Endovascular Embolization of Aneurysmal Renal Arteriovenous Malformation.

Renal arteriovenous malformations (AVM) represent an uncommon vascular condition characterized by an abnormal direct communication between an intrarenal artery and vein. Though asymptomatic in many individuals, treatment is often indicated if the AVM causes flank pain, hematuria, or medically refractory hypertension, or if there is an associated renal artery aneurysm. We present a case of a large right renal AVM with associated renal artery aneurysm and large varix which was incidentally found on magnetic resonance imaging of the spine. Endovascular and open surgical options were considered, including ex-vivo renal vascular reconstruction and nephrectomy. The patient was successfully treated with endovascular embolization of the AVM with coil packing of the arterial aneurysm and inflow artery. The patient recovered uneventfully with well-maintained renal function and blood pressure control. We review and discuss the literature on the etiology and treatment options for renal AVM.

Bow Hunter Phenomenon From Advanced Cerebrovascular Disease Treated With Subclavian Artery Stenting and Carotid Endarterectomy.

Bow Hunter syndrome (BHS) is a rare disorder characterized by mechanical occlusion of the vertebral artery (VA) during neck rotation, resulting in symptomatic, transient, and positional vertebrobasilar insufficiency. We describe a case of a 76-year-old female who presented with dizziness and right ear tinnitus triggered by right head rotation. Her symptoms would immediately resolve upon returning her head to the neutral position. CT angiogram showed 80% stenosis of the left subclavian artery origin, 50%-70% stenosis of the proximal right internal carotid artery (ICA), and near occlusive stenoses of the origins of the bilateral VAs. After failing conservative management, the patient was treated with left subclavian artery stenting, followed by a right carotid endarterectomy (CEA) 6 weeks later. Follow-up at 1 month showed resolution of paroxysmal symptoms and no neurological sequelae. To our knowledge, there have not yet been reported cases of patients with concurrent BHS, subclavian artery stenosis, and carotid artery stenosis. We suggest that global revascularization via subclavian artery stenting and CEA may be considered as treatment for patients with BHS complicated by other cerebrovascular disease secondary to stenoses of the ICA and subclavian artery. This approach obviates the need for more complex surgery or endovascular intervention of the VA.

Venous Stasis Ulceration due to Massive Splenomegaly Causing Iliac Vein Compression From Secondary Myelofibrosis.

Venous stasis ulcers are nonhealing lesions due to venous hypertension secondary to valvular dysfunction or deep venous outflow obstruction. We describe a case of a 71-year-old male with a history of polycythemia vera, secondary myelofibrosis, and massive splenomegaly up to 38 cm who presented with chronic, perimalleolar venous stasis ulcers and pain on the left lower extremity. CT showed significant compression of the left common iliac vein due to mass effect from the spleen. He was managed medically while being evaluated for partial splenic artery embolization but expired due to other chronic conditions before any intervention could be performed. Partial splenic artery embolization may be considered as a treatment option for patients with symptomatic iliac vein compression due to massive splenomegaly secondary to myelofibrosis, as long as extramedullary hematopoiesis is not compromised.

Killer Knots: Molecular Evolution of Inhibitor Cystine Knot Toxins in Wandering Spiders (Araneae: Ctenidae).

Venom expressed by the nearly 50,000 species of spiders on Earth largely remains an untapped reservoir of a diverse array of biomolecules with potential for pharmacological and agricultural applications. A large fraction of the noxious components of spider venoms are a functionally diverse family of structurally related polypeptides with an inhibitor cystine knot (ICK) motif. The cysteine-rich nature of these toxins makes structural elucidation difficult, and most studies have focused on venom components from the small handful of medically relevant spider species such as the highly aggressive Brazilian wandering spider Phoneutria nigriventer. To alleviate difficulties associated with the study of ICK toxins in spiders, we devised a comprehensive approach to explore the evolutionary patterns that have shaped ICK functional diversification using venom gland transcriptomes and proteomes from phylogenetically distinct lineages of wandering spiders and their close relatives. We identified 626 unique ICK toxins belonging to seven topological elaborations. Phylogenetic tests of episodic diversification revealed distinct regions between cysteine residues that demonstrated differential evidence of positive or negative selection, which may have structural implications towards the specificity and efficacy of these toxins. Increased taxon sampling and whole genome sequencing will provide invaluable insights to further understand the evolutionary processes that have given rise to this diverse class of toxins.

Multi-omic analysis of stroke recurrence in African Americans from the Vitamin Intervention for Stroke Prevention (VISP) clinical trial.

African Americans endure a nearly two-fold greater risk of suffering a stroke and are 2-3 times more likely to die from stroke compared to those of European ancestry. African Americans also have a greater risk of recurrent stroke and vascular events, which are deadlier and more disabling than incident stroke. Stroke is a multifactorial disease with both heritable and environmental risk factors. We conducted an integrative, multi-omic study on 922 plasma metabolites, 473,864 DNA methylation loci, and 556 variants from 50 African American participants of the Vitamin Intervention for Stroke Prevention clinical trial to help elucidate biomarkers contributing to recurrent stroke rates in this high risk population. Sixteen metabolites, including cotinine, N-delta-acetylornithine, and sphingomyelin (d17:1/24:1) were identified in t-tests of recurrent stroke outcome or baseline smoking status. Serum tricosanoyl sphingomyelin (d18:1/23:0) levels were significantly associated with recurrent stroke after adjusting for covariates in Cox Proportional Hazards models. Weighted Gene Co-expression Network Analysis identified moderate correlations between sphingolipid markers and clinical traits including days to recurrent stroke. Integrative analyses between genetic variants in sphingolipid pathway genes identified 29 nominal associations with metabolite levels in a one-way analysis of variance, while epigenomic analyses identified xenobiotics, predominately smoking-associated metabolites and pharmaceutical drugs, associated with methylation profiles. Taken together, our results suggest that metabolites, specifically those associated with sphingolipid metabolism, are potential plasma biomarkers for stroke recurrence in African Americans. Furthermore, genetic variation and DNA methylation may play a role in the regulation of these metabolites.

Virtual reality can reduce anxiety during office-based great saphenous vein radiofrequency ablation.

OBJECTIVE: Office-based treatment of venous pathology is common and frequently involves the use of anxiolytic medication to reduce anxiety. Virtual reality (VR) has been shown to effectively reduce pain and anxiety in a variety of settings. The objective of the present study was to determine whether VR could be smoothly integrated into office-based vascular procedures and to ascertain whether VR could reduce procedural pain or anxiety. METHODS: A total of 40 patients undergoing an office-based endovenous radiofrequency ablation were included in the present study. Of the 40 patients, 20 were randomized to the VR group and 20 to the control group. The patients in the VR group were equipped with a Samsung GearVR headset and headphones (Samsung, Suwon, South Korea) running AppliedVR software (AppliedVR Inc, Los Angeles, Calif), which ran throughout the duration of the procedure. All 40 patients underwent unilateral great saphenous vein radiofrequency ablation. After the procedure, the patients were surveyed regarding their preprocedure anxiety and their pain and anxiety during the procedure using the Wong-Baker scale. RESULTS: All procedures were successfully completed, and all patients were generally satisfied with their treatment. The average procedure time was not significantly different. No statistically significant differences were present in preprocedure anxiety or procedural pain between the two groups. The anxiety level during the procedure, however, was 4.09 of 10 in the control group vs 2.95 of 10 in the VR group, statistically significant difference using a paired t test. Furthermore, the anxiety level for the control group had increased during the procedure but that of the VR group had decreased. Finally, 85% of the patients in the VR group would recommend using VR to someone undergoing a similar procedure. CONCLUSIONS: VR can be safely and efficiently integrated into office-based vascular procedures. VR was generally well liked and recommended by those who used it. Most importantly, our findings suggest that VR can decrease procedural anxiety. Further research should examine whether this might obviate the need for anxiolytic medication.

Allocation of resources and development of guidelines for extracorporeal membrane oxygenation (ECMO): Experience from a pediatric center in the epicenter of the COVID-19 pandemic.

The rapid spread of coronavirus disease 2019 (COVID-19) has exceeded the standard capacity of many hospital systems and led to an unprecedented scarcity of resources, including the already limited resource of extracorporeal membrane oxygenation (ECMO). With the large amount of critically ill patients and the highly contagious nature of the virus, significant consideration of ECMO candidacy is crucial for both appropriate allocation of resources as well as ensuring protection of health care personnel. As a leading pediatric ECMO program in the epicenter of the pandemic, we established new protocols and guidelines in order to continue caring for our pediatric patients while accepting adult patients to lessen the burden of our hospital system which was above capacity. This article describes our changes in consultation, cannulation, and daily care of COVID-19 positive patients requiring ECMO as well as discusses strategies for ensuring safety of our ECMO healthcare personnel and optimal allocation of resources. LEVEL OF EVIDENCE: Level V.

Natural history of the social millipede Brachycybe lecontii Wood, 1864.

The millipede Brachycybe lecontii Wood, 1864 is a fungivorous social millipede known for paternal care of eggs and forming multi-generational aggregations. We investigated the life history, paternal care, chemical defence, feeding and social behaviour of B. lecontii and provided morphological and anatomical descriptions, using light and scanning electron microscopy. Based on observations of B. lecontii from 13 locations throughout its distribution, we report the following natural history aspects. The oviposition period of B. lecontii lasted from mid-April to late June and the incubation period lasted 3-4 weeks. Only males cared for the eggs and subsequent care of juveniles was not observed. In one case, the clutches of two males became combined and they were later cared for by only one of the males. The defensive compound of B. lecontii is stored in large glands occupying a third of the paranotal volume and were observed only in stadia II millipedes and older. We observed B. lecontii feeding on fungi of the order Polyporales and describe a cuticular structure on the tip of the labrum that may relate to fungivory. We found that their stellate-shaped aggregations (pinwheels) do not form in the absence of fungus and suggest the aggregation is associated with feeding. We describe and illustrate a previously undescribed comb-like structure on the tibia and tarsi of the six anterior-most leg-pairs and measure the colour and spectral reflectance of the B. lecontii exoskeleton.

Host and geography together drive early adaptive radiation of Hawaiian planthoppers.

The interactions between insects and their plant host have been implicated in driving diversification of both players. Early arguments highlighted the role of ecological opportunity, with the idea that insects "escape and radiate" on new hosts, with subsequent hypotheses focusing on the interplay between host shifting and host tracking, coupled with isolation and fusion, in generating diversity. Because it is rarely possible to capture the initial stages of diversification, it is particularly difficult to ascertain the relative roles of geographic isolation versus host shifts in initiating the process. The current study examines genetic diversity between populations and hosts within a single species of endemic Hawaiian planthopper, Nesosydne umbratica (Hemiptera, Delphacidae). Given that the species was known as a host generalist occupying unrelated hosts, Clermontia (Campanulaceae) and Pipturus (Urticaceae), we set out to determine the relative importance of geography and host in structuring populations in the early stages of differentiation on the youngest islands of the Hawaiian chain. Results from extensive exon capture data showed that N. umbratica is highly structured, both by geography, with discrete populations on each volcano, and by host plant, with parallel radiations on Clermontia and Pipturus leading to extensive co-occurrence. The marked genetic structure suggests that populations can readily become established on novel hosts provided opportunity; subsequent adaptation allows monopolization of the new host. The results support the role of geographic isolation in structuring populations and with host shifts occurring as discrete events that facilitate subsequent parallel geographic range expansion.

Endovascular Treatment of Claudication due to Isolated Internal Iliac Artery Occlusive Disease.

Aortoiliac occlusive disease is a common cause of lower extremity claudication. Patients are typically found to have diminished femoral pulses and abnormal noninvasive vascular studies of the lower extremities. Isolated lesions of the internal iliac arteries are much less commonly treated but can cause similar claudication symptoms in the buttocks, hips, or thighs. Occlusive disease in the internal iliac artery is more challenging to diagnose because the lower extremity pulses and vascular studies can be normal. This may falsely steer the diagnosis away from a vascular etiology. We present a case of disabling buttock claudication in a patient with normal pulses and isolated ipsilateral internal iliac artery stenosis. This was treated successfully with drug-eluting balloon angioplasty. We review the literature for similar cases of isolated internal iliac artery occlusive disease and summarize the disease characteristics and treatment modalities.

Co-occurrence of ecologically similar species of Hawaiian spiders reveals critical early phase of adaptive radiation.

BACKGROUND: The processes through which populations originate and diversify ecologically in the initial stages of adaptive radiation are little understood because we lack information on critical steps of early divergence. A key question is, at what point do closely related species interact, setting the stage for competition and ecological specialization? The Hawaiian Islands provide an ideal system to explore the early stages of adaptive radiation because the islands span ages from 0.5-5 Mya. Hawaiian spiders in the genus Tetragnatha have undergone adaptive radiation, with one lineage ("spiny legs") showing four different ecomorphs (green, maroon, large brown, small brown); one representative of each ecomorph is generally found at any site on the older islands. Given that the early stages of adaptive radiation are characterized by allopatric divergence between populations of the same ecomorph, the question is, what are the steps towards subsequent co-occurrence of different ecomorphs? Using a transcriptome-based exon capture approach, we focus on early divergence among close relatives of the green ecomorph to understand processes associated with co-occurrence within the same ecomorph at the early stages of adaptive radiation. RESULTS: The major outcomes from the current study are first that closely related species within the same green ecomorph of spiny leg Tetragnatha co-occur on the same single volcano on East Maui, and second that there is no evidence of genetic admixture between these ecologically equivalent species. Further, that multiple genetic lineages exist on a single volcano on Maui suggests that there are no inherent dispersal barriers and that the observed limited distribution of taxa reflects competitive exclusion. CONCLUSIONS: The observation of co-occurrence of ecologically equivalent species on the young volcano of Maui provides a missing link in the process of adaptive radiation between the point when recently divergent species of the same ecomorph occur in allopatry, to the point where different ecomorphs co-occur at a site, as found throughout the older islands. More importantly, the ability of close relatives of the same ecomorph to interact, without admixture, may provide the conditions necessary for ecological divergence and independent evolution of ecomorphs associated with adaptive radiation.

Management of a Large Abdominal Aortic Aneurysm in Conjunction with a Massive Inguinal Hernia.

The majority of inguinal hernias that are concomitant with abdominal aortic aneurysms (AAAs) are clinically insignificant. However, management of AAA associated with a complex hernia can be challenging. We report a case of a 72-year-old male with a 7-cm AAA and a massive inguinal hernia involving loss of abdominal domain. Using a multidisciplinary approach, a staged hybrid endovascular and open repair of the AAA was performed followed by hernia repair.

Enhanced Degradation of Misfolded Proteins Promotes Tumorigenesis.

An adequate cellular capacity to degrade misfolded proteins is critical for cell survival and organismal health. A diminished capacity is associated with aging and neurodegenerative diseases; however, the consequences of an enhanced capacity remain undefined. Here, we report that the ability to clear misfolded proteins is increased during oncogenic transformation and is reduced upon tumor cell differentiation. The augmented capacity mitigates oxidative stress associated with oncogenic growth and is required for both the initiation and maintenance of malignant phenotypes. We show that tripartite motif-containing (TRIM) proteins select misfolded proteins for proteasomal degradation. The higher degradation power in tumor cells is attributed to the upregulation of the proteasome and especially TRIM proteins, both mediated by the antioxidant transcription factor Nrf2. These findings establish a critical role of TRIMs in protein quality control, connect the clearance of misfolded proteins to antioxidant defense, and suggest an intrinsic characteristic of tumor cells.

Bloodless Repair of Isolated Pulmonary Artery in a Neonate.

Pediatric cardiac surgery, especially for small neonates, typically requires blood products to counter hemodilution during cardiopulmonary bypass. Children with congenital heart defects whose families adhere to faith-based proscriptions against blood transfusion therefore represent a challenging surgical population. Here, we report the case of a ten-day-old, 3.6-kg patient of Jehovah's Witness faith, who was diagnosed with unilateral pulmonary artery discontinuity, bilateral patent ductus arteriosus, and an otherwise structurally normal heart. Pulmonary artery reimplantation was successfully performed without giving blood products. This case adds to previous reports of successful bloodless cardiac surgery in neonates and describes the specific strategies that contributed to successful pulmonary artery reimplantation.

Sartorius Muscle Flaps for Vascular Groin Wound Complications.

Sartorius myoplasty (SM) has been used as an adjunct for soft tissue coverage in vascular groin wound complications. However, the reliability of SM as a primary muscle flap has been questioned. The purpose of this study is to determine the reliability of SM performed by vascular surgeons in the management of vascular groin wound complications. A retrospective review was performed on all patients who underwent SM from 1997 to 2012. The three indications for SM were prophylactic, infection, and noninfectious wound complication. Failure of SM was defined as operative reintervention for bleeding, persistent wound drainage, or infection. A total of 99 patients underwent 103 SM procedures. The patients were 43 per cent male and 57 per cent female; the mean age was 69 years. The indication for SM was infectious in 62 cases (60%), prophylactic in 21 cases (20%), and noninfectious in the remaining 20 cases. Failure of SM occurred in 11 cases (11%). Of these, salvage bypass and/or salvage muscle flap was required in eight cases (73%). When salvage bypass was required, extra-anatomic obturator bypass was performed in 80 per cent of cases. Salvage wound coverage included rectus abdominus flap (60%), rotational flap (20%), and skin grafting (20%).Seventy-three per cent of failures came from the infectious wound group. The most common reason for SM failure was hemorrhage (45%). In 82 per cent of the cases, the sartorius muscle was still viable at reoperation and was used for continued muscle coverage. SM performed by the vascular surgeon provides reliable soft tissue coverage for vascular groin wound complications and should be used as the primary muscle flap in the majority of patients. In cases of SM failure, the vascular surgeon should consider other more extensive muscle flap options.

Treatment options for late type III endoleaks after endovascular aneurysm repair.

Late type III endoleaks result from complete or partial separation of endograft device components. Component separation repressurizes the aortic sac and may result in aortic rupture. We report 4 cases of late type III endoleaks after initial successful endovascular aneurysm repair for abdominal aortic aneurysm. Our cases include 3 aortic cuff separations and 1 iliac limb separation. The average time before graft separation was 3.25 years with an average aneurysm size at re-presentation of 8.2 cm. Management of these complex cases will be discussed, the literature reviewed, and recommendations for treatment offered.

Radiation safety consideration during intraoperative radiation therapy.

Using in-house-designed phantoms, the authors evaluated radiation exposure rates in the vicinity of a newly acquired intraoperative radiation therapy (IORT) system: Axxent Electronic Brachytherapy System. The authors also investigated the perimeter radiation levels during three different clinical intraoperative treatments (breast, floor of the mouth and bilateral neck cancer patients). Radiation surveys during treatment delivery indicated that IORT using the surface applicator and IORT using balloons inserted into patient body give rise to exposure rates of 200 mR h(-1), 30 cm from a treated area. To reduce the exposure levels, movable lead shields should be used as they reduce the exposure rates by >95%. The authors' measurements suggest that intraoperative treatment using the 50-kVp X-ray source can be administered in any regular operating room without the need for radiation shielding modification as long as the operators utilise lead aprons and/or stand behind lead shields.

Shifting habitats, morphology, and selective pressures: developmental polyphenism in an adaptive radiation of Hawaiian spiders.

Particularly intriguing examples of adaptive radiation are those in which lineages show parallel or convergent evolution, suggesting utilization of similar genetic or developmental pathways. The current study focuses on an adaptive radiation of Hawaiian "spiny-leg" spiders in which diversification is associated with repeated convergent evolution leading to similar sets of ecomorphs on each island. However, two species on the oldest islands in the archipelago exhibit variability, occurring as two different ecomorphs. More derived species on the younger islands show much less variability, any one species displaying a single ecomorph. We measured ecomorphological features within individuals over time to determine the nature of the variability. Then, using transcriptomes, we conducted lineage-based tests for selection under varying models and analyses of gene tree versus species tree incongruencies. Our results provide strong evidence that variability in color in Tetragnatha kauaiensis and T. polychromata is associated with development within individuals (polyphenism). Moreover, a total of 28 loci showed a signature of selection associated with loss of the color-changing phenotype, and 37 loci showed a signature of selection associated with the colonization of a new environment. The results illustrate how developmental polyphenism might provide an avenue for the repeated evolution of ecomorphs during adaptive radiation.

Venous thromboembolism secondary to uterine fibroids: a case of phlegmasia cerulea dolens and review of the literature.

Uterine fibroids are usually benign soft tissue tumors, however, when they become large, they can cause external venous compression. We present a case of a 45-year-old woman who presented with phlegmasia cerulea dolens from a large uterine fibroid. She was successfully treated with hysterectomy, venous thrombectomy, and fasciotomy. We review the literature for previous reports of venous thromboembolism resulting from uterine fibroids. The patient characteristics, thrombotic complications, and treatment modalities are reviewed.

Massive localized lymphedema revisited: a quickly rising complication of the obesity epidemic.

Massive localized lymphedema (MLL) is a rising and potentially fatal complication of the obesity epidemic. Described as a benign lymphoproliferative overgrowth of obese patients, MLL is a form of secondary lymphedema, caused by the obstruction of lymphatic flow, with characteristic clinical and histological presentation. Patients have a large mass with classic skin changes often accompanied by lymphatic weeping that require complex reconstruction. Although oftentimes benign, if left untreated, MLL can progress to angiosarcoma, further supporting the need for more research into MLL and its sequelae. We present a unique case of MLL of the mons pubis in a 52-year-old man with a body mass index of 75.7 kg/m. The literature was comprehensively reviewed with a total of 65 cases of MLL being described, 9 of which resulted in angiosarcoma (10.3% of all cases), 6 of which resulted in death (9.2% of all cases). We found a female predominance of 1.24 to 1, an average weight of 183 kg, and a 48.5% majority of cases in the thigh.