Critical limb-threatening ischaemia and microvascular transformation: clinical implications.

BACKGROUND AND AIMS: Clinical management of critical limb-threatening ischaemia (CLTI) is focused on prevention and treatment of atherosclerotic arterial occlusions. The role of microvascular pathology in disease progression is still largely unspecified and more importantly not utilized for treatment. The aim of this explorative study was to characterize the role of the microvasculature in CLTI pathology. METHODS: Clinical high-resolution imaging of CLTI patients (n = 50) and muscle samples from amputated CLTI limbs (n = 40) were used to describe microvascular pathology of CLTI at the level of resting muscle blood flow and microvascular structure, respectively. Furthermore, a chronic, low arterial driving pressure-simulating ischaemia model in rabbits (n = 24) was used together with adenoviral vascular endothelial growth factor A gene transfers to study the effect of microvascular alterations on muscle outcome. RESULTS: Resting microvascular blood flow was not depleted but displayed decreased capillary transit time (P < .01) in CLTI muscles. Critical limb-threatening ischaemia muscle microvasculature also exhibited capillary enlargement (P < .001) and further arterialization along worsening of myofibre atrophy and detaching of capillaries from myofibres. Furthermore, CLTI-like capillary transformation was shown to worsen calf muscle force production (P < .05) and tissue outcome (P < .01) under chronic ischaemia in rabbits and in healthy, normal rabbit muscle. CONCLUSIONS: These findings depict a progressive, hypoxia-driven transformation of the microvasculature in CLTI muscles, which pathologically alters blood flow dynamics and aggravates tissue damage under low arterial driving pressure. Hypoxia-driven capillary enlargement can be highly important for CLTI outcomes and should therefore be considered in further development of diagnostics and treatment of CLTI.

Friendly Neck Anatomy Does Not Prevent Neck-Related Adverse Events After EVAR.

BACKGROUND: Life-long follow-up after endovascular aneurysm repair (EVAR) is costly and burdensome to the patient. Follow-up should be stratified based on the risk of EVAR failure. Aneurysm neck is thought to be the single most important risk factor. This study investigated neck anatomy as a predictor of neck-related adverse events after EVAR. METHODS: This retrospective single-center study included consecutive patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms between 2011 and 2016 (n = 222) who were followed with yearly imaging until December 2020. Hostile neck was defined as neck length ≤15 mm, width ≥28 mm, angulation ≥60°, calcification, or thrombus ≥50% of circumference or conical neck based on preoperative computed tomography angiography. Neck-related adverse event was defined as aneurysm rupture, any neck-related reintervention or type 1a endoleak during follow-up. RESULTS: Ninety (41%) patients had hostile neck and 132 (59%) had friendly neck. There were no differences in 30-day mortality (1% vs. 1%, P = 0.78), major adverse events (20% vs. 16%, P = 0.43) or reinterventions during the hospital stay (8% vs. 4%, P = 0.20) between patients with hostile and friendly neck. Estimated survival at 1 year was 89 ± 3% for hostile neck and 95 ± 2% for friendly neck patients (P < 0.01). Five-year survival estimates were 51 ± 6% and 66 ± 4%, respectively. Aneurysm-related mortality was higher after 6 years in patients with hostile neck (P < 0.01). Twenty-four patients (11%) suffered neck-related adverse events with mean time-to-event of 3.3 ± 2.8 years; there were no differences between the groups stratified by neck anatomy. Incidentally, preoperative aneurysm diameter was found to be an independent risk factor for neck-related adverse events and aneurysm-related mortality; 53 patients (24%) had aneurysm diameter ≥70 mm, which was associated with nearly 4-fold risk of neck-related complications during the follow-up. CONCLUSIONS: Friendly neck anatomy may not protect from neck-related adverse events after EVAR in the long-term. Especially patients with large aneurysms should be followed closely.

Radiographically quantified sarcopenia and traditional cardiovascular risk assessment in predicting long-term mortality after endovascular aortic repair.

OBJECTIVE: This study evaluated radiographically quantified sarcopenia and the patient's comorbidity burden based on traditional cardiovascular risk assessment as potential predictors of long-term mortality after endovascular aortic repair (EVAR). METHODS: The study included 480 patients treated with standard EVAR for intact infrarenal abdominal aortic aneurysms. Patient characteristics, comorbidities, aneurysm dimensions, and other preoperative risk factors were collected retrospectively. Preoperative computed tomography was used to measure psoas muscle area (PMA) at the L3 level. Patients were divided into three groups based on American Society of Anesthesiologists (ASA) score and PMA. In the high-risk group, patients had sarcopenia (PMA <8.0 cm2 for males and <5.5 cm2 for females) and an ASA score of 4. In the medium-risk group, patients had either sarcopenia or an ASA score of 4. Patients in the low-risk group had no sarcopenia and the ASA score was less than 4. Risk factors for long-term mortality were determined using multivariable analysis. Kaplan-Meier survival estimates were calculated for all-cause mortality. RESULTS: Patients in the high- and medium-risk groups were older than those in the low-risk group (77 ± 7, 76 ± 6, and 74 ± 8 years, respectively, P < .01). Patients in the high-risk group had higher prevalence of coronary artery disease, pulmonary disease, and chronic kidney disease. There were no differences in 30-day or 90-day mortality between the groups. The independent predictors of long-term mortality were age, ASA score, PMA, chronic kidney disease, and maximum aneurysm sac diameter. The estimated 1-year mortality rates were 5% ± 2% for the low-risk, 5% ± 2% for the medium-risk, and 18% ± 5% for the high-risk group (P < .01). Five-year mortality estimates were 23% ± 4%, 36% ± 3%, and 60% ± 6%, respectively (P < .01). The mean follow-up time was 5.0 ± 2.8 years. CONCLUSIONS: Both ASA and PMA were strong predictors of increased mortality after elective EVAR. The combination of these two can be used as a simple risk stratification tool to identify patients in whom aneurysm repair or the intensive long-term surveillance after EVAR may be unwarranted.

Long-term outcome over a decade after first rib resection for neurogenic thoracic outlet syndrome.

OBJECTIVES: The aim was to determine long-term outcomes over a decade after first rib resection (FRR) in patients with neurogenic thoracic outlet syndrome (NTOS). A secondary aim was to investigate correlation of residual rib stump with long-term symptoms. METHODS: This ambispective cohort included patients who underwent transaxillary FRRs for NTOS between 1998 and 2007. Short-term outcomes at 3-month clinical follow-up were retrospectively collected from medical records. Patients who agreed to participate in the study were invited to a long-term clinical follow-up in 2019. Disabilities of Arm, Shoulder, and Hand Score and Cervical Brachial Symptom Questionnaire were used. A chest X-ray limited to a clavicular projection was taken, and the length of the residual first rib was measured. RESULTS: Twenty patients {mean age 41.8 [standard deviation (SD): 10.3 years]} who underwent 27 FRRs participated in the study. The mean follow-up time was 14.9 (SD: 3.6) years. Excellent or good recovery was noted after 16 (59.3% of operated arms) operations in the short-term follow-up and 22 (81.5%) operations in the long-term follow-up. No reoperations were necessary for residual symptoms. The mean Cervical Brachial Symptom Questionnaire score was 26.7 (SD: 28.2) (maximum 120), and the Disabilities of Arm, Shoulder, and Hand Score was 21.1 (SD: 18.4) (maximum 100) points. Twenty-six patients (96.3%) had a noticeable residual first rib stump. The mean length of the residual first rib was 28.9 (SD: 9.5) mm. More than 30-mm rib stump did not indicate a worse long-term outcome. CONCLUSIONS: This study showed good long-term outcome without symptom recurrence after FRR for NTOS. In most patients, after surgery, quality of life and ability to work improved. Residual rib stump length was not associated with the treatment outcome.

Patient Self-Assessment and Acoustic Voice Analysis in Screening of Postoperative Vocal Fold Paresis and Paralysis.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the utility of two items in vocal fold paresis and paralysis screening after thyroid and parathyroid surgery: patient self-assessment of voice using the Voice Handicap Index and computer-based acoustic voice analysis using the Multi-Dimensional Voice Program. METHODS: This was a prospective study of 181 patients who underwent thyroid or parathyroid surgery over a 1-year study period (2017). Preoperatively, all patients underwent laryngoscopic vocal fold inspection and acoustic voice analysis, and they completed the Voice Handicap Index questionnaire. Postoperatively, all patients underwent laryngoscopy prior to hospital discharge; 2 weeks after the surgery, they completed the Voice Handicap Index questionnaire a second time. Two weeks postoperatively, patients with vocal fold paresis or paralysis and 20 randomly selected controls without vocal fold paresis or paralysis underwent a follow-up acoustic voice analysis. RESULTS: Fourteen patients had a new postoperative vocal fold paresis or paralysis. Postoperatively, the total Voice Handicap Index score was significantly higher (p = 0.040) and the change between preoperative and postoperative scores was greater (p = 0.028) in vocal fold paresis or paralysis patients. A total postoperative Voice Handicap Index score > 30 had 55% sensitivity, and 90% specificity, for vocal fold paresis or paralysis. In the postoperative Multi-Dimensional Voice Program analysis, vocal fold paresis or paralysis patients had significantly more jitter (p = 0.044). Postoperative jitter > 1.33 corresponded to 55% sensitivity, and 95% specificity, for vocal fold paresis or paralysis. CONCLUSIONS: In identifying postoperative vocal fold paresis or paralysis, patient self-assessment and jitter in acoustic voice analysis have high specificity but poor sensitivity. Without routine laryngoscopy, approximately half of the patients with postoperative vocal fold paresis or paralysis could be overlooked. However, if the patient has no complaints of voice disturbance 2 weeks after thyroid or parathyroid surgery, the likelihood of vocal fold paresis or paralysis is low.

Perceptual Assessment and Acoustic Voice Analysis as Screening Tests for Vocal Fold Paresis After Thyroid or Parathyroid Surgery.

BACKGROUND: The aim of this study was to evaluate the reliability of clinician-based perceptual assessment of voice and computerized acoustic voice analysis as screening tests for vocal fold paresis or paralysis (VFP) after thyroid and parathyroid surgery. METHODS: This was a prospective study of 181 patients undergoing thyroid or parathyroid procedure with pre and postoperative laryngoscopic vocal fold inspection, perceptual voice assessment using grade, roughness, breathiness, asthenia, and strain (GRBAS) scale and acoustic voice analysis using the multi-dimensional voice program (MDVP). Patients were divided into 2 groups for comparison; those with new postoperative VFP and those without. Potential screening tools were evaluated using the receiving operating characteristic (ROC) analysis. RESULTS: Fourteen (6.6%) patients had a new postoperative VFP. Postoperative GRBAS scores were significantly (P < 0.05) higher in patients with VFP compared to those without. However, there were no statistically significant differences in MDVP values between the groups. Postoperative GRBAS grade score (cut off > 0) had the best sensitivity, 93%, for predicting VFP, but the specificity was only 50%. Postoperative jitter (cut off > 1.60) in MDVP had a good specificity, 90%, but only 50% sensitivity. Combining all the GRBAS and MDVP variables with P < 0.05 in the ROC analysis yielded a test with 100% sensitivity and 55% specificity. CONCLUSIONS: Physician-based perceptual voice assessment has a high sensitivity for detecting postoperative VFP, but the specificity is poor. The risk of VFP is low in patients with completely normal voice at discharge. However, routine laryngoscopy after thyroid and parathyroid surgery is still the most reliable exam for VFP screening.

Treatment With FoxP3+ Antigen-Experienced T Regulatory Cells Arrests Progressive Retinal Damage in a Spontaneous Model of Uveitis.

We specify the clinical features of a spontaneous experimental autoimmune uveitis (EAU) model, in which foreign hen-egg lysozyme (HEL) is expressed in the retina, controlled by the promoter for interphotoreceptor retinol binding protein (IRBP). We previously reported 100% P21 (post-partum day) IRBP:HEL single transgenic (sTg) mice, when crossed to transgenic T cell receptor mice (3A9) generating the double transgenic (dTg) genotype, develop EAU despite profound lymphopenia (thymic HEL-specific T cell deletion). In this work, we characterized the immune component of this model and found conventional dTg CD4+ T cells were less anergic than those from 3A9 controls. Furthermore, prior in vitro HEL-activation of 3A9 anergic T cells (Tan) rendered them uveitogenic upon adoptive transfer (Tx) to sTg mice, while antigen-experienced (AgX, dTg), but not naïve (3A9) T cells halted disease in P21 dTg mice. Flow cytometric analysis of the AgX cells elucidated the underlying pathology: FoxP3+CD25hiCD4+ T regulatory cells (Treg) comprised ∼18%, while FR4+CD73+FoxP3-CD25lo/-CD4+ Tan comprised ∼1.2% of total cells. Further Treg-enrichment (∼80%) of the AgX population indicated FoxP3+CD25hiCD4+ Treg played a key role in EAU-suppression while FoxP3-CD25lo/-CD4+ T cells did not. Here we present the novel concept of dual immunological tolerance where spontaneous EAU is due to escape from anergy with consequent failure of Treg induction and subsequent imbalance in the [Treg:Teffector] cell ratio. The reduced numbers of Tan, normally sustaining Treg to prevent autoimmunity, are the trigger for disease, while immune homeostasis can be restored by supplementation with AgX, but not naïve, antigen-specific Treg.

Effect of Endovascular Treatment Rate on Population Level Outcomes and Survival After Intact Abdominal Aortic Aneurysm Repair.

OBJECTIVES: The aim was to study outcomes of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in four geographically adjacent populations with identical demographics and variable EVAR rates. METHODS: This was a multicentre cohort study based on local and national registry data from an area of 815 000 inhabitants. The study involved 527 consecutive patients with an intact AAA treated with EVAR (n = 327) or OSR (n = 200) between 2010 and 2016. The catchment area was divided into four health care districts (populations A, B, C, and D) with one central hospital in each district. Each hospital decided independently between OSR and EVAR for patients within their population; OSR was performed in all hospitals while EVAR was centralised in one of them. Patient demographics and treatment outcomes were extracted from local registries. Population demographics, overall AAA incidence, and mortality data were retrieved from a national database. RESULTS: The rate of new intact AAA diagnosis varied between 20 and 29 per 100 000 inhabitants/year with the highest incidence in population D (p < .001). The intact AAA repair rates were 9.8, 8.9, 9.9, and 8.7 per 100 000 inhabitants/year for populations A, B, C, and D, respectively (p = .64). There were no significant differences in mean age (73.6 ± 8.0 years) or mean aortic diameter (62 ± 13 mm) between the treated patient populations. Groups A and B had high EVAR rates (74% and 72%, respectively) whereas the EVAR rates were lower in groups C and D (50% and 38%, respectively) (p < .001). The 30 day mortality rates were 2%, 2%, 4%, and 1% (p = .55), and complication rates were 17%, 12%, 15%, and 11% (p = .39) for A, B, C and D, respectively. There were no significant differences in mortality, complication or re-intervention rates between the groups during the mean follow up of 3.3 ± 2.0 years. CONCLUSIONS: At population level, high EVAR rates had no measurable effect compared with lower EVAR rates on the outcomes in patients with intact AAA.

Preterm Birth: A Narrative Review of the Current Evidence on Nutritional and Bioactive Solutions for Risk Reduction.

Preterm birth (PTB) (<37 weeks of gestation) is the leading cause of newborn death and a risk factor for short and long-term adverse health outcomes. Most cases are of unknown cause. Although the mechanisms triggering PTB remain unclear, an inappropriate increase in net inflammatory load seems to be key. To date, interventions that reduce the risk of PTB are effective only in specific groups of women, probably due to the heterogeneity of its etiopathogenesis. Use of progesterone is the most effective, but only in singleton pregnancies with history of PTB. Thus, primary prevention is greatly needed and nutritional and bioactive solutions are a promising alternative. Among these, docosahexaenoic acid (DHA) is the most promising to reduce the risk for early PTB. Other potential nutrient interventions include the administration of zinc (possibly limited to populations with low nutritional status or poor zinc status) and vitamin D; additional preliminary evidence exists for vitamin A, calcium, iron, folic acid, combined iron-folate, magnesium, multiple micronutrients, and probiotics. Considering the public health relevance of PTB, promising interventions should be studied in large and well-designed clinical trials. The objective of this review is to describe, summarize, and discuss the existing evidence on nutritional and bioactive solutions for reducing the risk of PTB.

Incidence, Risk Factors, and Natural Outcome of Vocal Fold Paresis in 920 Thyroid Operations with Routine Pre- and Postoperative Laryngoscopic Evaluation.

BACKGROUND: The aim of this study was to determine the incidence, risk factors, and spontaneous recovery rate of vocal fold paresis (VFP) with routine laryngoscopy before and after thyroid surgery. METHODS: All consecutive patients undergoing primary or redo thyroid surgery between years 2011-2016 were prospectively registered in an electronic database, and scheduled for pre- and postoperative laryngoscopic vocal fold inspection by otolaryngologists independently of the surgical team. RESULTS: A total of 920 thyroid operations with 1296 nerves at risk were performed in 866 patients. Pre- and postoperative laryngoscopy was done in 95% and 98%, respectively. Preoperative VFP was detected in 24 (2.8%) patients. New postoperative VFP was found in 53 of 920 operations (5.8%) and in 55 of 1296 nerves at risk (4.2%). After 12 months, 14 had recovered full vocal fold function and eight had near-complete recovery. VFP was permanent after 29 operations (3.2%); two patients were lost to follow-up with uncertain outcome. Of the 1296 nerves at risk, injury was permanent in 30 (2.3%). In multivariate analysis, patients operated for recurrent goiter had nearly nine times higher risk of new VFP (23% rate), whereas patients with malignant histology had three times higher risk of postoperative VFP (up to 22% rate). CONCLUSION: VFP continues to be a serious complication of thyroid surgery, especially in operations for redo goiter and thyroid malignancy. The incidence of VFP may be underestimated unless laryngoscopic examinations are performed routinely.

Partial retinal photoreceptor loss in a transgenic mouse model associated with reduced levels of interphotoreceptor retinol binding protein (IRBP, RBP3).

Organ-specific transgenic membrane expression of hen egg lysozyme (HEL) as a "neo-self antigen" has been used in several models to study immunological tolerance. In this study we report the changes which occur in the B10.BR mouse retina when membrane-bound HEL is expressed in photoreceptors under the control of the promoter for interphotoreceptor retinoid binding protein (IRBP, RBP3). On direct clinical examination of the single transgenic (sTg-IRBP:HEL) mouse fundus, a low-level increase in retinal degeneration compared to non-transgenic controls was observed, presenting as drusenoid deposits and occasional small patches of atrophy. On histological examination, there was an overall shortening of outer segments and loss of photoreceptor nuclei in sTg-IRBP:HEL mice, which was more pronounced in the retinal periphery, particularly inferiorly. The fundoscopically observed lesions did not correlate with the photoreceptor shortening/loss but appeared to be located at the level of the retinal pigment epithelium/choriocapillaris layer and were an exaggeration in size and number of similar age-related changes found in wild type (WT) mice. In addition, neither the atrophic lesions nor the photoreceptor shortening were associated with common retinal degeneration genes, nor were they caused by exposure to light damage since mice housed at both high and low ambient light levels had similar degrees of retinal degeneration. Instead, sTg-IRBP:HEL mice expressed reduced levels of soluble retinal IRBP compared to WT mice which were present from postnatal day16 (P16) and preceded development of photoreceptor shortening (onset P21). We propose that insertion of the HEL transgene in the photoreceptor membrane disrupted normal photoreceptor function and led to reduced levels of soluble IRBP and retinal thinning. A similar phenotype has been observed in IRBP deficient mice. Despite the retinal thinning, the amount of HEL expressed in the retina was sufficient to act as an autoantigenic target when the mice were crossed to the HEL T cell receptor Tg mouse, since double transgenic (dTg-IRBP:HEL) mice spontaneously developed a severe uveoretinitis with onset at weaning. We suggest that, although membrane expression of foreign transgene products is likely to modify the structure and function of tissues and cells, the technology provides useful models to investigate mechanisms of antigen-specific immunological tolerance.

Thoracoscopic Versus Transaxillary Approach to First Rib Resection in Thoracic Outlet Syndrome.

BACKGROUND: This study assessed the feasibility of fully endoscopic thoracoscopic first rib resection (FRR) in the treatment of neurogenic thoracic outlet syndrome by comparing early outcomes of the thoracoscopic technique against the traditional transaxillary FRR. METHODS: Between 2009 and 2016, 60 consecutive FRRs were performed on 47 patients with neurogenic thoracic outlet syndrome (13 bilateral procedures). The first 30 procedures were performed using the traditional transaxillary technique, and the novel thoracoscopic technique was used in the next 30 operations with the same indications for operative repair. All data were collected retrospectively by independent investigators. The main issues were operation time, learning curve, hospital length of stay, complications, and clinical follow-up status at 3 months. RESULTS: The groups were similar at baseline. The mean operation time was 83 ± 27 minutes in the thoracoscopic group and 48 ± 12 minutes in the transaxillary group (p < 0.001). The first thoracoscopic procedures were 2 hours long, after which, a steady 1-hour procedure time was achieved. Differences regarding the hospital stay or the need for postoperative pain medication were not significant. Two-thirds reported good or excellent recovery at follow-up in both groups. There were no immediate complications. Plexus neuralgia developed in 1 patient 3 weeks after the thoracoscopic operation, and 3 patients were diagnosed with superficial wound infection after the transaxillary procedure. CONCLUSIONS: This study showed that FRR for neurogenic thoracic outlet syndrome can be done safely with a fully endoscopic approach. However, the technique requires experience with thoracoscopic surgery, and there is a learning curve to the procedure.

Ocular antigen does not cause disease unless presented in the context of inflammation.

Ocular antigens are sequestered behind the blood-retina barrier and the ocular environment protects ocular tissues from autoimmune attack. The signals required to activate autoreactive T cells and allow them to cause disease in the eye remain in part unclear. In particular, the consequences of peripheral presentation of ocular antigens are not fully understood. We examined peripheral expression and presentation of ocular neo-self-antigen in transgenic mice expressing hen egg lysozyme (HEL) under a retina-specific promoter. High levels of HEL were expressed in the eye compared to low expression throughout the lymphoid system. Adoptively transferred naïve HEL-specific CD4+ T cells proliferated in the eye draining lymph nodes, but did not induce uveitis. By contrast, systemic infection with a murine cytomegalovirus (MCMV) engineered to express HEL induced extensive proliferation of transferred naïve CD4+ T cells, and significant uveoretinitis. In this model, wild-type MCMV, lacking HEL, did not induce overt uveitis, suggesting that disease is mediated by antigen-specific peripherally activated CD4+ T cells that infiltrate the retina. Our results demonstrate that retinal antigen is presented to T cells in the periphery under physiological conditions. However, when the same antigen is presented during viral infection, antigen-specific T cells access the retina and autoimmune uveitis ensues.

Pharmacomechanical Thrombectomy in Paget-Schroetter Syndrome.

PURPOSE: The purpose of the study was to evaluate feasibility of pharmacomechanical thrombectomy (PMT) in the treatment of Paget-Schroetter syndrome (PSS) followed by thoracoscopic or open surgical decompression of the subclavian vein. METHODS: Twenty-two out of 27 consecutive patients with PSS received PMT using the Trellis-8 peripheral infusion system (Covidien) between 2010 and 2014. Subsequent surgery was performed in 18 of those patients, 9 patients were treated with thoracoscopic, 7 patients with subclavicular, and 2 patients with transaxillary first rib resection, 4 patients were treated with PMT and anticoagulation alone. Technical success, complications, and patency were registered. RESULTS: PMT was successful in 21 (95 %) patients; 1 patient with unsatisfactory lysis received further catheter-directed thrombolysis, which, however, did not improve the result. The mean endovascular procedure time was 105 ± 33 min (range 70-200 min), and the required median amount of thrombolytic agent was 500,000 international unit (IU; range 250,000-1,000,000 IU). Adjunctive balloon venoplasty and aspiration were used in 18 (82 %) and 7 (32 %) cases, respectively. One patient had an intimal tear of the subclavian vein that was discovered and repaired during surgery. There were no other complications related to the endovascular procedure. At follow-up, 18 of 21 patients (86 %) with follow-up imaging available had patent subclavian vein, and all except 1 of the 22 patients were asymptomatic. The mean follow-up time was 25 ± 17 months. CONCLUSIONS: In experienced hands, PMT is effective for early thrombus removal in PSS. Surgical decompression must be considered after PMT.

Global DNA methylation analysis of human atherosclerotic plaques reveals extensive genomic hypomethylation and reactivation at imprinted locus 14q32 involving induction of a miRNA cluster.

AIMS: We conducted a genome-wide analysis to identify differentially methylated genes in atherosclerotic lesions. METHODS: DNA methylation at promoters, exons and introns was identified by massive parallel sequencing. Gene expression was analysed by microarrays, qPCR, immunohistochemistry and western blots. RESULTS: Globally, hypomethylation of chromosomal DNA predominates in atherosclerotic plaques and two-thirds of genes showing over 2.5-fold differential in DNA methylation are up-regulated in comparison to healthy mammary arteries. The imprinted chromatin locus 14q32 was identified for the first time as an extensively hypomethylated area in atherosclerosis with highly induced expression of miR127, -136, -410, -431, -432, -433 and capillary formation-associated gene RTL1. The top 100 list of hypomethylated promoters exhibited over 1000-fold enrichment for miRNAs, many of which mapped to locus 14q32. Unexpectedly, also gene body hypermethylation was found to correlate with stimulated mRNA expression. CONCLUSION: Significant changes in genomic methylation were identified in atherosclerotic lesions. The most prominent gene cluster activated via hypomethylation was detected at imprinted chromosomal locus 14q32 with several clustered miRNAs that were up-regulated. These results suggest that epigenetic changes are involved in atherogenesis and may offer new potential therapeutic targets for vascular diseases.

Preoperative white matter lesions are independent predictors of long-term survival after internal carotid endarterectomy.

BACKGROUND: Cerebral white matter lesions (WMLs) predict long-term survival of conservatively treated acute stroke patients with etiology other than carotid stenosis. In carotid endarterectomy patients, WMLs are associated with severe carotid stenosis and unstable plaques, with the risk of perioperative complications and with increased 30-day perioperative risk of death. However, no data exist on their effect on postoperative long-term survival, a factor important when considering the net benefit from carotid endarterectomy. Whether this effect is independent of classical risk factors and indications for surgery is not known either. We hypothesized that WMLs could be evaluated from preoperative routine computed tomography (CT) scans and are predictors of postoperative survival, independent of classical cardiovascular risk factors, indication category and degree of carotid stenosis. METHODS: A total of 353 of 481 (73.4%) consecutive patients subjected to carotid endarterectomy due to different indications, i.e. asymptomatic stenosis (n = 28, 7.9%), amaurosis fugax (n = 52, 14.7%), transient ischemic attack (n = 135, 38.2%) or ischemic stroke (n = 138, 39.1%), from prospective vascular registries during the years 2001-2010 with digital preoperative CT scans, were included in the study. WMLs were rated by a radiologist (Wahlund criteria) in a blinded fashion. Internal carotid artery (ICA) stenoses were angiographically graded (<50, 50-69, 70-99 and 100%). Odds ratios (ORs) and hazard ratios (HRs) are reported (ORs and HRs ≤1 indicate a beneficial effect). The median follow-up time was 67 months (interquartile range 45.5, range 0-129 months). Spearman's rho was used to estimate intraobserver agreement. Binary logistic regression was performed to analyze the association of risk factors with WMLs. Cox regression proportional hazards analysis was used to study the effect of different factors on survival. RESULTS: WML severity could be assessed with a substantial intraobserver agreement (Spearman's rho 0.843, p < 0.0001). Only age (OR 1.10, 95% CI 1.06-1.15; p < 0.0001 per year), degree of ipsilateral ICA stenosis (OR 2.22, 95% CI 1.08-4.55; p < 0.05 per stenosis grade) and indication category (OR 1.63, 95% CI 1.19-2.24; p < 0.01 per category) remained independently associated with WMLs. Age (HR 1.04, 95% CI 1.01-1.08; p < 0.05 per year), diabetes (HR 1.59, 95% CI 1.01-2.49; p < 0.05), peripheral arterial disease (HR 2.47, 95% CI 1.46-4.15; p < 0.01), degree of ipsilateral ICA stenosis (HR 2.56, 95% CI 1.12-5.87; p < 0.05 per stenosis grade) and WMLs (HR 3.83, 95% CI 1.17-12.5; p < 0.05) remained independently associated with increased long-term mortality. CONCLUSIONS: WMLs in a preoperative CT scan provide a substantially reliable estimate of postoperative long-term survival of carotid endarterectomy patients independent of currently used criteria, i.e. cardiovascular risk factors, indication category and degree of ipsilateral ICA stenosis.

Effect of probiotic fermented milk on blood pressure: a meta-analysis of randomised controlled trials.

Previous studies have suggested that probiotic fermented milk may possess blood pressure (BP)-lowering properties. In the present study, we aimed to systematically examine the effect of probiotic fermented milk on BP by conducting a meta-analysis of randomised controlled trials. PubMed, Cochrane library and the ClinicalTrials.gov databases were searched up to March 2012 to identify eligible studies.The reference lists of the obtained articles were also reviewed. Either a fixed-effects or a random-effects model was used to calculate the combined treatment effect. Meta-analysis of fourteen randomised placebo-controlled trials involving 702 participants showed that probiotic fermented milk, compared with placebo, produced a significant reduction of 3·10 mmHg (95% CI 24·64, 21·56) in systolic BP and 1·09 mmHg (95% CI 22·11, 20·06) in diastolic BP. Subgroup analyses suggested a slightly greater effect on systolic BP in hypertensive participants than in normotensive ones (23·98 v. 22·09 mmHg). Analysis of trials conducted in Japan showed a greater reduction than those conducted in European countries for both systolic BP (26·12 v. 22·08 mmHg) and diastolic BP (23·45 v. 20·52 mmHg). Some evidence of publication bias was present, but sensitivity analysis excluding small trials that reported extreme results only affected the pooled effect size minimally. In summary, the present meta-analysis suggested that probiotic fermented milk has BP-lowering effects in pre-hypertensive and hypertensive subjects.

Recombination of replicon and helper RNAs and the emergence of propagation-competent vectors upon Sindbis virus vector production.

Sindbis vectors have shown remarkable antitumor efficacy and tumor-targeting capacity in animal models and hold promise for cancer therapy. Different packaging systems are used to produce propagation-incompetent Sindbis vectors. However, the vectors produced using either DH-BB single helper RNA or split helper RNA can spread in permissive cell cultures. We investigated the mechanisms of vector spreading and show, here, that recombination occurs between the replicon and DH-BB helper RNA, leading to formation of the full-length virus genome. Split helper RNA may not completely prevent wild-type reversion, although the frequency is greatly reduced. Contrary to propagation of Sindbis DH-BB vectors, Sindbis split helper vectors were frequently able to spread without cytopathic effect (CPE), a feature that was linked to wild-type reversion. Our results support the hypothesis that the non-cytopathic local spreading constantly observed with Sindbis split helper vector results from unspecific packaging of helper RNAs into vector particles and co-infection with particles containing replicon and helper RNAs. Several malignant cell lines with defective interferon responses were found to be permissive for non-cytopathic spreading of the Sindbis split helper vector. Interferon-α suppressed the spreading providing a possible option to control the vector.

Effect of triclosan-coated sutures on the incidence of surgical wound infection after lower limb revascularization surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. In a prospective study, triclosan-coated sutures were reported to decrease the incidence of surgical site infection after various surgical procedures. The aim of our study was to test the hypothesis that use of triclosan-coated sutures decreases the incidence of SWI after lower limb vascular surgery. METHODS: This prospective, randomized, multicenter, double-blinded trial was conducted between July 2010 and January 2011 in five hospitals in Finland. We randomly allocated 276 patients undergoing lower limb revascularization surgery to a study (n = 139) or a control (n = 137) group. Surgical wounds in the study group were closed with triclosan-coated suture material, and wounds in the control group were closed with noncoated sutures. The main outcome measure was SWI. A surgical wound complication was considered to be an infection if there were bacteria isolated from the wound or if there were areas of localized redness, heat, swelling, and pain around the wound appearing within 30 days after the operative procedure. Logistic regression analysis was used to assess the independent effect of triclosan-coated sutures on the incidence of SWI. RESULTS: Altogether, 61 (22.1 %) patients developed SWI. SWI occurred in 31 (22.3 %) patients in the study group and in 30 (21.9 %) patients in the control group (odds ratio 1.10, 95% confidence interval 0.61-2.01, p = 0.75.) CONCLUSIONS: The use of triclosan-coated sutures does not reduce the incidence of SWI after lower limb vascular surgery.

Supplemental postoperative oxygen in the prevention of surgical wound infection after lower limb vascular surgery: a randomized controlled trial.

BACKGROUND: Surgical wound infection (SWI) is a common complication after peripheral vascular surgery. Infections increase morbidity and costs of treatment. The aim of the present study was to test the hypothesis that supplemental postoperative oxygen decreases the incidence of SWI after lower limb revascularization. METHODS: This prospective, randomized, multicenter, single-blinded trial was conducted between May 2009 and February 2010 in six secondary referral hospitals in Finland. We randomly allocated 274 patients undergoing surgery for lower limb revascularization to the study group (n=137) or a control group (n=137). The study group received supplemental inspired oxygen for the first 2 days after surgery. The main outcome was SWI. Patients were followed up for 30 days or until the SWI was healed. Logistic regression analysis was used to assess the independent effect of supplemental oxygen on the incidence of SWI. RESULTS: Altogether 63 (23%) patients developed SWI; 47 (75%) of the infections were superficial. There were two vascular graft infections. SWI occurred in 25 patients (18.2%) in the study group and in 38 patients (27.7%) in the control group [odds ratio (OR) 0.56, 95% confidence interval (CI) 0.30-1.04; P=0.07]. In isolated groin incisions, 3 patients of 52 (5.8%) in the study group and 12 patients of 51 (23.5%) in the control group developed SWI; OR=0.20, 95% CI 0.04-0.95; P=0.04. CONCLUSIONS: There was an indication that supplemental inspired oxygen tended to decrease the incidence of SWI after lower limb vascular surgery. In isolated groin incisions, the decrease of SWI incidence in the supplemental oxygen group was significant.