Helios-Negative Regulatory T Cells as a Key Factor of Immune Tolerance in Nonallergic Beekeepers.

BACKGROUND AND OBJECTIVES: Although exposure to stings has been identified as the leading risk factor for anaphylaxis due to Hymenoptera venom allergy, professional beekeepers receive hundreds of stings yearly without developing systemic reactions. This study aims to analyze the mechanisms underlying bee venom tolerance in beekeepers. METHODS: A cross-sectional study was conducted. Participants were recruited and classified into 3 groups: allergic patients (APs), who experienced systemic reactions after bee stings, with a positive intradermal test and specific IgE (sIgE) to Apis mellifera venom (AmV); tolerant beekeepers (TBKs), who received ≥50 stings/year; and healthy nonexposed controls (HCs). We measured serum levels of sIgE and specific IgG4 (sIgG4) to AmV, rApi m 1, rApi m 2, rApi m 3, Api m 4, rApi m 5, and rApi m10, as well as AmV-induced basophil degranulation, percentage of T-cell subsets, regulatory T cells (Treg), and IL-10 production. RESULTS: Compared with TBKs, APs had high levels of sIgE to AmV and all its allergic components (P<.001), together with a high basophil activation rate (P<.001). Conversely, compared with APs, TBKs had higher levels of sIgG4 (P<.001) and IL-10 (P<.0001), as well as an enhanced CTLA-4+ Treg population (P=.001), expanded Helios- Treg (P<.003), and reduced type 1 helper T cells (TH1) (P=.008), TH2 (P=.004), and TH17 (P=.007) subsets. CONCLUSIONS: The profile of TBKs, which was strongly marked by Treg activity, differed from that of TBKs. This natural tolerance would be led by the expansion of inducible Helios- Treg cells at the peripheral level. The Helios- Treg population could be a novel candidate biomarker for monitoring tolerance.

MRP4-mediated cAMP efflux is essential for mouse spermatozoa capacitation.

Mammalian spermatozoa must undergo biochemical and structural changes to acquire the capacity for fertilization, in a process known as capacitation. Activation of PKA enzymes is essential for capacitation, and thus cAMP levels are tightly regulated during this process. Previously, we demonstrated that during capacitation, bovine spermatozoa extrude cAMP through multidrug resistance-associated protein 4 (MRP4, also known as ABCC4), which regulates intracellular levels of the nucleotide and provides cAMP to the extracellular space. Here, we report the presence of functional MRP4 in murine spermatozoa, since its pharmacological inhibition with MK571 decreased levels of extracellular cAMP. This also produced a sudden increase in PKA activity, with decreased tyrosine phosphorylation at the end of capacitation. Blockade of MRP4 inhibited induction of acrosome reaction, hyperactivation and in vitro fertilization. Moreover, MRP4 inhibition generated an increase in Ca2+ levels mediated by PKA, and depletion of Ca2+ salts from the medium prevented the loss of motility and phosphotyrosine inhibition produced by MK571. These results were supported using spermatozoa from CatSper Ca2+ channel knockout mice. Taken together, these results suggest that cAMP efflux via MRP4 plays an essential role in mouse sperm capacitation.This article has an associated First Person interview with the first author of the paper.

Immunological synapse formation inhibits, via NF-kappaB and FOXO1, the apoptosis of dendritic cells.

The immunological synapse (IS) is a cell-cell junction formed between CD4(+) T cells and dendritic cells (DCs). Here we show in vitro and in vivo that IS formation inhibits apoptosis of DCs. Consistent with these results, IS formation induced antiapoptotic signaling events, including activation of the kinase Akt1 and localization of the prosurvival transcription factor NF-kappaB and the proapoptotic transcription factor FOXO1 to the nucleus and cytoplasm, respectively. Inhibition of phosphatidylinositol 3-OH kinase and Akt1 partially prevented the antiapoptotic effects of IS formation. Direct stimulation of the IS component CD40 on DCs leads to the activation of Akt1, suggesting the involvement of this receptor in the antiapoptotic effects observed upon IS formation.

Rheological fingerprinting as an effective tool to guide development of personal care formulations.

OBJECTIVE: Conventional rheological techniques in the linear viscoelastic region provide insights about the spatial configuration of the microstructural components of personal care formulations in their 'at-rest' state. However, they fail to describe the textural experience associated with large and fast deformations during daily consumer application. In this study we present a non-conventional rheological technique-large amplitude oscillatory shear (LAOS)-for probing the transformation of a material during its application. This technique is proposed a practical tool for formulators in their efforts to design products with desired textural attributes. METHODS: A non-linear rheological technique termed LAOS was utilized to capture the textural expression perceived by consumers. Lissajous plots (stress vs. strain or strain rate) provide a fingerprint of the formula and are utilized to both analyse the thickening mechanism and monitor the influence of various parameters, such as the chemistry, molecular properties, colloidal parameters and processing conditions. RESULTS: In this study, we showcased several approaches for modifying the texture of personal care formulations and show the influence of various parameters on the characteristics of the Lissajous curves and their relation to sensorial perception. This fingerprinting technique shows that increasing the molecular weight or hydrophobic modification boosts the elasticity and thickening efficiency of a given polymer. Differences in the chemistry of rheological ingredients also influence the characteristic Lissajous fingerprint. In high concentration surfactant systems, which tend to form worm-like micelles, their unique Lissajous fingerprints indicate structure rebuild because of fast kinetics at large but slow deformations. Analysis of lamellar gel-based hair conditioner formulations demonstrates the unique high yield stress of these types of materials, accompanied by the fast breakdown transition from a solid to viscous structure because of their crystalline lamellar gel structure. CONCLUSION: The LAOS technique presented in this article is intended to better capture the textural expression perceived by consumers. Lissajous plots-generated from the LAOS experimental data-provide a fingerprint of the tested formula and are utilized to both analyse the thickening mechanism and monitor the influence of various parameters, such as the chemistry and molecular weight of the thickener, pH of the formula medium and influence of other ingredients in the formula (surfactants, emulsifiers, etc.).

OBJECTIF: Les techniques rhéologiques conventionnelles dans la région viscoélastique linéaire fournissent des informations sur la configuration spatiale des composants microstructurels des formulations de produits cosmétiques dans leur état « au repos ¼. Mais elles ne décrivent pas l'expérience de texture associée à des déformations importantes et rapides lors de l'application quotidienne par les consommateurs. Dans cette étude, nous présentons une technique rhéologique non conventionnelle, le cisaillement oscillatoire à grande amplitude (Large Amplitude Oscillatory Shear, LAOS), pour examiner la transformation d'un matériau pendant son application. Cette technique est proposée comme outil pratique pour aider les formulateurs dans leurs efforts pour concevoir des produits qui ont les attributs texturaux désirés. MÉTHODES: Une technique rhéologique non linéaire appelée LAOS a été utilisée pour capturer le style textural perçu par les consommateurs. Les courbes de Lissajous (stress vs contrainte ou taux de déformation) fournissent une empreinte de la formule et sont utilisées pour analyser le comportement épaississant et surveiller l'influence de divers paramètres, tels que les propriétés moléculaires et chimiques, les paramètres colloïdaux et les conditions de traitement. RÉSULTATS: Dans cette étude, nous avons présenté plusieurs approches pour modifier la texture des formulations cosmétiques et montrer l'influence de divers paramètres sur les caractéristiques des courbes de Lissajous et leur relation avec la perception sensorielle. Cette technique d'empreintes montre que l'augmentation du poids moléculaire ou la modification hydrophobe stimule l'élasticité et l'épaississement d'un polymère donné. Les différences dans la chimie des ingrédients rhéologiques influencent également l'empreinte caractéristique de Lissajous. Dans les systèmes de tensioactifs à haute concentration, qui ont tendance à former des micelles semblables à des vers, leurs empreintes Lissajous uniques indiquent une reconstruction de la structure à cause de cinétiques rapides dans leur ensemble mais des déformations lentes. L'analyse des des formulations lamellaires d'après-shampooing à base de gel démontre le stress unique à haut rendement de ces types de matériaux, accompagnés par la transition de répartition rapide d'une structure solide à visqueuse à cause de leur structure lamellaire cristalline. CONCLUSION: La technique LAOS présentée dans cet article vise à mieux appréhender le style de texture perçu par les consommateurs. Les graphiques de Lissajous, générées à partir de données LAOS expérimentales, fournissent une empreinte de la formule testée et sont utilisés pour analyser le mécanisme épaississant et surveiller l'influence de divers paramètres, tels que la chimie et le poids moléculaire de l'épaississant, le Ph moyen et l'influence des autres ingrédients (tensioactifs, émulsifiants, etc.) dans la formule.

Optimization of Ni (II) biosorption from aqueous solution on modified lemon peel.

The valorization of agricultural waste peels as a low-cost biosorbent is a promising approach to water treatment. In this work, the improvement of the adsorption capacity of lemon peel to remove Ni (II) from aqueous effluents was explored using several chemical modifiers: HNO3, HCl, H3PO4, CaCl2, NH3 and NaOH. The surface pretreatment using NaOH was selected as the best option because of the improvement of the maximum adsorption capacity. The maximum adsorption capacity was of 36.74 mg g-1 according to the Langmuir model at optimum conditions (pH = 5, S/L = 5 g L-1, 25 °C). The pseudo-first order model of biosorption kinetics provides the best fit for experimental data. From thermodynamic studies, it was concluded that Ni (II) biosorption by modified lemon peel was endothermic and spontaneous. After five consecutives adsorption-desorption cycles using 0.1 M of HNO3 and H2SO4, a recovery of 90% of Ni (II) was obtained. Regarding characterization of the biosorbent, the surface morphology was studied by Scanning Electron Microscopy while the functional groups responsible for Ni (II) adsorption were evaluated by Fourier transform infrared spectroscopy.

Short communication: Effect of refrigerated storage on the pH and bacterial content of pasteurized human donor milk.

Once pasteurized donor milk is thawed for its administration to a preterm or sick neonate, and until it is administered, it is kept refrigerated at 4 to 6°C for 24 h. After this time, unconsumed milk is discarded. This time has not been extended, primarily because of the concern of bacterial contamination. The aim of this study was to determine the changes in pH and bacterial count when pasteurized donor milk was kept under refrigeration for a prolonged period (14 d). In this prospective study, 30 samples of pasteurized donor milk from 18 donors were analyzed. Milk was handled following the regular operating protocols established in the neonatal unit and was kept refrigerated after thawing. pH measurements and bacteriology (on blood agar and MacConkey agar plates) were performed on each sample at time 0 (immediately after thawing) and then every day for 14 d. Changes in pH of samples over time were evaluated with linear mixed-effects regression models. A slow but gradual increase in milk pH was observed starting from the first day [mean (±SD) pH of 7.30 (±0.18) at time 0 and 7.69 (±0.2) on d 14]. No bacterial growth was observed in any of the samples throughout the complete trial except in one sample, in which Bacillus flexus was isolated. In conclusion, pasteurized human donor milk maintains its microbiological quality when properly handled and refrigerated (4-6°C). The slight and continuous increase in milk pH after the first day could be due to changes in the solubility of calcium and phosphate during refrigerated storage.

Thermodynamic sorption analysis and glass transition temperature of faba bean (Vicia faba L.) protein.

Freeze-dried faba bean (Vicia faba L.) protein adsorption isotherms were determined at 25, 35 and 40 °C and fitted with the Guggenheim-Anderson-de Boer model. The pore radius of protein was in the range of 0.87-6.44 nm, so that they were considered as micropores and mesopores. The minimum integral entropy ranged between 4.33 and 4.44 kg H2O/100 kg d.s., was regarded as the point of maximum of stability. The glass transition temperature of the protein equilibrated at the different conditions of storage was determined, showing that the protein remained in glassy state for all cases. The protein showed compact and rigid structures, evidenced by microscopy analysis.

Lack of adherence to SHEA-IDSA treatment guidelines for Clostridium difficile infection is associated with increased mortality.

OBJECTIVES: The objective of this study was to determine our institution's compliance with 2010 Society for Healthcare Epidemiology of America and IDSA Clostridium difficile infection (CDI) treatment guidelines and their respective outcomes. METHODS: We collected clinical parameters, laboratory values, antibiotic therapy and clinical outcomes from the electronic medical records for all patients hospitalized at our institution with a diagnosis of CDI from December 2012 to November 2013. We specifically evaluated whether SHEA-IDSA treatment guidelines were followed and evaluated the associations between guideline adherence and severe outcomes including mortality. RESULTS: We identified 230 patients with CDI meeting inclusion criteria during the study period. Of these, 124 (54%) were appropriately treated, 46 (20%) were under-treated and 60 (26%) were over-treated. All-cause 90 day mortality was 17.4% overall; 43.5% in the under-treated group versus 12.9% in those appropriately treated (P < 0.0001) and 10.9% in those appropriately treated plus over-treated (P < 0.0001). Similarly, 90 day mortality attributed to CDI was 21.7% in those under-treated versus 8.9% in those appropriately treated (P = 0.03) and 8.2% in those either appropriately treated or over-treated (P = 0.015). Severe-complicated CDI occurred in 46 patients. In this subgroup, there was a non-significant trend towards increased mortality in under-treated patients (56.7%) compared with appropriately treated patients (37.5%, P = 0.35). Under-treatment was also associated with a higher rate of CDI-related ICU transfer (17.4% versus 4.8% in those appropriately treated, P = 0.023). CONCLUSIONS: Adherence to CDI treatment guidelines is associated with improved outcomes especially in those with severe disease. Increased emphasis on provision of appropriate, guideline-based CDI treatment appears warranted.

Antibiotic resistance in Escherichia coli in husbandry animals: the African perspective.

In the last few years, different surveillances have been published in Africa, especially in northern countries, regarding antimicrobial resistance among husbandry animals. Information is still scarce, but the available data show a worrying picture. Although the highest resistance rates have been described against tetracycline, penicillins and sulphonamides, prevalence of plasmid-mediated quinolone resistance genes and extended spectrum ß-lactamase (ESBL) are being increasingly reported. Among ESBLs, the CTX-M-1 group was dominant in most African surveys. Within this group, CTX-M-15 was the main variant both in animals and humans, except in Tunisia where CTX-M-1 was more frequently detected among Escherichia coli from poultry. Certain blaCTX-M-15 -harbouring clones (ST131/B2 or ST405/D) are mainly identified in humans, but they have also been reported in livestock species from Tanzania, Nigeria or Tunisia. Moreover, several reports suggest an inter-host circulation of specific plasmids (e.g. blaCTX-M-1 -carrying IncI1/ST3 in Tunisia, IncY- and Inc-untypeable replicons co-harbouring qnrS1 and blaCTX-M-15 in Tanzania and the worldwide distributed blaCTX-M-15 -carrying IncF-type plasmids). International trade of poultry meat seems to have contributed to the spread of other ESBL variants, such as CTX-M-14, and clones. Furthermore, first descriptions of OXA-48- and OXA-181-producing E. coli have been recently documented in cattle from Egypt, and the emergent plasmid-mediated colistin resistance mcr-1 gene has been also identified in chickens from Algeria, Tunisia and South Africa. These data reflect the urgent need of a larger regulation in the use of veterinary drugs and the implementation of surveillance programmes in order to decelerate the advance of antimicrobial resistance in this continent.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. / Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

Sperm Release From the Oviductal Epithelium Depends on Ca(2+) Influx Upon Activation of CB1 and TRPV1 by Anandamide.

The oviduct acts as a functional sperm reservoir in many mammalian species. Both binding and release of spermatozoa from the oviductal epithelium are mainly modulated by sperm capacitation. Several molecules from oviductal fluid are involved in the regulation of sperm function. Anandamide is a lipid mediator involved in reproductive physiology. Previously, we demonstrated that anandamide, through activation of the cannabinoid receptor type 1 (CB1), promotes sperm release from bovine oviductal epithelial cells, and through CB1 and the transient receptor potential vanilloid 1 (TRPV1), induces sperm capacitation. Herein we investigate co-activation between CB1 and TRPV1, and Ca(2+) influx as part of the mechanism of action of anandamide during sperm release from oviductal cells. Our results indicate that in the absence of Ca(2+) anandamide failed to release spermatozoa from oviductal epithelial cells. Additionally, sperm release promoted by cannabinoid and vanilloid agonists was abolished when the spermatozoa were preloaded with BAPTA-AM, a Ca(2+) chelator. We also determined Ca(2+) levels in spermatozoa preloaded with FURA2-AM co-cultured with oviductal cells and incubated with different cannabinoid and vanilloid agonists. The incubation with different agonists induced Ca(2+) influx, which was abolished by CB1 or TRPV1 antagonists. Our results also suggest that a phospholypase C (PLC) might mediate the activation of CB1 and TRPV1 in sperm release from the bovine oviduct. Therefore, our findings indicate that anandamide, through CB1 and TRPV1 activation, is involved in sperm release from the oviductal reservoir. An increase of sperm Ca(2+) levels and the PLC activation might be involved in anandamide signaling pathway.

Validation of the International Metastatic Renal-Cell Carcinoma Database Consortium (IMDC) prognostic model for first-line pazopanib in metastatic renal carcinoma: the Spanish Oncologic Genitourinary Group (SOGUG) SPAZO study.

BACKGROUND: Patients with metastatic renal carcinoma (mRCC) treated with first-line pazopanib were not included in the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) prognostic model. SPAZO (NCT02282579) was a nation-wide retrospective observational study designed to assess the effectiveness and validate the IMDC prognostic model in patients treated with first-line pazopanib in clinical practice. PATIENTS AND METHODS: Data of 278 patients, treated with first-line pazopanib for mRCC in 34 centres in Spain, were locally recorded and externally validated. Mean age was 66 years, there were 68.3% male, 93.5% clear-cell type, 74.8% nephrectomized, and 81.3% had ECOG 0-1. Metastatic sites were: lung 70.9%, lymph node 43.9%, bone 26.3%, soft tissue/skin 20.1%, liver 15.1%, CNS 7.2%, adrenal gland 6.5%, pleura/peritoneum 5.8%, pancreas 5%, and kidney 2.2%. After median follow-up of 23 months, 76.4% had discontinued pazopanib (57.2% due to progression), 47.9% had received second-line targeted therapy, and 48.9% had died. RESULTS: According to IMDC prognostic model, 19.4% had favourable risk (FR), 57.2% intermediate risk (IR), and 23.4% poor risk (PR). No unexpected toxicities were recorded. Response rate was 30.3% (FR: 44%, IR: 30% PR: 17.3%). Median progression-free survival (whole population) was 11 months (32 in FR, 11 in IR, 4 in PR). Median and 2-year overall survival (whole population) were 22 months and 48.1%, respectively (FR: not reached and 81.6%, IR: 22 and 48.7%, PR: 7 and 18.8%). These estimations and their 95% confidence intervals are fully consistent with the outcomes predicted by the IMDC prognostic model. CONCLUSION: Our results validate the IMDC model for first-line pazopanib in mRCC and confirm the effectiveness and safety of this treatment.

The influence of hair lipids in ethnic hair properties.

OBJECTIVE: Biochemical studies have mainly focused on the composition of hair. African hair exhibited lower moisturization and less radial swelling when flushing with water compared with Asian or Caucasian hair, and they assumed a possible lipid differentiation among human populations. This study consists in the lipid characterization of different ethnic hairs (Caucasian, Asian and African hairs) and the influence of these lipids in different hair properties such as humidity and mechanical properties. Evaluation of water sorption and desorption of the different ethnic hairs and with and without lipids is also studied mainly to determine permeation changes of the keratin fibres. METHODS: Extractions of exogenous and endogenous lipids with different organic solvents were performed; lipid analysis and its quantification using thin-layer chromatography coupled to an automated flame ionization detector (TLC/FID) were performed. Absorption and desorption curves were obtained in a thermogravimetric balance equipped with a controlled humidity chamber, the Q5000SA Sorption Analyzer (TA Instruments, New Castle, IL, U.S.A.). Also, mechanical properties (breaking stress and breaking elongation) were analysed using a computer programmable dynamometer (Instron 5500R). RESULTS: Lipid extraction showed the highest amount of total lipids for the African hair which may come from external sebaceous lipids compared with Asian or Caucasian hair. Caucasian fibres were found to be the most hydrated fibre, and a decrease in moisture was found in the extracted fibres, again, which is more important for the Caucasian hair. A superior lineal mass was found for the Asian fibres which supported their higher strength. The results obtained from the analysis of the mechanical properties of delipidized fibres indicate a surprising increase in the strength of African and Caucasian fibres. Perhaps this increase in strength could be related to the humidity decrease in lipid-extracted hair fibres. Results of water uptake and desorption indicate that Asian and Caucasian hairs present the lower diffusion coefficients compared with the African ones. At least for the African fibre, an extraction of its lipids that mainly account for apolar lipids ameliorates the fibre structure, decreasing its permeability to water and increasing its tensile strength. CONCLUSION: The ethnic hairs were assessed related to their lipid composition, and some differences between them were found in terms of water uptake and mechanical properties.

Recommendations in dispatcher-assisted bystander resuscitation from emergency call center.

Dispatch-assisted bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest has been shown as an effective measure to improve the survival of this process. The development of a unified protocol for all dispatch centers of the different emergency medical services can be a first step towards this goal in our environment. The process of developing a recommendations document and the realization of posters of dispatch-assisted cardiopulmonary resuscitation, agreed by different actors and promoted by the Spanish Resuscitation Council, is presented.

Emerging pathogen in immunocompromised hosts: Exophiala dermatitidis mycosis in graft-versus-host disease.

Infection with the dematiaceous environmental fungus Exophiala, an emerging pathogen in immunocompromised individuals, poses a diagnostic and therapeutic challenge. Herein, we report the first Exophiala dermatitidis fungemia case, to our knowledge, in an allogeneic hematopoietic stem cell transplant patient with graft-versus-host disease, expanding the clinical setting where Exophiala species mycosis should be suspected.

An alternative easy method for antibody purification and analysis of protein-protein interaction using GST fusion proteins immobilized onto glutathione-agarose.

Immobilization of small proteins designed to perform protein-protein assays can be a difficult task. Often, the modification of reactive residues necessary for the interaction between the immobilized protein and the matrix compromises the interaction between the protein and its target. In these cases, glutathione-S-transferase (GST) is a valuable tag providing a long arm that makes the bait protein accessible to the mobile flow phase of the chromatography. In the present report, we used a GST fusion version of the 8-kDa protein serine protease inhibitor Kazal-type 3 (SPINK3) as the bait to purify anti-SPINK3 antibodies from a rabbit crude serum. The protocol for immobilization of GST-SPINK3 to glutathione-agarose beads was modified from previously reported protocols by using an alternative bifunctional cross-linker (dithiobis(succinimidyl propionate)) in a very simple procedure and by using simple buffers under physiological conditions. We concluded that the immobilized protein remained bound to the column after elution with low pH, allowing the reuse of the column for alternative uses, such as screening for other protein-protein interactions using SPINK3 as the bait.

Treatment of displaced intra-articular calcaneal fractures using a sinus tarsi approach. Surgical technique. / Técnica quirúrgica del manejo de las fracturas de calcáneo a través de un abordaje del seno del tarso.

Calcaneal articular fractures are fractures classically associated with a high rate of complications and poor outcomes. Osteosynthesis of the calcaneus through a sinus tarsi approach has shown results equal to or superior to those of the extended approach, having become the new gold standard. The objective of this article is to detail step by step the surgical technique of osteosynthesis of intra-articular fractures of the calcaneus through a sinus tarsi approach, from the selection of the fracture, positioning of the patient, layout of the operating room and the fluoroscope, the entire surgical process until postoperative treatment. The surgical technique described below is described in 6 steps. Anatomical reduction of complex calcaneal fractures through an Sinus Tarsi Approach requires an understanding of the fracture and its associated deformities. Following the described sequence step by step will help to achieve a better reduction in order to achieve better functional results.