor amputations and 4 surgical debridements. The median time to DREAM clinic evaluation from first presentation was 3 days (IQR 7). Eleven (16.2%) required >1 specialist consult. Twenty (29.4%) were hospitalised for treatment. Twelve underwent revascularisation within 4 days (IQR 3.5). Twenty-four patients (35.3%) continued podiatry follow-up, having 28 DFUs in which 20 (71.4%) healed within 12 weeks. Conclusion: The fast-access multidisciplinary DREAM clinic shows promising outcomes with lower major amputation rates and exemplary DFU healing outcomes.

Abstract Sirolimus-coated balloons (SCB) have demonstrated much promise as an alternative drug eluting device to the existing paclitaxel coated balloon platforms for the treatment of peripheral arterial disease (PAD). They have been well tested pre-clinically and have demonstrated anti-restenotic effects as well as clinical safety in its use for treatment of coronary artery disease. The existing approved SCBs have thus far demonstrated good short-term patency (12-months) and did not exhibit any major adverse events or device related shortcomings in its use for treatment of PAD. There are several studies ongoing which aim to further investigate the efficacy of existing SCBs and establish a direct comparison of its outcomes compared with plain balloon angioplasty. Also, SCB utility to salvage failing arteriovenous fistulas for haemodialysis patients has also been explored. We review the current progress made in the establishment of SCB in the treatment of PAD as well as highlight ongoing studies investigating the role of SCB in various settings.

Abstract Background Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. Methods/design This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. Discussion This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. Trial registration ClinicalTrials.gov NCT04409912 . Registered on 1 June 2020

(1) Background: Integrative taxonomy has been important in the comprehension of relationships among nematode parasites. Philometridae is a highly diverse family of these organisms, but poorly-known regarding genetic characterization and evolution. An integrative taxonomic analysis was performed to improve the knowledge of the evolutionary history of Philometridae. (2) Methods: Phylogenies were reconstructed based on genetic sequences alone and integrated with morphological/life history traits, which were phylogenetically mapped. The host–parasite cophylogeny was evaluated. (3) Results: Previously unpublished 28S rDNA sequences are given for some species. The phylogeny from this marker, although limited by data scarcity, showed similar patterns as that from 18S rDNA. Clades shared common features related to the structure of the esophagus and of the tail in males (especially the gubernaculum), site of infection, habitat, host taxa and geographic origin; most of these features were phylogenetically informative. The integrative phylogeny was better resolved. A cophylogenetic signal was present mainly in clades of freshwater species. (4) Conclusions: The speciation process in Philometridae is not unique or uniform; host capture, host–parasite co-evolution and allopatric (especially in freshwater) events may be occurring simultaneously in different lineages, places and times. Cases of plesiomorphy retention probably occur. Evolutionary convergence of poorly-informative characters is suggested, even though they are important for species diagnosis.

Dissecting splenic artery pseudoaneurysm due to segmental arterial mediolysis (SAM) is a rare condition. We describe a case of direct percutaneous transgastric–transpancreatic thrombin injection into a dissecting splenic artery pseudoaneurysm due to SAM. The direct thrombin injection resulted in successful thrombosis of the pseudoaneurysm. At 1-month follow-up, the patient remained well with persistent thrombosis of the pseudoaneurysm.

The creation of an arteriovenous fistula instead of a synthetic vascular graft is a smart decision in hemodialysis patients who do not have a suitable superficial vein. Basilic vein transposition (BVT) is a viable option in most cases, except in patients who do not have a proper basilic vein. In patients with inadequate superficial veins, another source of the autogenous vein is the brachial vein, a deep vein of the upper arm. Most surgeons choose a full medial arm incision to perform brachial vein exploration. We describe a patient in whom BVT was not possible and so brachial vein transposition using skip incisions was performed, with good results.

(1) Background: Although Physaloptera retusa is one of the most widespread species infecting reptiles in the Americas, numerous taxonomic problems and little genetic data are associated with it. To clarify the taxonomy of this species, we used an integrative approach. (2) Methods: Physaloptera retusa-infecting Erythrolamprus typhlus (snake) from the Pantanal wetlands, Brazil, was morphologically and genetically characterised (18S and 28S rDNA; COI mtDNA) and compared with conspecific sequences available in GenBank, from parasites of Tupinambis teguixin (lizard), using species delimitation methods. Type specimens of P. liophis were re-evaluated given its morphological similarities with P. retusa. (3) Results: The morphology of the present specimens was equal to that of P. retusa, in which the only difference from P. liophis was the relative position of the vulva. Species delimitation methods were more accurate for the COI dataset; all of them (except ABGD) indicated interspecificity among P. retusa sequences. However, a lack of morphological data or voucher material, associated with the deposited sequences, prevented more assertive conclusions. (4) Conclusions: The present results highlight the importance of a clear association between genetic data and morphology of the isolation source, or at least its adequate vouchering. Moreover, P. retusa may represent a species complex in cryptic speciation, since it is widespread and has low hosts specificity. [ABSTRACT FROM AUTHOR]

May-Thurner syndrome (MTS) is rare condition thought to occur due to an anatomical variation. In MTS, there is left iliac vein compression by the right iliac artery and lumbar spine resulting in left lower limb deep venous thrombosis. The authors report a rare cause of MTS postarterial intervention. They describe the unusual case of an Asian man who presented with acute left lower limb deep venous thrombosis 5 days following left common iliac artery angioplasty and stent insertion. Computed tomographic (CT) venogram demonstrated the left iliac vein compression by the left iliac artery stent. Successful recanalization of the thrombosed iliac vein was achieved with a combination of pulse spray thrombolysis and rheolytic mechanical thrombectomy, followed by angioplasty and stent placement in the iliac vein. There was rapid and complete resolution of symptoms. This report illustrates the use of complementary imaging modalities and a multidisciplinary team approach to achieve a successful technical and clinical outcome following an unusual case of MTS postarterial intervention and the subsequent successful endovascular management.

Este documento deve ser referenciado citando também a versão original em Inglês: Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg. 2020 Feb;59(2):173-218. Epub 2019 Dec 31. PMID: 31899099. Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. https://doi.org/10.1016/j.ejvs.2019.09.006

Peripheral artery mycotic aneurysms are rare occurrences. In this case, we review a 52-year-old lady with poorly controlled diabetes who developed a spontaneous left superficial artery mycotic aneurysm. She underwent excision and subsequent extra-anatomic bypass with a great saphenous vein graft. She had full functional recovery after a short period of rehabilitation.

Heparin-induced thrombocytopaenia (HIT) is a rare life-threatening complication following exposure to heparin. It is mediated by immune-mediated thrombocytopaenia due to antibody against heparin platelet factor 4 complex. Early identification of the condition and the prompt administration of appropriate treatment are important to prevent morbidity and mortality from HIT. We report a case of HIT associated with open abdominal aortic aneurysm repair causing anterior tibial artery and peroneal artery thrombosis following prophylactic use of unfractionated heparin for prophylaxis of venous thromboembolism. Even though enoxaparin was switched to rivaroxaban after HIT was suspected, our patient unfortunately developed a minor cerebrovascular accident during the hospital stay as a consequence of HIT.

Infection of the sternoclavicular joint (SCJ) is rare and often missed at early stage. In extensive disease with bony and soft tissue destruction, radical excision is indicated. The loss of SCJ results in exposure of vital structures of the anterior mediastinum and instability of the shoulder girdle. SCJ reconstruction using locoregional muscle flaps like the pectoralis major or latissimus dorsi flap has been well described. While these options can provide soft tissue coverage, they do not restore the structural framework of the SCJ which is important for shoulder excursion and chest wall movement. We describe a case of SCJ reconstruction using a free vascularized fibular flap following the resection of sternoclavicular tubercular osteomyelitis. The fibula bone was used to restore the clavicular strut by anchoring it to the remaining manubrium with a steel wire and by plating the lateral end to the remnant clavicle. The steel wire served as a “defunctioning” cerclage that allowed motion of the joint to induce fibrous union. A strict post-operative rehabilitation protocol keeping the shoulder adducted at the initial phase was prescribed. At one year follow up, the patient achieved good shoulder function with 140 degrees of shoulder abduction and 110 degrees flexion.

Purpose: Ruptured abdominal aortic aneurysm (AAA) is almost always considered fatal without open surgical or endovascular repair. We report a case that has defied this norm and explore the possible factors involved in this exceedingly rare outcome. Case Report: An 87 year old gentleman presented with an acute ruptured AAA with left retroperitoneal hematoma. He was counseled for emergent repair, but opted for conservative management instead. He has remained well at the time of writing, 13 months from the rupture, with clinical resolution of symptoms along with radiological resolution of the hematoma. Conclusion: Timely repair remains the mainstay of management for ruptured AAA, although this rare case highlights that it is possible for ruptured AAA to seal spontaneously with patient surviving up to 13 months. We have sought to hypothesize the factors in this case that may have contributed to prolonged survival following untreated ruptured AAA. Clinical Impact Statement: While the overwhelming evidence is that a ruptured AAA left unrepaired is fatal, our case report illustrates a rare case that shows it is possible for ruptured AAA to seal spontaneously, with patient surviving up to 13 months. We seek to hypothesize the factors that may contribute to such prolonged survival. [ABSTRACT FROM AUTHOR]

Abstract Background Feature selection (FS) process is essential in the medical area as it reduces the effort and time needed for physicians to measure unnecessary features. Choosing useful variables is a difficult task with the presence of censoring which is the unique characteristic in survival analysis. Most survival FS methods depend on Cox’s proportional hazard model; however, machine learning techniques (MLT) are preferred but not commonly used due to censoring. Techniques that have been proposed to adopt MLT to perform FS with survival data cannot be used with the high level of censoring. The researcher’s previous publications proposed a technique to deal with the high level of censoring. It also used existing FS techniques to reduce dataset dimension. However, in this paper a new FS technique was proposed and combined with feature transformation and the proposed uncensoring approaches to select a reduced set of features and produce a stable predictive model. Methods In this paper, a FS technique based on artificial neural network (ANN) MLT is proposed to deal with highly censored Endovascular Aortic Repair (EVAR). Survival data EVAR datasets were collected during 2004 to 2010 from two vascular centers in order to produce a final stable model. They contain almost 91% of censored patients. The proposed approach used a wrapper FS method with ANN to select a reduced subset of features that predict the risk of EVAR re-intervention after 5 years to patients from two different centers located in the United Kingdom, to allow it to be potentially applied to cross-centers predictions. The proposed model is compared with the two popular FS techniques; Akaike and Bayesian information criteria (AIC, BIC) that are used with Cox’s model. Results The final model outperforms other methods in distinguishing the high and low risk groups; as they both have concordance index and estimated AUC better than the Cox’s model based on AIC, BIC, Lasso, and SCAD approaches. These models have p-values lower than 0.05, meaning that patients with different risk groups can be separated significantly and those who would need re-intervention can be correctly predicted. Conclusion The proposed approach will save time and effort made by physicians to collect unnecessary variables. The final reduced model was able to predict the long-term risk of aortic complications after EVAR. This predictive model can help clinicians decide patients’ future observation plan.

Fresh and conserved pangola grass (Digitaria eriantha Steud., synonym D. decumbens) were compared in terms of in vitro gas production and in vivo nutrient digestibility, metabolisable energy (ME) concentration and average daily gain (ADG) of Thai indigenous cattle. The study was designed as a completely randomised design with Ruzi grass (Brachiaria ruziziensis) as a control and pangola grass in fresh, hay and silage forms at the same age at harvest (45 days regrowth) as treatments. As intended, the dry matter (DM) intake of forages supplemented with concentrate and a protein block was not different (p > .05) among treatments. All forms of pangola ranked higher in crude protein and ME concentrations than Ruzi grass. Pangola silage, to which 5% sugarcane molasses was added at ensiling to minimise the risk of bad fermentation, produced more gas in vitro after 96 hours of incubation and had greater (p

BackgroundThe aim of this pilot study was to evaluate the safety and efficacy of the MagicTouch™ sirolimus-coated balloon (SCB) catheter (Concept Medical Inc., Tampa, FL, US) on improving the patency of failing arterio-venous fistulas (AVF) with de novo and recurrent stenoses. MATILDA reports early outcomes at 3- and 6 months post intervention.MethodsSingle-centre, single-arm prospective pilot study of 33 (18 males; mean age 64.7±11.6 years) end-stage renal failure Asian patients with a dysfunctional AVF, who underwent SCB angioplasty between May 2019-January 2020. All procedures were performed under local anaesthetic without sedation and as day surgery. All patients were prescribed dual antiplatelet therapy for 3 months and followed up with Duplex ultrasound at 3 and 6 months.Results47 stenotic target lesions treated and 24/33 (72.7%) patients were for restenosis. Main indications for intervention was low/dropping access flow (21/33; 63.6%) and most common target lesion was in the juxta-anastomosis (19/47; 40.4%). There was 100% technical and procedural success. There were no peri-procedural complications related to the SCB. The target lesion primary patency rates at 3 and 6 months were 46/47 (97.9%) and 29/35 (82.9%) respectively. Circuit access patency rates at 3 and 6 months were 31/33 (93.9%) and 17/25 (68%) respectively. There was one (2.9%) death at 6 months and 4/33 (12.1%) overall to date, all from patients' underlying co-morbidities.ConclusionsSCB angioplasty for dysfunctional AVF circuits is a safe and efficacious modality in Asian haemodialysis patients at six months comparable if not better than the paclitaxel data reported to date in the literature.

May–Thurner syndrome (MTS) is an underdiagnosed cause of lower limb deep vein thrombosis (DVT). The clinical prevalence of MTS-related DVT is likely underestimated, particularly in patients with other more recognisable risk factors. MTS is classically described in females between the age group of 20–50 years. In patients with acute iliofemoral thrombosis, medical treatment with anticoagulation alone has been associated with higher risk of postthrombotic syndrome (PTS) and lower iliofemoral patency rates, as compared to endovascular correction. We describe a case of MTS-related extensive iliofemoral DVT occurring in a middle age male who presented with acute onset of left lower limb swelling and pain, complicated by pulmonary embolism. Doppler compression ultrasonography of the left lower limb showed partial DVT extending from the left external iliac to the popliteal veins, and contrasted computed tomography (CT) of the thorax abdomen and pelvis established features of MTS, together with right pulmonary embolism. He was started on low molecular weight heparin (LMWH) and then underwent left lower limb AngioJet pharmacomechanical thrombolysis/thrombectomy, iliac vein stenting, and temporary inferior vena cava (IVC) filter insertion. After the procedure, the patient recovered and improved symptomatically with rapid resolution of this left lower limb swelling and pain. He was switched to an oral Factor Xa inhibitor and was subsequently discharged. After 1-month follow-up, he remained well with stent patency visualised on repeat ultrasound and underwent an uneventful elective IVC filter retrieval with subsequent plans for a 1-year follow-up.

Abstract Background The pubic region is often involved in accidental hot water or soup-spill burns. Most of these wounds are superficial partial thickness burns. Due to their proximity to the urinary system, as well as vaginal and anal openings, these burns are easily contaminated. Daily dressings are routinely prescribed as the sole treatment. The cumbersome dressing process is uncomfortable and embarrassing for patients. Biobrane™ is a bilayered biosynthetic dressing. Its coverage of superficial partial thickness burns promotes wound healing and allows one-time application. Case presentations We report two patients who suffered superficial dermal burns over their pubic region. One patient had 23% total body surface area (TBSA) burns over her lower abdomen, both thighs and pubic region. The second patient had 10% TBSA burns that involved her perineum and the medial sides of both thighs and buttocks. Both were managed with the standard resuscitation protocol in the initial phase. Their burn injuries were managed by shaving, Foley catheterization and Biobrane™ coverage. Their wounds healed uneventfully without complications. Full epithelization was achieved by post-operative day seven. Both patients consented to medical photography and academic publication. Conclusion Shaving and catheterization improved the hygiene of the burns of the pubic area. The Biobrane™ method circumvents the need of regular dressing changes, eliminating the pain due to dressing changes and preserving patient dignity.