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Self-expandable metal stents (SEMS) have been widely used for the palliation of esophageal malignant dysphagia. Stent-related dysphagia is frequent and should raise the suspicion of stent migration, tumor ingrowth or overgrowth. In addition, bleeding has been reported in nearly 7% of patients. Nonetheless, this is the first case report of a complete stent obstruction by abundant blood clot formation. The authors present a 76-year-old male with severe ischemic heart disease and atrial fibrillation, requiring cardiac resynchronization therapy defibrillator and anticoagulation. After being diagnosed with metastasized squamous cell mid-esophageal cancer, he was proposed for chemotherapy and palliative esophageal stenting.

(1) Background: An elevated wrist circumference may indicate excess weight and cardiometabolic risk. The present study aims to identify wrist circumference cutoff points (WrC) to determine excess weight levels and predict cardiometabolic risk in adults. (2) Methods: A cross-sectional study was conducted with adults aged 20 to 59 years old, attending the outpatient clinic at University Hospital/Federal University of Sergipe HU/UFS-EBSERH. Demographic, anthropometric, biochemical, and blood pressure (BP) data were collected. Cardiometabolic risk was assessed, according to the global risk score (ERG) and Framingham score criteria. The descriptive analysis included calculating medians and frequencies of anthropometric, demographic, biochemical, and blood pressure variables. The gender and age of adult groups were compared using the Mann-Whitney test. Spearman's correlation coefficient and multiple regression analysis were used to assess the association between wrist circumference (WrC) and the variables mentioned above. The predictive validity of WrC in identifying excess weight levels and cardiometabolic risk was analyzed using the ROC curve. The sample consisted of 1487 adults aged 20 to 59 years, 55.7% of whom were female; (3) Results: WrC correlated positively with other adiposity indicators such as waist circumference and Body Mass Index. WrC was the anthropometric indicator most significantly associated with cardiometabolic risk factors. WrC cutoff points identified by the study for determining excess weight were categorized by gender and age group. For males aged 20 to 40 years and >40 years, respectively, the cutoff points for overweight were 17.1 cm and 17.3 cm, and for obesity, 17.9 cm and 17.5 cm. For females aged 20 to 40 years and >40 years, respectively, the cutoff points for overweight were 15.6 cm and 15.4 cm, and for obesity, 16.1 cm and 16 cm (4). Conclusions: Wrist circumference showed a significant correlation with other adiposity indicators and can be used to identify adults with excess weight and predict cardiometabolic risk.

Competing Interests: The authors declare that they have no conflict of interest.

Background: Early biologic therapy within the first 18-24 months after diagnosis is associated with improved clinical outcomes in Crohn's disease [CD]. However, the definition of the best time to initiate biologic therapy remains unclear. We aimed to assess if there is an optimal timing for early biologic therapy initiation., Methods: This was a multicentre retrospective cohort study including newly diagnosed CD patients who started anti-tumour necrosis factor [TNF] therapy within 24 months from diagnosis. The timing of initiation of biologic therapy was categorised as ≤6, 7-12, 13-18, and 19-24 months. The primary outcome was CD-related complications defined as a composite of progression of Montreal disease behaviour, CD-related hospitalisations, or CD-related intestinal surgeries. Secondary outcomes included clinical, laboratory, endoscopic, and transmural remission., Results: We included 141 patients where 54%, 26%, 11%, and 9% started biologic therapy at ≤6, 7-12, 13-18, and 19-24 months after diagnosis, respectively. A total of 34 patients [24%] reached the primary outcome: 8% had progression of disease behaviour, 15% were hospitalised, and 9% required surgery. There was no difference in the time to a CD-related complication according to the time of initiation of biologic therapy within the first 24 months. Clinical, endoscopic, and transmural remission was achieved in 85%, 50%, and 29%, respectively, but no differences were found according to the time of initiation of biologic therapy., Conclusion: Starting anti-TNF therapy within the first 24 months after diagnosis was associated with a low rate of CD-related complications and high rates of clinical and endoscopic remission, although we found no differences with earlier initiation within this window of opportunity., (© The Author(s) 2023. Published by Oxford University Press on behalf of European Crohn’s and Colitis Organisation. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Introduction: Obinutuzumab is a type II anti-CD20 monoclonal antibody associated with a higher rate of toxicity when compared to rituximab. Gastrointestinal side-effects have been reported but data is still sparse., Case Presentation: A 47-year-old female with medical history of stage IV follicular non-Hodgkin lymphoma under chemotherapy presented with chronic bloody diarrhea and iron deficiency anemia. Endoscopic and histologic features resembled inflammatory bowel disease (IBD), imposing a thorough differential diagnosis. The diagnosis of obinutuzumab-induced pancolitis was made and the drug was suspended with subsequent clinical improvement., Conclusion: This is the first case report of obinutuzumab-induced pancolitis. The challenging differential diagnosis of IBD required a multidisciplinary approach with subsequent outcome and management implications., Competing Interests: The authors have no conflicts of interest to declare., (© 2023 The Author(s).Published by S. Karger AG, Basel.)

Background: Endoscopic submucosal dissection (ESD) is a minimally invasive technique for en bloc resection of superficial neoplastic lesions, independent of their size. However, for giant gastrointestinal superficial neoplasia, the risk of invasive cancer is higher, and ESD is typically challenging. Despite the increasing literature on giant resections, data on their efficacy and safety are still lacking., Objective: The aim of this study was to describe ESD outcomes from a Portuguese center, compare them with other international studies, and analyze the possible risk factors influencing outcomes., Methods: We conducted a retrospective single-center review using a prospectively collected database, including patients with rectal ESD resections larger than 10 cm, between January 2016 and December 2021. Clinical, procedural, and pathological data were collected and analyzed. Revision of the literature for comparison with international results was done through PubMed. Data were analyzed and statistical analysis performed, using Microsoft Excel and SPSS, to identify significant risk factors., Results: The study included 15 rectal resections, with a mean diameter of 140.9 mm (range 105-270), corresponding to lesions of 125.9 mm (87-238). The overall en bloc resection rate was 100% ( n = 15). According to ESGE criteria, procedure was considered curative in 53.3% ( n = 8), non-curative with high risk in 13.3% ( n = 2), and local-risk recurrence in 33.3% ( n = 5). Adverse events occurred in 26.7% ( n = 4): 1 minor perforation and 3 stenosis, most endoscopically managed. For non-curative resections with local-risk recurrence, surveillance without adjuvant therapy was performed in all cases. For high-risk non-curative resections, surgery was performed in 1 patient and adjuvant chemoradiation therapy in another. Follow-up (mean 16 months) demonstrated a recurrence rate of 0%. Statistical analysis revealed resection size ≥20 cm as a risk factor for perforation ( p value 0.067), and involvement of ≥90% of the circumference and procedural time ≥4 h as risk factors for stenosis ( p value 0.029 and 0.009, respectively)., Conclusions: Although challenging, ESD for giant lesions seems effective and safe, with a still relevant rate of complications, which were mostly endoscopically treated. Rigorous characterization of lesions is crucial to predict and avoid complications or the need for therapy escalation., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2023 by The Author(s). Published by S. Karger AG, Basel.)

Competing Interests: The authors have no conflicts of interest to declare.

Conyza species are important weeds in global agriculture, especially due to their capacity to evolve resistance to multiple herbicide mechanisms of action. We aimed to evaluate the frequency and distribution of resistance to glyphosate and chlorimuron-ethyl in Conyza spp. populations from Brazil. Seed samples were collected from grain production areas across nine Brazilian states over five consecutive years (2014 to 2018). Prior to resistance monitoring trials, dose-response assays were conducted to determine a single dose of glyphosate or chlorimuron-ethyl to discriminate resistant and susceptible populations. Resistance monitoring based on plant responses to the application of discriminatory doses of glyphosate (960 g ha-1) or chlorimuron-ethyl (20 g ha-1). Populations were classified as resistant, moderately resistant, or susceptible to either herbicide. While glyphosate resistance was highly frequent (71.2%) in all the five years, chlorimuron-ethyl resistant populations occurred at 39.8% of the total. The frequency of multiple resistance to both herbicides (35.3%) was proportional to the occurrence of chlorimuron-ethyl resistance (39.6%). Resistance to glyphosate and to chlorimuron-ethyl were found across all states evaluated.

Background: High-intensity functional training (HIFT) has become more popular, and the number of practitioners has increased; however, it remains unclear whether perturbations in the immune parameters occur, even after one single bout. Our aim was to examine acute leucocyte, muscle damage, and stress marker responses following a single 'Cindy' workout session, and compare the results between novice and experienced participants., Material and Methods: Twenty-three HIFT practitioners (age 31.0 ± 1.0 years) completed the 'Cindy' workout. They were categorized as novice (3-8 months of experience; n = 10) and experienced (≥18 months; n = 13). White blood cell (WBC) count, plasma creatine kinase (CK) activity, blood cortisol level, and lactate concentration were measured. Blood analysis was performed before (pre-ex), immediately after (post-ex), 30 min after (post-30 min), and 24 h after (post-24 h) a single 'Cindy' workout session., Results: WBC count was higher post-ex (6.8 to 11.8x103/μL) and returned to baseline values within post-30 min (p<0.01). Neutrophil (3.3 to 4.5x103/μL) and lymphocyte levels (2.8 to 5.9x103/μL) were higher post-ex and returned to baseline values after post-24 h, yet lymphocytopoenia (2.2x103/μL) was observed at post-30 min (p<0.01). CK increased post-ex (174.9 to 226.7 U.L-1) and remained elevated post-24 h. Cortisol (14.7 to 17.0 μg/dL) and lactate (1.9 to 13.5 mmol.l-1) responses increased post-ex, but only the lactate level was reduced at post-30 min (p<0.01). The experienced participants had higher WBC, lymphocyte, and cortisol concentrations post-ex than the novice ones (p<0.01)., Conclusions: A single HIFT session elicited significant acute perturbations in WBC count, stress markers, and muscle tissue, which is like other similar regimens. Importantly, the experienced participants showed greater lymphocyte and cortisol responses than the novice ones., Competing Interests: The authors have declared that no competing interests exist.

The evolution of glyphosate resistance (GR) in weeds is an increasing problem. Glyphosate has been used intensively on wild poinsettia (Euphorbia heterophylla L.) populations for at least 20 years in GR crops within South America. We investigated the GR mechanisms in a wild poinsettia population from a soybean field in southern Brazil. The GR population required higher glyphosate doses to achieve 50% control (LD50) and 50% dry mass reduction (MR50) compared to a glyphosate susceptible (GS) population. The ratio between the LD50 and MR50 of GR and GS resulted in resistance factors (RF) of 6.9-fold and 6.1-fold, respectively. Shikimate accumulated 6.7 times more in GS than in GR when leaf-discs were incubated with increasing glyphosate concentrations. No differences were found between GR and GS regarding non-target-site mechanisms. Neither population metabolized glyphosate to significant levels following treatment with 850 g ha-1 glyphosate. Similar levels of 14C-glyphosate uptake and translocation were observed between the two populations. No differences in EPSPS expression were found between GS and GR. Two target site mutations were found in all EPSPS alleles of homozygous resistant plants: Thr102Ile + Pro106Thr (TIPT-mutation). Heterozygous individuals harbored both alleles, wild-type and TIPT. Half of GR individuals were heterozygous, suggesting that resistance is still evolving in the population. A genotyping assay was developed based on the Pro106Thr mutation, demonstrating high efficiency to identify homozygous, heterozygous or wild-type EPSPS sequences across different plants. This is the first report of glyphosate-resistant wild-poinsettia harboring an EPSPS double mutation (TIPT) in the same plant., Competing Interests: The authors have read the journal's policy and have the following competing interests: author HT was a student at Colorado State University during the duration of the study. However, they are now affiliated with Corteva Agriscience. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction: This study aimed to determine the frequencies of bacterial isolates cultured from diabetic foot infections and assess their resistance and susceptibility to commonly used antibiotics., Methods: This prospective study included 41 patients with diabetic foot lesions. Bacteria were isolated from foot lesions, and their antibiotic susceptibility pattern was determined using the Kirby-Bauer disk diffusion method and/or broth method [minimum inhibitory concentration (MIC)]., Results: The most common location of ulceration was the toe (54%), followed by the plantar surface (27%) and dorsal portion (19%). A total of 89 bacterial isolates were obtained from 30 patients. The infections were predominantly due to Gram-positive bacteria and polymicrobial bacteremia. The most commonly isolated Gram-positive bacteria were Staphylococcus aureus, followed by Staphylococcus saprophyticus, Staphylococcus epidermidis, Streptococcus agalactiae, and Streptococcus pneumoniae. The most commonly isolated Gram-negative bacteria were Proteus spp. and Enterobacterspp., followed by Escherichia coli, Pseudomonasspp., and Citrobacterspp. Nine cases of methicillin-resistant Staphylococcus aureus (MRSA) had cefoxitin resistance, and among these MRSA isolates, 3 were resistant to vancomycin with the MIC technique. The antibiotic imipenem was the most effective against both Gram-positive and Gram-negative bacteria, and gentamicin was effective against Gram-negative bacteria., Conclusions: The present study confirmed the high prevalence of multidrug-resistant pathogens in diabetic foot ulcers. It is necessary to evaluate the different microorganisms infecting the wound and to know the antibiotic susceptibility patterns of the isolates from the infected wound. This knowledge is crucial for planning treatment with the appropriate antibiotics, reducing resistance patterns, and minimizing healthcare costs.

Introduction:  OBJECTIVE evaluation of nasal function is a constant challenge for plastic surgeons, otolaryngologists, and allergists. The modified Glatzel mirror can evaluate nasal expiratory flow; however, there is little information on this method and its use in the measurement of nasal patency after surgical procedures., Objective:  To compare, in a prospective study, the functional results before and after cosmetic rhinoplasty and evaluate the use of the Glatzel mirror as an objective method to assess nasal patency., Methods:  To achieve this objective, we analyzed the functional results of surgery through a subjective questionnaire and objective evaluation through a modified Glatzel mirror, and evaluated the correlation between the 2 methods. Twenty patients (14 women and 6 men) underwent aesthetic rhinoplasty using spreader grafts. Pre- and postoperative evaluation (90-120 days) included a respiratory quality score (subjective) and modified Glatzel mirror test (objective). Subsequently, the Spearman test was used to compare the pre- and postoperative subjective and objective data., Results:  The subjective evaluation demonstrated a statistical difference between pre- and postoperative scores (8 ± 2 and 9.4 ± 0.7, P ≤ 0.001). There was no statistical difference in mean nasal patency by modified Glatzel mirror. No statistically significant correlation was observed when comparing the modified Glatzel mirror values with the subjective scores reported by patients pre- or postoperatively., Conclusion:  The Glatzel method lacks sensitivity in detecting patient-reported improvements in breathing following rhinoplasty. This suggests that the method is a poor assessment tool to detect small, post-surgical changes in the nasal airways.

Background: Spreader grafts have been used in cosmetic rhinoplasty, but little information is available about the objective results of treatment. This study sought to determine subjective and objective functional results of open cosmetic rhinoplasty with spreader grafts., Methods: Twenty patients (14 women, six men; mean age, 31 ± 6 years) had open cosmetic rhinoplasty. Surgery included dissection of the upper lateral cartilages, from the septum, and placement of spreader grafts, symmetrically, along the dorsal edge of the septal cartilage. Preoperative and postoperative evaluation included breathing quality score, acoustic rhinometry and a modified Glatzel mirror test., Results: Evaluation after surgery (range, 5-18 months) showed significant improvement of breathing quality (before surgery, 8; after surgery, 9.4; P ≤ 0.001) and a mean minimal cross-sectional area of the left side (before surgery, 0.6 cm(2); after surgery, 0.9 cm(2); P ≤ 0.01). There was no significant change of the mean minimal cross-sectional area of the right side (acoustic rhinometry) or nasal patency (modified Glatzel mirror test) between preoperative and postoperative evaluation. Complications included postoperative synechiae in two patients and septal granuloma in one patient., Conclusions: Open structure rhinoplasty using spreader grafts is effective in reconstructing the internal nasal valve and preserving or improving nasal patency., Level of Evidence: IV (case series with preoperative and postoperative testing)., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: To develop an experimental model of global normothermic ischemia able to demonstrate the transient ischemia and reperfusion periods required for development of ischemia/reperfusion injury in the small intestines of Wistar rats by clamping the abdominal aorta., Methods: Twenty adult male Wistar rats weighing 250-350g were randomly divided into five groups with four rats each and submitted to increasing times of ischemia (0 - 30 - 45 - 60 - 90 minutes). Within each group, except the control one, two rats underwent 60 minutes of reperfusion and two 90 minutes. After the procedures, histological analysis was conducted by measurement of areas of necrosis., Results: The degree of intestinal necrosis ranged from 15% to 54% (p = 0.0004). There was progressive increase in the degree of injury related to increase in ischemic time. However, greater degrees of injury were observed in the lowest times of reperfusion. The analysis of the coefficient of variation of necrosis among the ten groups of ischemia/reperfusion showed a statistically significant difference in 15 areas, 13 related to the control group., Conclusion: The model was able to show the periods required for the occurrence of ischemia/reperfusion injury by aortic clamping and can serve as a basis to facilitate the development of studies that aim at understanding this kind of injury.

Background: In addition to providing nearly 50% of total airway resistance via the internal valve, the nasal septum provides support for the cartilaginous portion of the nasal dorsum, and it is responsible for determining the projection of the nasal tip. In modern rhinoplasty, septal cartilage plays an important role as a donor graft material., Objectives: The authors evaluate the anatomy of nasal septal cartilage, identifying variations according to certain regions of the septum and proposing a correlation between the topography and morphology of septal cartilage and graft choice., Methods: An anatomical study was performed on 14 fresh adult cadavers. The excised septal cartilage was placed on grid paper; digital images were taken; all septal cartilage was divided into nine equivalent quadrants; and quantitative measurements for length, height, and area were calculated and compared. Statistical significance was set at P < .05., Results: The average length of the septum was 35.14 mm, while the average height was 32.5 mm. The average septal area was 933.11 mm(2). The septal thickness mean values were analyzed in nine quadrants, ranging from 1.04 to 1.71 mm. Statistically-significant differences in mean values were found in 13 of the 14 cadavers. Specifically, the central and cranial areas were thickest, and the area corresponding to the L-strut was thinnest., Conclusions: Anatomical variations of the thickness of septal cartilage excisions were found to be statistically significant, and these differences play an important role in the proper selection of the septal grafts.

Background: Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented for open surgical or endovascular repair., Methods: Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n = 48, 77%), or endovascular repair (n = 14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open surgical and endovascular groups., Results: Age, gender, race, and mechanism of injury did not differ between open surgical and endovascular groups. Additionally, RTS, ISS, and NISS values were not significantly different. The proportion of patients with sternal fractures (14% vs 0%), or unstable spinal fractures (36% vs 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n = 13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic endografts (n = 6; 43%) and abdominal aortic endograft components (n = 8; 57%). Forty-one interposition grafts were placed in the open surgical group. Renal complications (32% vs 7%), and urinary tract infections (35% vs 7%) approached significance between surgical and endovascular groups (P = .082 and P = .077, respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0%, respectively (P = .056). Endovascular repair was associated with significant reductions in operative time (118 vs 209 minutes), estimated blood loss (77 vs 3180 ml), and intraoperative blood transfusions (0.9 vs 6.1 units). No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group., Conclusion: Endovascular repair of blunt descending thoracic aortic injuries utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short term and associated with a lower intraoperative mortality (P = .056). Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions.

Aneurysmal lesions of the external carotid artery are extremely rare. A case is presented of a 3.8 cm right external carotid artery pseudoaneurysm treated by transluminal exclusion using an endovascular stent-graft. Following stent-graft placement, complete occlusion of the aneurysmal sac and main vessel lumen patency was successfully demonstrated. This report demonstrates the technical feasibility of utilizing stent-grafts to treat aneurysmal lesions involving the external carotid artery.

Background: Thoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions., Methods: Between October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia., Results: Mean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures., Conclusion: Intentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions.

This investigation was designed to determine whether minimally invasive radiofrequency or laser ablation of the saphenous vein corrects the hemodynamic impact and clinical symptoms of chronic venous insufficiency (CVI) in CEAP clinical class 3-6 patients with superficial venous reflux. Patients with CEAP clinical class 3-6 CVI were evaluated with duplex ultrasound and air plethysmography (APG) to determine anatomic and hemodynamic venous abnormalities. Patients with an abnormal (>2 mL/second) venous filling index (VFI) and superficial venous reflux were included in this study. Saphenous ablation was performed utilizing radiofrequency (RF) or endovenous laser treatment (EVLT). Patients were reexamined within 3 months of ablation with duplex to determine anatomic success of the procedure, and with repeat APG to determine the degree of hemodynamic improvement. Venous clinical severity scores (VCSS) were determined before and after saphenous ablation. Eighty-nine limbs in 80 patients were treated with radiofrequency ablation (RFA) (n = 58), or EVLT (n = 31). The average age of patients was 55 years and 66% were women. There were no significant differences in preoperative characteristics between the groups treated with RFA or EVLT. Postoperatively, 86% of limbs demonstrated near total closure of the saphenous vein to within 5 cm of the saphenofemoral junction. Eight percent remained open for 5-10 cm from the junction, and 6% demonstrated minimal or no saphenous ablation. The VFI improved significantly after ablation in both the RF and EVLT groups. Postablation, 78% of the 89 limbs were normal, with a VFI <2 mL/second, and 17% were moderately abnormal, between 2 and 4 mL/second. VCSS scores (11.5 +/-4.5 preablation) decreased significantly after ablation to 4.4 +/-2.3. Minimally invasive saphenous ablation, using either RFA or EVLT, corrects or significantly improved the hemodynamic abnormality and clinical symptoms associated with superficial venous reflux in more than 90% of cases. These techniques are useful for treatment of patients with more severe clinical classes of superficial CVI.

Background: Vascular lesions involving the thoracic aorta are often life-threatening conditions that carry significant morbidity and mortality with traditional open surgical repair. Preliminary results suggest that endovascular therapy is an effective and possibly advantageous treatment for diseases of the descending thoracic aorta., Methods: Between October 2000 and May 2004, 50 consecutive patients underwent endovascular stent-grafting of lesions involving the descending thoracic aorta. Attempted stent-graft deployment was performed electively in 39 patients and emergently in 11. The pathology of electively treated aortic lesions included degenerative/atherosclerotic aneurysms (n = 24), pseudoaneurysms (n = 11), aortic dissections (n = 2), and penetrating ulcers (n = 2). Emergently treated aortic lesions were for acute rupture due to infectious (mycotic) aneurysms (n = 4), atherosclerotic/degenerative aneurysms (n = 3), acute type B dissections (n = 2), and acute transections (n = 2). Devices used include Talent (n = 45), AneuRx aortic cuffs (n = 2), custom-fabricated Gianturco-Dacron grafts (n = 2), and a modified Cook-Zenith abdominal aortic graft (n = 1). Follow-up was performed at 1-month, 6-months, 1-year, and annually thereafter., Results: Primary technical success, defined as successful deployment and exclusion of the lesion without evidence of type I or type III endoleak, was achieved in 48 (96%) of 50 patients. In one patient, the procedure was terminated due to inability to access the iliac vessels. In another patient, a type III endoleak was observed at the completion of the primary procedure that required deployment of an additional stent-graft component 2 months later. Of the 49 patients who received endografts, seven underwent secondary procedures to correct endoleaks, with five of these seven requiring the deployment of additional endovascular stent-graft components. Major complications included four in-hospital deaths, with three of these occurring in patients treated emergently. Additionally, respiratory failure (n = 6), multisystem organ failure (n = 2), cerebrovascular accident (n = 2), retroperitoneal hematoma (n = 2), acute renal insufficiency (n = 1), and pulmonary embolus (n = 1) were also observed. The overall endoleak rate was 20%, with five primary (< or = 30 days) and five secondary (> 30 days) endoleaks observed. Five of the endoleaks were treated with the deployment of one or more additional endovascular stent-graft components. Two of the endoleaks were treated with endovascular balloon remolding. Mean follow-up was 271 days. There were no aneurysm ruptures or aneurysm-related deaths., Conclusions: Endovascular treatment of vascular lesions involving the descending thoracic aorta can be safely performed with low morbidity in high-risk patients. Endovascular repair may become an attractive alternative for the treatment of a wide range of pathology along this vascular territory.

The overtraining syndrome is characterized by an excessive training that results in several adverse effects the main of which being the decay in performance. Its incidence among elite athletes has been experiencing a significant increase lately, which prompted a rush of interest in the search for efficient measures to prevent and treat this condition. It is necessary, however, to clarify possible mechanisms involved in the development of overtraining. Several hypothesis are being proposed, such as a greater activation of both the autonomic nervous system and the hypothalamic-pituitary-adrenal axis, and suppression of the hypothalamic-pituitary-gonadal axis. On the contrary, some studies suggest that the modulation of such systems is but a consequence of the overtraining syndrome and not its cause. Thus, recent hypothesis related to cytokine release, to central fatigue, to depletion of muscle and liver glycogen, and to a reduction in glutamine availability during physical activity are being raised.

The objective of this study was to determine the effect of creatine supplementation on performance and body composition of swimmers. Eighteen swimmers were evaluated in terms of post-performance lactate accumulation, body composition, creatine and creatinine excretion, and serum creatinine concentrations before and after creatine or placebo supplementation. No significant differences were observed in the marks obtained in swimming tests after supplementation, although lactate concentrations were higher in placebo group during this period. In the creatine-supplemented group, urinary creatine, creatinine, and body mass, lean mass and body water were significantly increased, but no significant difference in muscle or bone mass was observed. These results suggest that creatine supplementation cannot be considered to be an ergogenic supplement ensuring improved performance and muscle mass gain in swimmers.

Purpose: We investigated whether routine ligation of incompetent perforator veins is necessary in treatment of symptomatic chronic venous insufficiency (CVI) due to combined superficial and perforator vein incompetence, without deep venous insufficiency., Methods: This was a retrospective review of prospectively collected data. Twenty-four limbs with both superficial and perforator venous incompetence but no deep venous insufficiency were identified at venous duplex scanning. Air plethysmography (APG) was performed preoperatively, to obtain venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) of the affected limb. Saphenous vein stripping from the groin to knee and powered transilluminated phlebectomy for varicosity ablation were performed in all patients. Postoperatively, all patients underwent duplex scanning and APG to determine the status of the perforator veins and hemodynamic improvement from surgery., Results: Average patient age was 55.8 years; 62% of patients were women. CVI was class 3 in 4 limbs, class 4 in 12 limbs, and class 5 and class 6 in 4 limbs each. Postoperative duplex scans demonstrated that 71% of previously incompetent perforator vessels were now competent or absent. Significant improvement in all APG values was documented after superficial surgery. VFI improved from 6.0 +/- 2.9 preoperatively to 2.2 +/- 1.3 after surgery (P <.001); EF improved from 56.3 +/- 18 to 62 +/- 21 (P =.02); and RVF improved from 40.1 +/- 19 to 28.3 +/- 18 (P =.009). Mean preoperative symptom score (5.3 +/- 1.9) was significantly improved at mean follow-up of 18.3 months (1.4 +/- 1.2; P <.001)., Conclusion: Patients with superficial and perforator vein incompetence and a normal deep venous system experienced significant improvement in APG-measured hemodynamic parameters and clinical symptom score after superficial ablative surgery alone. This suggests that ligation of the perforator veins can be reserved for patients with persistent incompetent perforator vessels, with abnormal hemodynamic parameters or continued symptoms after superficial ablative surgery.

Objective: The purpose of this study was to determine whether the preoperative minimal cephalic vein size in the forearm was predictive of successful wrist fistula maturation to a functional hemodialysis access., Methods: Forty-four consecutive patients underwent evaluation before surgery with ultrasound scan imaging to map the entire cephalic vein in preparation for the construction of an arteriovenous fistula at the wrist. Measurements of the vein diameter were obtained from the ultrasound scan images at eight representative sites. Patients were clinically followed to determine maturation of the fistula to provide a functional hemodialysis access. The smallest diameter of the cephalic vein then was used as a preoperative predictor of fistula maturation., Results: Successful maturation of the arteriovenous fistula was achieved in 22 of the procedures (50%). Cephalic veins with a minimal diameter of 2.0 mm or less were used for anastamosis in 19 patients (43%), and three of these procedures (16%) led to a functional access site. The remaining 25 patients (57%) had minimal cephalic vein diameters greater than 2.0 mm, producing a successful maturation in 19 of the fistula creations (76%). A significantly higher rate of successful fistula maturation in those patients with a preoperative minimal cephalic vein size greater than 2.0 mm was realized (P =.0002, chi(2) test, with Yates correction for continuity)., Conclusion: In patients with a minimal cephalic vein size of 2.0 mm or less, a procedure other than wrist fistula should be considered for optimization of dialysis access.

Creatine, a natural nutrient found in animal foods, is alleged to be an effective nutritional ergogenic aid to enhance sport or exercise performance. It may be formed in kidney and liver from arginina and glicina. Creatine may be delivered to the muscle, where it may combine readily with phosphate to form creatine phosphate, a high-energy phosphagen in the ATP-CP system, and is stored. The ATP-CP energy system is important for rapid energy production, such as in speed and power events. Approximately 120 g of creatine is found in a 70 kg male, 95% in the skeletal muscle. Total creatine exists in muscle as both free creatine (40%) and phosphocreatine (60%). It is only recently that a concerted effort has been undertaken to investigate its potential ergogenic effect relative to sport or exercise performance. It does appear that oral creatine monohydrate may increase muscle total creatine, including both free and phosphocreatine. Many, but not all studies suggest that creatine supplementation may enhance performance in high intensity, short-term exercise task that are dependent primarily on the ATP-CP energy system, particularly on laboratory test involving repeated exercise bouts with limited recovery time between repetitions. Short-term creatine supplementation appears to increase body mass, although the initial increase is most likely water associated with the osmotic effect of increased intramuscular total creatine. Chronic creatine supplementation in conjunction with physical training involving resistance exercise may increase muscle mass. However, confirmatory research data are needed. Creatine supplementation up to 8 weeks, with high doses, has not been associated with major health risks; with low doses, it was demonstrated that in 5 years period supplementation, there are no adverse effects. The decision to use creatine as a mean to enhance sport performance is left to the description to the individual athlete.

Introduction: Leg ulcers associated with chronic venous insufficiency (CVI) frequently recur after healing. The risk of recurrence has not been well defined for patients in different anatomic and hemodynamic groups. We reviewed the risk of ulcer recurrence on the basis of clinical, etiologic, anatomic, and pathophysiologic criteria and hemodynamic characteristics of the affected limb as assessed with air plethysmography (APG)., Methods: Ninety-nine limbs with class 6 CVI were assessed clinically and with standing duplex ultrasound scanning and APG for the definition of clinical, etiologic, anatomic, and pathophysiologic criteria. Leg ulcers were treated with high-pressure compression protocols. Surgical correction of venous abnormalities was offered to patients with appropriate conditions. After ulcer healing, the limbs were placed in compressive garments and followed at 6-month intervals for ulcer recurrence., Results: The mean patient age was 54.3 years, and 46% of the patients were female. Corrective venous surgery was performed in 37 limbs. The mean follow-up time for all 99 limbs was 28 months. The ulcer recurrence rate with life table was 37% +/- 6% at 3 years and 48% +/- 10% at 5 years. The patients who underwent venous surgery had a significantly lower recurrence rate (27% +/- 9% at 48 months) than did those patients who had not undergone surgery (67% +/- 8% at 48 months; P =.005). The patients with deep venous insufficiency (DVI; n = 51) had significantly higher recurrence rates (66% +/- 8% at 48 months) than did the patients without DVI (n = 48; 29% +/- 9% at 48 months; P =.006). This difference was significant even after accounting for the effects of surgery (P =.03). The hazard ratio of ulcer recurrence increases by 14% for every unit increase in the venous filling index (VFI; P =.001). This remains significant even after accounting for the effects of surgery (P =.001). The combination of DVI and a VFI of more than 4 mL/s yields a risk of ulcer recurrence of 43% +/- 9% at 1 year and 60% +/- 10% at 2 years., Conclusion: Leg ulcers associated with CVI have a high rate of recurrence. Ulcer recurrence is significantly increased in patients with DVI and in patients who do not have venous abnormalities corrected surgically. The VFI obtained from APG is useful in the prediction of increased risk for recurrence, particularly in association with anatomic data.