The Utilization of Protamine during Peripheral Vascular Interventions in the VQI.

BACKGROUND: Protamine administration was shown to reduce bleeding after carotid surgery but the role of protamine during peripheral vascular interventions (PVIs) remains unknown. This study evaluates the trend and outcomes of protamine use in the Vascular Quality Initiative (VQI). Our hypothesis is that the use of protamine is associated with decreased bleeding after PVI. METHODS: Patients undergoing elective PVI in the VQI (2016-2020) for peripheral arterial disease were reviewed and the utilization trend for protamine was described. The characteristics of patients undergoing PVI with and without protamine use were compared. After propensity score matching based on the patient's comorbidities, access site, and procedural characteristics, the perioperative outcomes of both groups were compared using multivariable Poisson regression to estimate adjusted rate ratios (aRRs) and 95% confidence intervals (95% CIs). RESULTS: The total number of patients was 131,618 and patients who received protamine constituted 29.8% of the sample (N = 38,191). After propensity matching, the total number of patients was 94,582, and patients who received protamine constituted 28.8% of the sample (N = 27,275). Protamine use significantly increased during the study period from 5.2 to 22.9%. Before propensity score matching, patients who received protamine were more likely to be white (79% vs. 76.8, P ≤ 0.001), smokers (80.5% vs. 78.5%, P ≤ 0.001), with medical comorbidities including hypertension (88.9% vs. 88.5%, P = 0.074), congestive heart failure (20.5% vs. 19.8%, P = 0.006), and chronic obstructive pulmonary disease (28.2% vs. 26.5%). They were also more likely to be on perioperative medications such as P2Y12 inhibitors (44.3% vs. 45, P = 0.013%) and statin (77.4% vs. 76.5%, P = 0.001) compared to patients who did not receive protamine. After propensity matching, there were no significant differences between the 2 groups. There was a significant decrease in bleeding during procedures where protamine was administered compared to no protamine (2.0% vs. 2.2%) (aRR, 0.89 [95% CI 0.80, 0.98]). Protamine was more likely to be given in procedures complicated by perforation (0.8% vs. 0.5%) (aRR, 1.48 [95% CI 1.24, 1.76]) and less likely to be given during procedures with distal embolization (0.4% vs. 0.7%) (aRR, 0.59 [95% CI 0.49, 0.73]). However, patients receiving protamine had significantly higher cardiac complications (1.4% vs. 1.1%) (aRR, 1.27 [95% CI 1.12, 1.43]). There was no significant difference in mortality between the 2 groups. CONCLUSIONS: Protamine use is associated with decreased perioperative bleeding but increased cardiac complications. Protamine should be selectively administered to patients at high risk of bleeding during PVI.

[Use of contrast-enhanced mammography for diagnosis of breast cancer]. / Einsatz der kontrastmittelverstärkten Mammographie in der Brustkrebsdiagnostik.

BACKGROUND: Contrast-enhanced mammography (CEM) is an imaging method that is able to improve visualization of intramammary tumors after peripheral venous administration of an iodine-containing contrast medium (ICM). OBJECTIVES AND METHODS: The current significance of CEM is discussed. RESULTS: Studies were able to show an advantage of CEM in the diagnosis of breast cancer compared to mammography, especially for women with dense breasts. Indications for CEM currently depend on the availability of magnetic resonance imaging (MRI). If MRI is available, CEM is indicated in those cases when MRI cannot be performed. Use of CEM for breast cancer screening is currently viewed critically. This view can change when results and updated assessments of large CEM studies in Europe and USA become available. Patients must be informed about the use of an ICM. As ICM administration for CEM is carried out in a similar manner to established imaging methods, the authors expect the use of ICM for CEM to be unproblematic as long as general contraindications are adhered to. CONCLUSIONS: In the future, CEM could have greater importance for the diagnosis of breast cancer, as this imaging method has diagnostic advantages compared to conventional mammography. A great advantage of CEM is its availability. For those who use breast MRI, CEM is helpful when MRI is not feasible due to contraindications or other reasons.

Breast MRI - The champion in the millimeter league: MIO breast MRI - The method of choice in women with dense breasts.

We perform MRI of the breast as a first pass technique. We successfully established 10-minute-protocols (including T2 images) with a fixed dosage of 5 ml 1 M CM. A high spatial resolution of 526 × 526, better 672 × 672 or maximum (1.024 × 1.024, MIO MRI) is vital to achieve best results. We use fixation tools to avoid motion artifacts. Motion correction algorithms can, however, often eliminate such artifacts when they are present. In initial breast MRI exams, morphologic features are the most important criteria for lesion evaluation. If previous exams are available for comparison, the main criteria indicating a suspicious lesion are an increase in lesion size or the depiction of new lesions. High quality HR MRI of the breast is the method of choice in women with dense or extremely dense breasts in all cases (screening, assessment, follow up). In density type A or B, MRI can be helpful in defined constellations, e.g. when MX and US are limited or contraindicated. According to our experience, 95% or more of all carcinomas of the breast are detectable on MRI. The remaining 5% of MRI-occult lesions are intraductal tumors or very small invasive carcinomas depicted with mammography due to associated microcalcifications. MRI is, however, superior to all other imaging modalities in the detection of the clinically relevant DCIS (high risk DCIS, intermediate type). Consecutive MRI examinations in intervals of 12 to 24 months allow a reliable detection of invasive breast cancer with an average size of 7-8 mm. This corresponds to a rate of metastasis-free locoregional lymph nodes in >95% of cases. The rate of interval cancers is <2%. In conclusion, this strategy may increase the overall-lifetime survival of breast cancer patients to more than 95%. Inversely, mortality may be reduced to <5%. Taking these improvements in early breast cancer detection and survival that can be achieved through the implementation of QA HR MRI of the breast into account, it should be discussed to modify oncologic guidelines for the treatment of breast cancer. MRI is the best diagnostic tool we have and according to our experience, a first pass, quality-assured high-resolution breast MRI protocol provides best diagnostic results at minimal procedural effort.

Technical Feasibility and Safety of a Snare-Less, EVAR-First Technique for Iliac Branch Endoprosthesis.

OBJECTIVE: The purpose of this study was to evaluate the technical feasibility, safety, and early outcomes of a snare-less, endovascular abdominal aortic aneurysm repair (EVAR)-first technique (SET) for iliac branch endoprosthesis (IBE) placement. METHODS: We retrospectively reviewed all patients who received IBEs between July 2018 and March 2022. Patients were divided into 2 categories based on method of IBE deployment: SET or Standard. Primary endpoints were technical success, major adverse events, mortality, reintervention, internal iliac artery (IIA) patency, and freedom from IIA branch instability. Technical success was defined by successful deployment of both the EVAR and the IBE with maintained patency of the IIA and no stent graft migration. RESULTS: There were 20 patients (90% male, median age 72 [65.4-74.5] years) who underwent IBE placement. Among these, 5 (33.3%) underwent SET to treat 5 common iliac artery (CIA)/IIA aneurysms, while the remaining 15 (66.7%) underwent standard IBE deployment with through-and-through femoral access (n=13) or trans-brachial access (n=2) to treat 19 CIA/IIA aneurysms. Overall median renal to iliac bifurcation length was 169 (152-177) mm, with 9 patients falling short of the minimum of 165 mm for on-label IBE placement. Median contrast used was 148 (120-201) mL, fluoroscopy time 42.8 (35.0-49.8) minutes, estimated blood loss 200 (100-275) mL, and procedure time 192 (167-246) minutes, with no significant differences between the 2 groups. Technical success was achieved in 100% of cases. At 30 days, there were no mortalities or major adverse events in either group; there were 100% IIA patency, no IIA instability, and no reinterventions in both groups. Median follow-up in the SET group was 5.7 (5.5-6.2) months, with 1 death at 6 months and 1 type 1B endoleak at 6 months requiring reintervention. Median follow-up for the Standard group was 1.6 (0.8-2.1) years with 2 non-aneurysm-related deaths and no reinterventions at 1 year. CONCLUSIONS: SET for IBE is a safe and effective approach that decreases technical complexity and mitigates anatomic barriers to IBE placement. CLINICAL IMPACT: SET for IBE is a safe and effective approach to IBE placement that decreases technical complexity. A critical component to this technique is a large bore sheath with a stiff steerable tip. Importantly, this approach also mitigates anatomic barriers to IBE placement, expanding applicability of IBE technology to patients who may be otherwise ineligible.

Comparison between cone-beam breast-CT and full-field digital mammography for microcalcification detection depending on breast density.

The purpose of this study was to evaluate the impact of breast density on the diagnostic performance of cone-beam breast-CT (CBBCT) in comparison to full-field digital mammography (FFDM) for the detection of microcalcifications. This retrospective IRB-approved study was conducted between December 2015 and March 2017 and enrolled 171 women with Breast Imaging Reporting and Data System category 4 or 5 lesions on FFDM and additional CBBCT; 56 of which were ineligible. The inclusion was restricted to 83 women (90 breasts, 90 lesions) with microcalcifications. All lesions underwent histology or were monitored by FFDM and a clinical examination at least 2 years after enrollment. Two breast radiologists independently read each data set twice. Sensitivity, specificity and area under the curve were compared between the modalities. Thirty-two breasts (35.5%) were grouped as non-dense breasts (American College of Radiology types a/b) and 58 breasts (64.5%) as dense breasts (American College of Radiology types c/d). Histopathological assessment was performed in 61 of 90 breast lesions (32 malignant, 1 high-risk and 28 benign). Area under the curve was larger for FFDM than for CBBCT (P = .085). The sensitivity was significantly higher for FFDM compared to CBBCT (P = .009). The specificity showed no significant differences comparing FFDM (both readers: 0.62) versus CBBCT (reader 1: 0.76, reader 2: 0.60; P = .192). Inter-observer-reliability on BI-RADS readings was almost perfect for FFDM and moderate for CBBCT (κ = 0.84, κ = 0.54, respectively). Intra-observer agreement was substantial to almost perfect for both methods and readers. Compared with FFDM, CBBCT demonstrated non-comparable results for microcalcification detection in dense and non-dense breasts.

Endovascular fenestration and iliac stenting for acute limb ischemia caused by type B aortic dissection.

A 60-year-old man presented with chest pain and acute limb ischemia of the right leg. He was found to have a type B aortic dissection with a flap occluding the origin of the right common iliac artery. The dissection flap was fenestrated endovascularly with the placement of a covered stent in the right common iliac artery. After 10 years, the dissection remains stable with a minimal increase in the aorta size. The stent is patent with no lower extremity symptoms or reintervention. Fenestration and stenting of the obstructing flap can be a durable reperfusion strategy for patients with aortic dissection presenting with acute limb ischemia.

Using immersive externship experiences within medical education to bridge the physician-administrator divide.

The composition of early trainee medical education is highly influential as it shapes the future of medicine and healthcare. Despite being frequently neglected, education about and exposure to hospital administration should be important aspects of medical student learning. Understanding how health systems coordinate and optimize functions of different departments to enhance patient care is a critical component of being a physician. In this Personal View, we share the tangible impact that a short immersive experience with hospital administration can bring to not only enrich medical student education but also influence their future perspectives and interactions within healthcare systems. Early integration of these learning opportunities has the potential to improve the physician-administrator relationship within hospitals and encourage innovative collaboration to provide more patient-centered and financially sustainable healthcare.

Aneurysmal degeneration of the hood of a cryopreserved vein allograft two years after thrombosis.

Cryopreserved vein allografts are used as alternative conduits for infrainguinal bypass but are prone to aneurysmal degeneration. A 60-year-old man presented with a pulsatile, tender right groin mass 2 years after thrombosis of a cryopreserved vein jump graft emanating from a prosthetic axillary to profunda bypass. Intraoperatively, the aneurysm was consistent with isolated dilatation of the hood of the thrombosed cryopreserved vein graft. This was excised and repaired with bovine pericardial patch angioplasty. The patient recovered with no recurrence for 2 years. Aneurysmal degeneration of the cryopreserved vein allograft can occur even after graft thrombosis.

Elucidating the Role of the AFX2 Endograft in Endovascular Treatment of Aortic Pathology.

BACKGROUND: The purpose of this study is to elucidate the role of the AFX2 platform in the endovascular treatment of aortic pathology. METHODS: All procedures by a single surgeon resulting in implantation of a bifurcated unibody stent graft were reviewed retrospectively. Indications for selection of the AFX2 endograft in each case were evaluated. Aortic anatomy was determined via review of pre-operative computed tomography (CT) scans. Cumulative event probabilities for endoleak, reintervention, and mortality were estimated. Patient and procedural details were described using mean, standard deviation, medians, and interquartile range (IQR). Kaplan-Meier survival analysis estimated freedom from mortality and reintervention. Cumulative incidence probabilities were calculated as one minus the Kaplan-Meier estimator. RESULTS: Between March 2018 and December 2020, the author (NN) used 142 aortic endografts in 142 patients. Of these, 46 (32.4%) were AFX2 endografts and the remaining were modular bifurcated devices, predominantly Medtronic Endurant II and Terumo Treo. No AFX-Strata or AFX-Duraply devices were placed. Amongst the patients who received an AFX2, mean age was 71.3 +/- 9.8 years with 84.8% male. Median operative time was 116 (86-166) min, with contrast dose of 79 (41-120) milliliters and fluoroscopy time of 12 (8.6-18) min. Overall, 78.3% (n = 36) of AFX2 devices were placed in aortas with maximum true lumen diameter <5.0 cm. Median postoperative follow-up was 1.7 years (IQR 1.0-2.4 years), with a maximum follow-up of 3.6 years. There was 1 patient lost to follow-up at 5 months. The 2-year incidence of type II endoleak, reintervention, and all-cause mortality was 12.7% (95% confidence interval CI, 0-29.6%), 2.2% (95% CI, 0-6.3%), and 11.3% (95% CI, 0.1-2.1.2%), respectively. There were no type I or III endoleaks. CONCLUSIONS: The AFX2 endograft plays a safe and effective role in treatment of infrarenal aortic pathologies that may be otherwise more technically challenging for traditional modular, bifurcated devices.

Cold-induced secondary dormancy and its regulatory mechanisms in Beta vulgaris.

The dynamic behaviour of seeds in soil seed banks depends on their ability to act as sophisticated environmental sensors to adjust their sensitivity thresholds for germination by dormancy mechanisms. Here we show that prolonged incubation of sugar beet fruits at low temperature (chilling at 5°C, generally known to release seed dormancy of many species) can induce secondary nondeep physiological dormancy of an apparently nondormant crop species. The physiological and biophysical mechanisms underpinning this cold-induced secondary dormancy include the chilling-induced accumulation of abscisic acid in the seeds, a reduction in the embryo growth potential and a block in weakening of the endosperm covering the embryonic root. Transcriptome analysis revealed distinct gene expression patterns in the different temperature regimes and upon secondary dormancy induction and maintenance. The chilling caused reduced expression of cell wall remodelling protein genes required for embryo cell elongation growth and endosperm weakening, as well as increased expression of seed maturation genes, such as for late embryogenesis abundant proteins. A model integrating the hormonal signalling and master regulator expression with the temperature-control of seed dormancy and maturation programmes is proposed. The revealed mechanisms of the cold-induced secondary dormancy are important for climate-smart agriculture and food security.

Phylogenetic Relatedness and Genome Structure of Yersinia ruckeri Revealed by Whole Genome Sequencing and a Comparative Analysis.

Yersinia ruckeri is the causative agent of enteric redmouth disease (ERM), a serious infection that affects global aquaculture with high economic impact. The present study used whole genome sequences to perform a comparative analysis on 10 Y. ruckeri strains and to explore their genetic relatedness to other members of the genus. Y. ruckeri, Yersinia entomophaga, and Yersinia nurmii formed a species complex that constitutes the most basal lineage of the genus. The results showed that the taxonomy of Y. ruckeri strains is better defined by using a core genome alignment and phylogenetic analysis. The distribution of accessory genes in all Yersinia species revealed the presence of 303 distinctive genes in Y. ruckeri. Of these, 169 genes were distributed in 17 genomic islands potentially involved in the pathogenesis of ERM via (1) encoding virulence factors such as Afp18, Yrp1, phage proteins and (2) improving the metabolic capabilities by enhancing utilization and metabolism of iron, amino acids (specifically, arginine and histidine), and carbohydrates. The genome of Y. ruckeri is highly conserved regarding gene structure, gene layout and functional categorization of genes. It contains various components of mobile genetic elements but lacks the CRISPR-Cas system and possesses a stable set of virulence genes possibly playing a critical role in pathogenicity. Distinct virulence plasmids were exclusively restricted to a specific clonal group of Y. ruckeri (CG4), possibly indicating a selective advantage. Phylogenetic analysis of Y. ruckeri genomes revealed the co-presence of multiple genetically distant lineages of Y. ruckeri strains circulating in Germany. Our results also suggest a possible dissemination of a specific group of strains in the United States, Peru, Germany, and Denmark. In conclusion, this study provides new insights into the taxonomy and evolution of Y. ruckeri and contributes to a better understanding of the pathogenicity of ERM in aquaculture. The genomic analysis presented here offers a framework for the development of more efficient control strategies for this pathogen.

Current applications of artificial intelligence in vascular surgery.

Basic foundations of artificial intelligence (AI) include analyzing large amounts of data, recognizing patterns, and predicting outcomes. At the core of AI are well-defined areas, such as machine learning, natural language processing, artificial neural networks, and computer vision. Although research and development of AI in health care is being conducted in many medical subspecialties, only a few applications have been implemented in clinical practice. This is true in vascular surgery, where applications are mostly in the translational research stage. These AI applications are being evaluated in the realms of vascular diagnostics, perioperative medicine, risk stratification, and outcome prediction, among others. Apart from the technical challenges of AI and research outcomes on safe and beneficial use in patient care, ethical issues and policy surrounding AI will present future challenges for its successful implementation. This review will give a brief overview and a basic understanding of AI and summarize the currently available and used clinical AI applications in vascular surgery.

Alternative Endograft Aortoiliac Reconstruction for Iliac Branch Endoprostheses.

BACKGROUND: Endovascular treatment of complex common iliac artery (CIA) and internal iliac artery (IIA) aneurysms using iliac branch endoprostheses (IBE) has proven safe and effective. Instructions for use (IFU) require deployment of current IBE technology with the corresponding manufacturer's modular bifurcated aortic endograft. Concomitant aortoiliac occlusive disease, inadequate renal artery-iliac bifurcation length, and unfavorable aortic anatomy preclude on-label IBE deployment. This study aimed to evaluate the technical feasibility and safety of Alternative Endograft Aortoiliac Reconstruction (AEGAR) for branched endovascular treatment of complex iliac artery aneurysms. METHODS: In 7 consecutive patients with CIA or IIA aneurysms, computed tomography angiography (CTA) and center-line reconstruction revealed aortoiliac anatomy incompatible with the current IBE IFU due to inadequate proximal CIA landing zone (n = 7), inadequate renal artery to iliac bifurcation length (n = 2), compromised aortic anatomy (n = 3), or short infrarenal neck <15 mm (n = 1), either alone or in combination. To overcome these restrictions and facilitate IBE deployment, aortoiliac reconstruction was performed using the Endologix AFX, Endologix Ovation limbs or the Medtronic Endurant II platforms (AEGAR technique). All internal iliac artery reconstructions and external iliac artery extensions were performed using the Gore VBX or Viabahn stent grafts. Technical success was defined as successful delivery of all endograft components without migration or endoleak. RESULTS: The mean patient age was 69 years (range 52-82 years; 6 male). Four patients had bilateral CIA aneurysms and 3 patients had unilateral CIA aneurysms (mean diameter 4.3cm; range 2.2-7 cm). There were 13 IIA VBX stent grafts used for a total of 9 IIAs treated with IBE (bilateral IBE = 2 patients). The mean fluoroscopy time was 38.8 min (range 21.3-64.3 min) and the mean contrast volume was 168.5 mL (range 122-226 mL). Technical success was achieved in all patients and there were no perioperative complications. Mean hospital-stay was 2.2 days (range 1-3 days). Follow-up ranged from 82-957 days (mean = 487 days). At last follow-up, all patients were alive without cardiovascular morbidity; and CTA revealed stable or decreased aneurysm size, patent endografts, and no evidence of endoleak or migration. CONCLUSIONS: The AEGAR technique can be used to safely and effectively overcome certain aortoiliac anatomic constraints that preclude use of current IBE technology. We encourage broader use of these alternative endografts in pertinent anatomic configurations.

Cell-mediated immune response against mycolic acids of Mycobacteroides salmoniphilum in rainbow trout Oncorhynchus mykiss.

Mycobacteriosis caused by Mycobacterium spp. causes economic damages to the world aquaculture industry. In mammals, mycolic acids contained in the cell wall of Mycobacterium spp. are presented by CD1b molecule as lipid antigens and induce cell-mediated immunity (CMI). Here, we investigated CMI responses against the mycolic acids of Mycobacterioides salmoniphilum in a CD1-lacking teleost fish, rainbow trout. After stimulation of trout leukocytes with mycolic acids, the number and percentage of CD8α+ T cells increased. Fish immunized with mycolic acids showed an up-regulation of IFN-γ. Further, in vitro re-stimulation of leukocytes derived from immunized fish resulted in proliferation of CD8α+ cells. These data suggest that mycolic acids are recognized as lipid antigens resulting in an activation of rainbow trout CD8α+ cells and up-regulation of the Th1 cytokine IFN-γ. The mycolic acids are promising candidates for vaccines to activate CD8α+ T cells against fish mycobacteriosis.

Removal of Trace Organic Contaminants by Parallel Operation of Reverse Osmosis and Granular Activated Carbon for Drinking Water Treatment.

In response to increasingly stringent restrictions for drinking water quality, a parallel operation of two common technologies, low-pressure reverse osmosis (LPRO) and activated carbon filtration (ACF), was investigated in a comprehensive five-month pilot study for the removal of 32 typical trace organic contaminants (TrOCs) from Rhine bank filtrates employing a semi- technical plant. TrOCs have been divided into three groups: polyfluorinated aliphatic compounds; pharmaceuticals, pesticides and metabolites; in addition to volatiles, nitrosamines and aminopolycarboxylic acids, which were also examined. The net pressure behavior, normalized salt passage and rejection of TrOCs by LPRO were investigated and compared with ACF operation. In addition, autopsies from the leading and last membrane modules were performed using adenosine triphosphate (ATP), total organic carbon (TOC), ICP-OES and SEM-EDX techniques. Generally, rather stable LPRO membrane performance with limited membrane fouling was observed. TrOCs with a molecular weight of ≥ 150 Da were completely retained by LPRO, while the rejection of di- and trichloro compounds improved as the filtration progressed. ACF also showed significant removal for most of the TrOCs, but without desalination. Accordingly, the ACF and LPRO can be operated in parallel such that the LPRO permeate and the ACF-treated bypass can be mixed to produce drinking water with adjustable hardness and significantly reduced TrOCs.

Lower Extremity Revascularization for Chronic Limb-Threatening Ischemia among Patients at the Extremes of Age.

BACKGROUND: Patients with chronic limb-threatening ischemia (CLTI) at the extremes of age are thought to have distinct risk factor profiles and poor outcomes after lower extremity revascularization (LER). The aim of this study is to examine the relationships among age, risk factor profiles, and outcomes of LER in patients with CLTI in a large database focusing on the extreme age groups. METHODS: Patients undergoing LER for CLTI in the Vascular Quality Initiative suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention files were reviewed through 2019. Patients were stratified into 3 groups: premature peripheral artery disease (PAD) (≤50 years old), 51-84 years old, and elderly (≥85 years old). Trends in major amputation and mortality by age group were analyzed. RESULTS: There were 156,513 patients who underwent LER for CLTI. Of these, 9,063 (5.79%) patients had premature PAD, 131,694 (84.14%) patients were 51-84 years old, and 15,756 (10.07%) were elderly. Patients with premature PAD were more likely to have insulin-dependent diabetes, be dialysis-dependent, and be active smokers compared to patients 51-84 years old and the elderly. Elderly patients were more likely to undergo an endovascular procedure for tissue loss compared to younger groups. Perioperative and 1-year major amputation rates were highest among patients with premature PAD and decreased with increasing age (P < 0.001), while perioperative and 1-year mortality increased with age (P < 0.001). On multivariable analysis, premature PAD was associated with an increased risk of major amputation (odds ratio, OR = 1.41 [1.22-1.62]), while elderly age was associated with decreased odds of major amputation compared to patients 51-84 years old (OR = 0.61 [0.51-0.73]). CONCLUSIONS: Patients at the extremes of age have significantly different outcomes after LER for CLTI. Although mortality increases with age, the risk of major amputation decreases. Patients with premature PAD constitute a group of patients with a high risk of perioperative and 1-year major amputation.

Multiple duplications of the superficial femoral artery - Case report and review of the literature.

OBJECTIVES: Lower extremity arterial anatomic variations are rare, with duplication of the superficial femoral artery being an extremely uncommon variant with few prior reports in the literature.Methods/Results: We report the case of a 68-year-old male with calf claudication who underwent angiography and was found to have two separate areas of vessel duplication along the superficial femoral artery, which has not previously been described in the literature. CONCLUSION: Although uncommon, recognition of a duplicated superficial femoral artery is important to avoid difficulties and complications that may arise during open or endovascular procedures.

Telemedicine platforms and their use in the coronavirus disease-19 era to deliver comprehensive vascular care.

Implementation of telemedicine for patient encounters optimizes personal safety and allows for continuity of patient care. Embracing telehealth reduces the use of personal protective equipment and other resources consumed during in-person visits. The use of telehealth has increased to historic levels in response to the coronavirus disease 2019 (COVID-19) pandemic. Telehealth may be a key modality to fight against COVID-19, allowing us to take care of patients, conserve personal protective equipment, and protect health care workers all while minimizing the risk of viral spread. We must not neglect vascular health issues while the coronavirus pandemic continues to flood many hospitals and keep people confined to their homes. Patients are not immune to diseases and illnesses such as stroke, critical limb ischemia, and deep vein thrombosis while being confined to their homes and afraid to visit hospitals. Emerging from the COVID-19 crisis, incorporating telemedicine into routine medical care is transformative. By leveraging digital technology, the authors discuss their experience with the implementation, workflow, coding, and reimbursement issues of telehealth during the COVID-19 era.

Cellular Immune Responses in Rainbow Trout (Onchorhynchus mykiss) Following Vaccination and Challenge Against Salmonid Alphavirus (SAV).

Viral disease outbreaks remain a significant limiting factor for aquaculture. The majority of licensed vaccines used in the industry are administered as oil-adjuvanted formulations carrying inactivated whole pathogens. Cell-mediated immune responses, in particular those based on virus-specific cytotoxic T-cells (CTLs) to conventional inactivated oil-based vaccines, are largely unexplored. As vaccines cannot be optimized against viral pathogens if knowledge of host cellular immune mechanisms remains unknown, in this study we examined fundamental cell-mediated immune responses after vaccination of rainbow trout with an oil-adjuvanted inactivated vaccine against salmonid alphavirus (SAV) and after infection with SAV. A unique in vitro model system was developed to examine MHC class I restricted CTL responses in a clonal line of rainbow trout. The levels of cell-mediated cytotoxicity were compared to pathology, virus load, specific antibody response, changes in immune cell populations, and mRNA expression. Our results hint that different protective mechanisms are being triggered by infection compared to vaccination. While vaccination itself did not cause a strong cytotoxic or humoral response, subsequent challenge of vaccinated fish resulted in significantly stronger and faster specific cytotoxicity, alongside reduced viral titers and pathology. Hence, testing a vaccine on the capacity to induce cell-mediated cytotoxicity will still require a challenge test. Examination of cellular markers additionally indicates that the initial innate response induced by the vaccine could play an important role in steering adaptive mechanisms.

Ancient Cytokine Interleukin 15-Like (IL-15L) Induces a Type 2 Immune Response.

Related interleukin-2, -15, and -15-like (IL-2, -15, and -15L) are ancient cytokines, with all three genes surviving in extant fish and some mammals. The present study is the first to identify IL-15L functions, namely in rainbow trout. In isolated trout splenocytes, and in vivo, purified recombinant IL-15L+IL-15Rα molecules induced expression of IL-4 and IL-13 homologs, which are markers of type 2 immunity. In contrast, trout IL-15 stimulated type 1 immunity markers, thus IL-15 and IL-15L can have opposing functions. Trout IL-15L was more dependent on "in trans" presentation by the receptor chain IL-15Rα than IL-15, and stimulated CD4-CD8-(IgM-) lymphocytes from thymus and spleen. We propose an important role for IL-15L early in the type 2 immunity cytokine cascade. Trout IL-2 and IL-15 exhibited features reminiscent of their mechanistic and functional dichotomy observed in mammals; for example, IL-15 but not IL-2 required a receptor alpha chain (only IL-15Rα in the case of fish) for its stability, and only IL-15 was efficient in stimulating lymphocytes from mucosal tissues. Data suggest that IL-15L and IL-15 may be particularly effective in stimulating innate lymphocyte type 2 cells (ILC2) and natural killer (NK) cells, respectively, but further identification of the cell types is needed. An interesting finding different from in mammals was the efficient stimulation of CD4+CD8+ thymocytes by IL-2. In short, this study presents fundamental information on the evolution of the IL-2/15/15L cytokine family.