Frozen Elephant Trunk Procedure for Acute Type a Aortic Dissection: Analysis of Distal Aortic Remodeling According to the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS) Reporting Standard.

BACKGROUND: To investigate impact of frozen elephant trunk (FET) on long-term distal aortic remodeling in acute A aortic dissection (AAD) according to the latest recommended standards from the Society for Vascular Surgery (SVS)/Society of Thoracic Surgeons (STS). METHODS: Clinical data and imaging of patients who underwent FET to treat acute AAD over the last 8 years were retrospectively reviewed. Patients were included if a pre and postoperative computed angio tomographies at least 30 days from surgery was available for comparison. Contrasted postprocessed imaging were analyzed with Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA) to analyze long-term positive aortic remodeling, false lumen thrombosis, and aortic expansion according to the SVS or STS recommendations. Secondary endpoints were the rate of in-hospital and long-term mortality, spinal cord ischemia (SCI), and aortic-related reinterventions. RESULTS: Out of 75 patients who underwent FET for type A AAD, n = 41 (54.6%) were included. Significant positive aortic remodeling was reported in Ishimaru zone 1-4 but not in visceral or infrarenal aorta (P < 0.001), and the overall rate of false lumen thrombosis was 95.1% (n = 39). Aortic expansion rates were as follows: 4.9% in zones 1-4, 8.3% in zones 5-6, and 15% in zone 7. The rates of in-hospital mortality and long-term mortality were 7.3% (n = 3) and 9.7% (n = 4), respectively. At a median follow-up of 11 months (range 1-141, reintervention rate was 17.1%. CONCLUSIONS: We report positive aortic remodeling of the distal thoracic aorta in patients who underwent FET for acute AAD according to the SVS or STS reporting standards. The positive effect on the distal aorta is limited to the thoracic segments but not in the visceral aorta.

Prevalence of Pain With Movement in Active Duty US Army Soldiers.

INTRODUCTION: Soldiers must be able to perform a multitude of physically demanding tasks as part of their regular duty, but their physical readiness is often degraded due to pain and musculoskeletal injury (MSKI). The presence of pain with movement has been associated with increased MSKI risk in Soldiers. Improved awareness of the prevalence of painful movements in uninjured Soldiers could help inform Army injury mitigation efforts. The purpose of this study was to identify the prevalence of pain with movement in a population of healthy active duty Soldiers. MATERIALS AND METHODS: The Selective Functional Movement Assessment-Top Tier Movements (SFMA-TTM), active range of motion (AROM) of the hips and shoulders, and the elicitation of pain with movement were measured in 268 healthy US Army Soldiers. Descriptive statistics were generated for the number of painful movements for each measure and inferential statistics; independent t-test and one-way independent analysis of variance (ANOVA) were used for analysis of the other measures. RESULTS: Greater than half (59%) of the participants reported pain with at least 1 movement and more than 41% reported pain with 2 or more movements. Soldiers reported a mean of 1.35 painful movements on the SFMA-TTM assessment and a mean of 1.54 painful AROM movements. CONCLUSIONS: Pain with functional movement patterns was common across a sample of uninjured Soldiers. The presence of pain with movement warrants further evaluation as it may impact a Soldier's physical performance, risk for future injury, and overall quality of life.

Reproducible responses of geochemical and microbial successional patterns in the subsurface to carbon source amendment.

Carbon amendments designed to remediate environmental contamination lead to substantial perturbations when injected into the subsurface. For the remediation of uranium contamination, carbon amendments promote reducing conditions to allow microorganisms to reduce uranium to an insoluble, less mobile state. However, the reproducibility of these amendments and underlying microbial community assembly mechanisms have rarely been investigated in the field. In this study, two injections of emulsified vegetable oil were performed in 2009 and 2017 to immobilize uranium in the groundwater at Oak Ridge, TN, USA. Our objectives were to determine whether and how the injections resulted in similar abiotic and biotic responses and their underlying community assembly mechanisms. Both injections caused similar geochemical and microbial succession. Uranium, nitrate, and sulfate concentrations in the groundwater dropped following the injection, and specific microbial taxa responded at roughly the same time points in both injections, including Geobacter, Desulfovibrio, and members of the phylum Comamonadaceae, all of which are well established in uranium, nitrate, and sulfate reduction. Both injections induced a transition from relatively stochastic to more deterministic assembly of microbial taxonomic and phylogenetic community structures based on 16S rRNA gene analysis. We conclude that geochemical and microbial successions after biostimulation are reproducible, likely owing to the selection of similar phylogenetic groups in response to EVO injection.

Human proximal tubular epithelial cell-derived small extracellular vesicles mediate synchronized tubular ferroptosis in hypoxic kidney injury.

Hypoxia is the key pathobiological trigger of tubular oxidative stress and cell death that drives the transition of acute kidney injury (AKI) to chronic kidney disease (CKD). The mitochondrial-rich proximal tubular epithelial cells (PTEC) are uniquely sensitive to hypoxia and thus, are pivotal in propagating the sustained tubular loss of AKI-to-CKD transition. Here, we examined the role of PTEC-derived small extracellular vesicles (sEV) in propagating the 'wave of tubular death'. Ex vivo patient-derived PTEC were cultured under normoxia (21 % O2) and hypoxia (1 % O2) on Transwell inserts for isolation and analysis of sEV secreted from apical versus basolateral PTEC surfaces. Increased numbers of sEV were secreted from the apical surface of hypoxic PTEC compared with normoxic PTEC. No differences in basolateral sEV numbers were observed between culture conditions. Biological pathway analysis of hypoxic-apical sEV cargo identified distinct miRNAs linked with cellular injury pathways. In functional assays, hypoxic-apical sEV selectively induced ferroptotic cell death (↓glutathione peroxidase-4, ↑lipid peroxidation) in autologous PTEC compared with normoxic-apical sEV. The addition of ferroptosis inhibitors, ferrostatin-1 and baicalein, attenuated PTEC ferroptosis. RNAse A pretreatment of hypoxic-apical sEV also abrogated PTEC ferroptosis, demonstrating a role for sEV RNA in ferroptotic 'wave of death' signalling. In line with these in vitro findings, in situ immunolabelling of diagnostic kidney biopsies from AKI patients with clinical progression to CKD (AKI-to-CKD transition) showed evidence of ferroptosis propagation (increased numbers of ACSL4+ PTEC), while urine-derived sEV (usEV) from these 'AKI-to-CKD transition' patients triggered PTEC ferroptosis (↑lipid peroxidation) in functional studies. Our data establish PTEC-derived apical sEV and their intravesicular RNA as mediators of tubular lipid peroxidation and ferroptosis in hypoxic kidney injury. This concept of how tubular pathology is propagated from the initiating insult into a 'wave of death' provides novel therapeutic check-points for targeting AKI-to-CKD transition.

Timing of Outcomes and Expectations After Knee Surgery in the US Military: A Systematic Review.

CONTEXT: Knee injury and subsequent surgery are widespread in the military setting. Associations between knee surgery and expected outcomes over time have not been consolidated and characterized systematically by procedure type across the body of literature, and the temporal expectations of these outcomes remain unclear. OBJECTIVE: To summarize common postoperative follow-up times and associated outcomes that determine clinical or surgical failure in US service members after elective knee surgery. DATA SOURCES: A systematic search was conducted with 3 bibliographic databases of published research reports from 2010 through 2021. STUDY SELECTION: Studies in US military service members undergoing elective knee surgery, with a minimum of 1-year follow-up, and reporting on a functional/occupational outcome were included. Three reviewers screened all abstracts and full-text articles to determine eligibility. STUDY DESIGN: Systematic review of longitudinal cohort studies. LEVEL OF EVIDENCE: Level 2a. DATA EXTRACTION: Extracted data included military demographics, surgical procedure variables, surveillance period, and outcome measures. The Newcastle-Ottawa Scale and the Grading of Recommendations Assessment, Development, and Evaluation approach were used to determine study quality and risk of bias. RESULTS: A total of 22 studies (mean follow-up time of 40.7 months) met the inclusion criteria. For cruciate ligament repair, approximately one-third of patients required a second surgery or were medically separated from military service by 2 years from surgery; 100% were reinjured by 4 years, and 85% sustained a new injury within 5 years of surgery. For meniscal repair, nearly one-third of patients were medically separated, and half were placed on activity restrictions within 3 years of surgery. For articular cartilage repair, within 5 years, 39% of patients required a second surgery, 30% were placed on activity restrictions, and 36% were medically separated. For patellar repair, 37% of patients were medically separated and over half were placed on activity restrictions within 5 years. CONCLUSION: Common knee surgeries can have long-term implications for military careers that may not become apparent with shorter follow-up periods (<2 years). When longer surveillance periods are used (eg, up to 5 years), additional surgical procedures are more common and the likelihood of being injured or medically separated from military service is higher.

Listening Preferences of New Adult Hearing Aid Users: A Registered, Double-Blind, Randomized, Mixed-Methods Clinical Trial of Initial Versus Real-Ear Fit.

Hearing aid verification with real-ear measurement (REM) is recommended in clinical practice. Improvements, over time, in accuracy of manufacturers' initial fit mean the benefit of routine REM for new adult users is unclear. This registered, double-blinded, randomized, mixed-methods clinical trial aimed to (i) determine whether new adult hearing aid users prefer initial or real-ear fit and (ii) investigate the reasons for preferences. New adult hearing aid users (n = 45) were each fitted with two programs: the initial fit and real-ear fit, both with adjustments based on immediate feedback from the patient. Participants were asked to complete daily paired-comparisons of the two programs with a magnitude estimation of the preference, one for each of clarity/comfort in quiet/noise as well as overall preference. The results revealed gain adjustment requests were low in number and small in magnitude. Deviation from NAL-NL2 targets (after adjustment for a 65 dB SPL input) was close to zero, except at high frequencies where real-ear fits were around 3 dB closer to target. There was no difference in clarity ratings between programs, but comfort ratings favored initial fit. Overall, 10 participants (22%) expressed a preference for real-ear fit. Reasons for preference were primarily based on comfort with the initial fit and clarity with real-ear fit. It may be acceptable to fit new adult users with mild-to-moderate hearing loss without the need for REMs, if the primary outcome of interest is user preference. It remains to be seen if the findings generalize to other fitting software, other outcome measures and more severe hearing loss.

Competition and habitat availability interact to structure arboreal ant communities across scales of ecological organization.

Understanding how resource limitation and biotic interactions interact across spatial scales is fundamental to explaining the structure of ecological communities. However, empirical studies addressing this issue are often hindered by logistical constraints, especially at local scales. Here, we use a highly tractable arboreal ant study system to explore the interactive effects of resource availability and competition on community structure across three local scales: an individual tree, the nest network created by each colony and the individual ant nest. On individual trees, the ant assemblages are primarily shaped by availability of dead wood, a critical nesting resource. The nest networks within a tree are constrained by the availability of nesting resources but also influenced by the co-occurring species. Within individual nests, the distribution of adult ants is only affected by distance to interspecific competitors. These findings demonstrate that resource limitation exerts the strongest effects on diversity at higher levels of local ecological organization, transitioning to a stronger effect of species interactions at finer scales. Collectively, these results highlight that the process exerting the strongest influence on community structure is highly dependent on the scale at which we examine the community, with shifts occurring even across fine-grained local scales.

Predicting Postoperative Injury and Military Discharge Status After Knee Surgery in the US Army.

BACKGROUND: Researchers have assessed postoperative injury or disability predictors in the military setting but typically focused on 1 type of surgical procedure at a time, used relatively small sample sizes, or investigated mixed cohorts with civilian populations. PURPOSE: To identify the relationship between baseline variables and injury incidence or military discharge status in US Army soldiers after knee surgery. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Data were obtained from a repository containing personnel, performance, and medical records for all active-duty US Army soldiers. Multivariate logistic regressions were used to estimate the effects of numerous variables on postoperative injury or on medical discharge. Variable selection and model validation were conducted using the k-fold method. RESULTS: A total of 7567 soldiers underwent knee surgery between 2017 and 2019. Meniscal procedures were the most common type of surgery (39%), and approximately 71% of the cohort had a postoperative injury. Significant predictors for sustaining a postoperative injury included having a previous nonknee injury (odds ratio [OR], 1.5), female sex (OR, 1.3), and Black race (OR, 1.2). Within 4 years after surgery, 17% of soldiers were discharged from the military because of knee-related disability. Significant predictors for discharge from duty included enlisted rank (OR, 2.3), recent fitness test failure (OR, 1.9), number of previous knee surgeries (OR, 1.7), and having a previous nonknee injury (OR, 1.6). CONCLUSION: After knee surgery, nearly three-fourths of the soldiers in this cohort sustained a postoperative injury and almost one-fifth of soldiers were medically discharged from the military within 4 years. This study identified variables that indicate statistically increased risk for these postoperative outcomes and highlighted potentially modifiable factors.

Implantation of frozen elephant trunk (FET)-surgical technique-Thoraflex.

The development of the frozen elephant trunk (FET) prosthesis has revolutionised how we treat some of the most complex aortic pathology, including in the emergency setting of acute type A aortic dissection. The design of the prosthesis is fundamental to the success of the procedure in combination with the surgeon's skill in interpreting the pre-operative scan and procedural planning to juggling the technical aspects of the deployment and reimplantation of the supra-aortic vessels. Furthermore, organ protection strategies and techniques to reduce the complications of neurological and renal impairment are paramount. This article focuses on the Thoraflex Hybrid prosthesis including the evolution of the concept, design features unique to the device and surgical technique including fundamentals of sizing and implantation steps with illustrations. The Thoraflex Hybrid prosthesis provides an ergonomic and neat delivery system with a trusted gelatin coated surgical graft material making implantation and use as straightforward as possible. These features have meant that the device is a market leader in the field of FETs with outcome data and implant figures to support its efficacy globally. The success of the device is also reflected in the literature. For example, in the UK study from Mariscalco et al., the mortality of FET implantation in acute type A dissection, of which most were using the Thoraflex device, was only 12%. This is comparable to leading centres in Europe with the inherent advantage of improving long-term outcomes in addition. Of course, this strategy is not appropriate in all cases and precise judgement of when to deploy a FET in both the emergency and elective setting is key to achieving good outcomes.

Open descending and thoracoabdominal aortic replacement: operative steps for patients with prior endovascular treatment.

Open surgery remains the gold standard for the treatment of the thoracoabdominal aorta. The rising number of endovascularly treated patients comes with an increase in the number of patients who require secondary open interventions due to the complex nature of the aortic disease or to treat endovascular complications. We describe our current approach to secondary open extent II thoracoabdominal aortic repair in patients with prior endovascular repair. In this case report, we show two different cases that exemplify this scenario.

Managing the Root in Acute Type A Aortic Dissections: Are We Ready for a Standardized Approach?

OBJECTIVES: Surgical repair of Type A aortic dissection (TAAD) requires exclusion of the primary entry tear and reestablishment of flow into the distal true lumen. Provided that the majority of tears occur within the ascending aorta (AA), replacing only that segment seems a safe option; however, this strategy leaves the root susceptible to dilatation and need for reintervention. We aimed to review the outcomes of the two strategies: aortic root replacement (ARR) and isolated ascending aortic replacement. METHODS: Retrospective analysis of prospectively collected data for all consecutive patients who underwent repair of acute TAAD at our institution from 2015 to 2020 was conducted. Patients were divided into two groups: (1) ARR and (2) isolated AA replacement as index operation for TAAD repair. Primary outcomes were mortality and need for reintervention during the follow-up. RESULTS: A total of 194 patients were included in the study; 68 (35%) in the ARR group and 126 (65%) in the AA group. There were no significant differences in postoperative complications or in-hospital mortality (23%; p = 0.51) between groups. Seven patients (4.7%) died during follow-up and eight patients underwent aortic reinterventions, including proximal aortic segments (two patients) and distal procedures (six patients). CONCLUSION: Both aortic root and AA replacement are acceptable and safe techniques. The growth of an untouched root is slow, and reintervention in this aortic segment is infrequent compared with distal aortic segments, hence preserving the root could be an option for older patients provided that there is no primary tear within the root.

Thoracoabdominal Aneurysm Repair During Early Stage of Pregnancy: Can and Should We Save the Baby?

Aortic dissection during pregnancy is a life-threatening condition for both mother and fetus. We present the case of a 34-year-old woman with a rapidly expanding abdominal aorta in the context of a chronic type B aortic dissection. A 4 to 6 weeks' viable pregnancy was incidentally diagnosed during the preoperative workup. She underwent urgent extent II thoracoabdominal aortic aneurysm repair with left-sided heart bypass. Postoperatively, vaginal ultrasound evaluation confirmed viability of the fetus, but the patient wished to terminate the pregnancy because of the possible unknown hypoxic effects on the fetus.

The Relationship Between Physical Mobility and Firefighter Occupational Task Performance.

Firefighters work in a dangerous profession with high injury rates. Mobility dysfunction in firefighters may impact performance and contribute to injury. The Functional Movement Screen (FMS) is commonly used to evaluate individuals for mobility dysfunction and compensatory movements. The purpose of this study was to identify if mobility is related to firefighters' occupational task performance. This was a retrospective study assessing 29 career firefighters using FMS and occupational performance task scores. Statistical analyses consisted of a multiple linear regression assessing predictors on occupational task performance, and 21 point-biserial correlations ran to assess the relationship between each individual predictor and occupational task performance. Of the 21 point-biserial correlations, four were found to be significant, indicating a relationship between the FMS and occupational task performance. Inline Lunge L had a negative correlation with occupational task time and was statistically significant (rpb = -0.46, p = 0.012); Inline Lunge R had a negative correlation of moderate strength (rpb = -0.583, p = 0.001), Inline Lunge Combined had a negative correlation of moderate strength (rpb = -0.523, p = 0.004), and Shoulder Mobility L had a negative correlation of moderate strength (rpb = -0.445, p = 0.016). This study determined that the Inline Lunge component of the FMS may be a key element in occupational task performance.

Retrograde type A aortic dissection: a different evil.

Retrograde type A aortic dissection (RTAAD) can be spontaneous or secondary to the instrumentation of the descending and thoraco-abdominal aorta. It has anatomical differences compared to antegrade type A aortic dissection that impact the management and prognosis. Treatment is not standardized. We report our approach to spontaneous RTAAD in our institution between 2018 and 2022 (n = 15). The mean age was 60.1 years and 93% were male. Aortic valve, coronary arteries and supra-aortic trunks were spared by the dissection in 80% of the cases; distal extension to iliacs was common and lower limb malperfusion was present in 4 cases (27%). The ascending aorta was dilated at presentation in 60% of the cases. Emergency surgery with arch/FET replacement was offered to 11 patients (73%); 3 patients (20%) received a limited proximal aortic repair; 1 patient was treated conservatively. Overall mortality was 47% (100% for limited proximal repair and 22% for those who received arch/FET). We advocate for aggressive treatment of RTAAD excluding the primary entry tear to prevent immediate- and mid-term complications.

ATP13A1 prevents ERAD of folding-competent mislocalized and misoriented proteins.

The biosynthesis of thousands of proteins requires targeting a signal sequence or transmembrane segment (TM) to the endoplasmic reticulum (ER). These hydrophobic ɑ helices must localize to the appropriate cellular membrane and integrate in the correct topology to maintain a high-fidelity proteome. Here, we show that the P5A-ATPase ATP13A1 prevents the accumulation of mislocalized and misoriented proteins, which are eliminated by different ER-associated degradation (ERAD) pathways in mammalian cells. Without ATP13A1, mitochondrial tail-anchored proteins mislocalize to the ER through the ER membrane protein complex and are cleaved by signal peptide peptidase for ERAD. ATP13A1 also facilitates the topogenesis of a subset of proteins with an N-terminal TM or signal sequence that should insert into the ER membrane with a cytosolic N terminus. Without ATP13A1, such proteins accumulate in the wrong orientation and are targeted for ERAD by distinct ubiquitin ligases. Thus, ATP13A1 prevents ERAD of diverse proteins capable of proper folding.

Persistent cancer-related fatigue after breast cancer treatment predicts postural sway and post-exertional changes in sit-to-stand strategy.

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is considered a primary mechanism of imbalance among women diagnosed with breast cancer. Recent evidence, however, suggests that cancer-related fatigue (CRF) may also influence balance. Purpose: Examine the contributions of CRF and CIPN to static and dynamic balance before and after a period of fatiguing exercise. Methods: This is a secondary analysis of data examining functional differences between women with breast cancer with and without persistent CRF. Postural sway was measured during static standing and the rising phase of an instrumented sit-to-stand (ISTS) before and after exercise. Regression analyses were performed to determine how CRF and severity of CIPN predicted sway and how much variance was attributable to each. Results: Greater CRF predicted increased pre-, p=.04, and post-exertional, p=.02, static sway in the anterior-posterior plane. CRF accounted for 10.5% and 9.5% of the variance in pre- and post-exertional sway (respectively) compared to the 0.9% and 1.4% accounted for by CIPN severity which was not a significant predictor. After exercise, greater CRF predicted smaller, more conservative, anterior weight shifting during the ISTS, p=.01, and accounted for 6.6% of the variance in sway compared to 3% attributed to CIPN which was not a significant predictor. Limitations: This analysis is limited by its small and demographically homogenous sample. Conclusions: These results suggest that CRF may influence balance independent of CIPN symptoms. While CIPN remains a risk factor for imbalance in this population, CRF warrants consideration in clinical practice and research as a mechanism of postural instability.

Annotation of the Complete Genome Sequences of Bacteriophages Sara and Birdfeeder.

Sara is a siphovirus with a linear 17,362bp genome containing 25 genes. Birdfeeder is a podovirus with a circularly permuted 53,897bp genome containing 52 genes. Sara and Birdfeeder were isolated from environmental samples in Plattsburgh, NY, USA and Forest Hill, MD, USA, respectively, using Microbacterium foliorum NRRL B-24224.

Type-A acute aortic dissection complicated by parenchymal hemorrhagic stroke: Timing of surgery for a rare presentation of aortic dissection.

Acute type-A aortic dissection is a rare but life-threatening cardiac surgery emergency. Immediate operative management is important to give patients the best chance of survival. However, where an aortic dissection is complicated by a concurrent hemorrhagic stroke the risks of precipitating a catastrophic intracranial hemorrhage during surgery must be balanced against the risk of aortic rupture. The optimal timing of surgery in this rare presentation of type-A aortic dissection is unknown. In this case report we describe a 67-year-old gentleman who initially presented with neurological symptoms, and was diagnosed with an acute intracerebral hemorrhage, but was subsequently also diagnosed with an acute type-A aortic dissection. He proceeded to have a successful tissue aortic root replacement, total arch replacement with zone two frozen elephant trunk implantation 4 weeks after his initial diagnosis.