Ascending aortobifemoral and adjunct carotid bypass grafts.

We describe a case of simultaneous ascending aortobifemoral and right common carotid artery bypass to treat a symptomatic brachiocephalic artery and juxtarenal chronic total occlusion in a 68-year-old female patient with unfavorable characteristics for endovascular and standard aortofemoral procedures. Mid-term follow-up revealed sustained remission of symptoms, quality of life quality of life improvement, and patent bypass grafts. In highly selected patients, this solution can be useful when treating other intrathoracic diseases, as well as allowing the simultaneous revascularization of two remote arterial beds.

Simultaneous sequencing of genetic and epigenetic bases in DNA.

DNA comprises molecular information stored in genetic and epigenetic bases, both of which are vital to our understanding of biology. Most DNA sequencing approaches address either genetics or epigenetics and thus capture incomplete information. Methods widely used to detect epigenetic DNA bases fail to capture common C-to-T mutations or distinguish 5-methylcytosine from 5-hydroxymethylcytosine. We present a single base-resolution sequencing methodology that sequences complete genetics and the two most common cytosine modifications in a single workflow. DNA is copied and bases are enzymatically converted. Coupled decoding of bases across the original and copy strand provides a phased digital readout. Methods are demonstrated on human genomic DNA and cell-free DNA from a blood sample of a patient with cancer. The approach is accurate, requires low DNA input and has a simple workflow and analysis pipeline. Simultaneous, phased reading of genetic and epigenetic bases provides a more complete picture of the information stored in genomes and has applications throughout biomedicine.

Oyster beds in the United Arab Emirates: Important fishing grounds in need of protection.

There is scarce information on the current importance of oyster beds as fishing grounds in the United Arab Emirates (UAE). This study aims to understand the socio-economic value of oyster bed fisheries through questionnaire-based surveys with fishers. Of 106 Emirati fishers interviewed, 67 % use oyster beds due to the proximity to shore, better catch quality, and species abundance. Oyster bed fisheries are recreational and commercial, with handline and fish traps the most common used gears. They provide food for local consumption and cash income. All respondents noticed a fish abundance and size decrease throughout the last decade. Fishers suggest establishing marine protected areas and updating fishing regulations to improve fishing stock status. During the Covid-19 pandemic, oyster fisheries increased, highlighting the value of these fishing grounds for food availability. These fisheries support the local economy and heritage, and urgently need management to ensure the protection of these often-overlooked habitats.

Intravascular foreign body retrieval.

INTRODUCTION: Intravascular foreign body (IFB) embolization is a potential complication of any vascular procedure. Intravascular foreign body retrieval (IFBR) can be achieved using percutaneous techniques, open surgery, or both combined. METHODS: We completed a retrospective review of patients who underwent endovascular or open IFBR since 2011 on our institution. Primary end-point was technical retrieval success, and secondary end-points were procedure-related compli- cations and 30-days survival. RESULTS: Twenty-seven patients underwent IFBR. Median time from intravascular device loss and retrieval was less than one day. 67% were non-endovascular guidewires and sheath fragments (N=28). 59% of IFBs were lost during their deployment (N=16); 41% during their removal attempts (N=11). 44% were lost in the arterial system (N=12) and 52% in the venous system (N=14). An endovascular procedure was used as the first approach in IFBR in 56% of patients (N=15) and open procedure in 44% (N=12). In the presence of IFB on the thoracic or abdominal cavity, it was always tried a first-endo approach; if IFB was present on the neck or limbs, 75% were retrieved by open surgery (N=20; p<0.001). Success rates were 100% for open and 87% for endovascular procedures. IFB caused five acute complications: one IJV thrombosis, two strokes and three acute limb ischemia. There were no IFBR-related complications. 30 days-survival was 100%. CONCLUSION: Embolization of IFBs can be minimized with proper device selection, deployment and removal. In this study, open and endovascular retrieval had high success rates and minimal morbidity. Its choice is surgeon-dependent and restrained by devices availability.

Coral reefs at Sir Bu Nair Island: An offshore refuge of Acropora in the southern Arabian Gulf.

Coral reefs across the southern Arabian Gulf have declined in the past two decades, with extensive loss of formerly Acropora table corals, which are now functionally extinct in nearshore reefs. This study documents the coral community at Sir Bu Nair (SBN), an offshore island buffered by less extreme environmental conditions, which contains the last remaining large stands of Acropora in the southern Gulf. We found that Acropora is a major reef-building coral throughout SBN. Mean coral cover was 27% (range: 6%-49%) across all sites and depths, of which more than half was comprised by Acropora. This varied around the island, with the highest densities to the south and southwest in shallow waters. Our study provides essential information for the management and conservation of these highly valuable and vulnerable corals.

Cystic Adventitial Disease of the Popliteal Vein, a Rare Cause of Lower Limb Deep Vein Thrombosis.

Introduction: Cystic adventitial disease (CAD) is characterised by the accumulation of gelatinous fluid within the adventitial layer of a blood vessel. Over 90% of CAD occurs in the arterial system. Venous CAD most commonly involves the iliofemoral rather than the popliteal segments. Report: This is the report of a 49 year old female patient with a previous right leg deep vein thrombosis (DVT). She presented to a vascular outpatient appointment with recurrent right lower extremity swelling. Venous duplex ultrasound showed an ectatic and incompetent right popliteal vein. Computed tomography (CT) venography showed focal ectasia of the right popliteal vein resulting from an eccentric low density cyst with a diameter of 15 mm. Under general anaesthesia, the patient was placed in the prone position. A lazy S incision was performed in the right popliteal fossa. The popliteal vein had an eccentrically thickened lateral bulge. After heparinisation, a longitudinal venotomy, endophlebectomy, and en bloc cyst removal were performed sequentially. Popliteal patch venoplasty was performed subsequently using the ipsilateral small saphenous vein. After six months, the patient remains on rivaroxaban. A follow up venous duplex ultrasound showed vein reflux through a standard calibre popliteal vein without evidence of cyst recurrence. Conclusion: Venous CAD is a rare disease and should be considered if previous DVT or symptoms mimicking DVT occur. Cyst resection and reconstruction with vein patch, venous or synthetic graft is the most commonly used strategy and has lower rates of cyst recurrence and need for re-operation.

Dissection Flap Fenestration with a Transjugular Intrahepatic Portosystemic Shunt Needle: An Adjuvant Technique in Endovascular Treatment of Post-Dissection Thoraco-Abdominal Aortic Aneurysms.

INTRODUCTION: In chronic aortic dissection complicated by aneurysmal degeneration, the absence of spontaneous tears between the true and false lumen at visceral artery level may limit treatment by fenestrated/branched endovascular aneurysm repair (F/BEVAR). The creation of new fenestrations may be required to allow access to the visceral vessels. TECHNIQUE: In this video, the endovascular treatment of a 70 year old white man with chronic type B aortic dissection complicated by Crawford type II thoraco-abdominal aortic aneurysmal degeneration is presented. The right renal artery had a false lumen origin without nearby visible re-entry tears. He underwent dissection flap fenestration at visceral vessel level using a transjugular intrahepatic portosystemic shunt (TIPS) needle and subsequent dilation with a high pressure balloon. A Zenith TX2 dissection endovascular graft was deployed proximally and extended distally with a Zenith dissection endovascular stent until the fenestration level was reached. In a second stage, a F/BEVAR was performed, with fenestration to the left renal artery and branches to right renal artery, superior mesenteric artery, and coeliac trunk. One year follow up computed tomography angiography showed visceral branch patency and a reduction of the aneurysm sac. DISCUSSION: The chronic dissection flap may be thick and fibrotic, creating a technical challenge for endovascular fenestration. The off label use of a TIPS needle in this procedure created a new fenestration at the desired level and allowed definitive post-dissection treatment of the thoraco-abdominal aneurysm.

Fluctuations of the transcription factor ATML1 generate the pattern of giant cells in the Arabidopsis sepal.

Multicellular development produces patterns of specialized cell types. Yet, it is often unclear how individual cells within a field of identical cells initiate the patterning process. Using live imaging, quantitative image analyses and modeling, we show that during Arabidopsis thaliana sepal development, fluctuations in the concentration of the transcription factor ATML1 pattern a field of identical epidermal cells to differentiate into giant cells interspersed between smaller cells. We find that ATML1 is expressed in all epidermal cells. However, its level fluctuates in each of these cells. If ATML1 levels surpass a threshold during the G2 phase of the cell cycle, the cell will likely enter a state of endoreduplication and become giant. Otherwise, the cell divides. Our results demonstrate a fluctuation-driven patterning mechanism for how cell fate decisions can be initiated through a random yet tightly regulated process.

Median Arcuate Ligament Syndrome - Literature Review and Case Report.

INTRODUCTION: Median arcuate ligament syndrome (MALS) or Dunbar syndrome is a rare clinical entity characterized by celiac trunk compression by median arcuate ligament and variable gastrointestinal symptoms (postprandial epigastric pain, nausea, weight loss, anorexia and diarrhea). However, some degree of radiographic compression is observed in 10%-24% of asymptomatic patients. Besides the extrinsic vascular compression, MALS has a multifactorial etiology and it has been suggested as a neurogenic disease resulting in altered sensation and pain from the somatic nerves in the splanchnic plexus. MALS is a diagnosis of exclusion, so other causes must be excluded. Treatment options include release of median arcuate ligament (open, laparoscopic or robot-assisted) and open vascular reconstruction. Endovascular treatment is currently used only as adjuvant procedure after surgical approach, in refractory cases with residual stenosis of celiac trunk. OBJECTIVE: To report a case of MALS and to review current literature. METHODS: The authors report a clinical case and present a literature review using PubMed with the terms "median arcuate ligament", "Dunbar syndrome" and "MALS treatment" as major topics. The bibliography of relevant articles has been checked to identify other significant papers. RESULTS: A 34-year-old woman, previously healthy, recurred to a General Practitioner with a recurrent epigastric pain, exacerbated by ingestion, without relieving factors, in the previous 6 months. Patient also reported anorexia and unprovoked weight loss of 8Kg over 3 months. Physical examination was normal. Other gastrointestinal pathologies were ruled out. Computed Tomography Angiography (CTA) abdomen revealed a focal 80% stenosis of the celiac trunk, located 8mm from its origin in aorta and a post- -stenotic enlargement of 9mm. An open decompression of the celiac trunk was performed. Through an 8cm median supraumbilical laparotomy, supraceliac abdominal aorta was approached. The compressive band across the celiac trunk was identified and cut. Further dissection was performed until the celiac artery became completely exposed and its branches identified. The postoperative period was uneventful and the patient was discharged 5 days later, with normal gastrointestinal transit and without recurrence of the abdominal pain. 1 month later, the patient remained asymptomatic. A long-term follow-up with annual duplex scan and clinical evaluation must be done, in order to evaluate the need of a revascularization due to persistent stenosis or aneurysmal degeneration. CONCLUSION: MALS diagnostic and therapeutic approach must be patient focused, bearing in mind the multiple clinical presentation and treatment options. Open surgical decompression of median arcuate ligament is the base of therapy.

Influence of Interhospital Transfer on Outcomes of Symptomatic and Ruptured Abdominal Aortic Aneurysms.

INTRODUCTION: Symptomatic or ruptured abdominal aortic aneurysms (rAAA) maintains a high mortality index despite technical advances in its treatment. The influence of patients' geographic location on rAAA outcomes, when the rupture occurs or when the AAA becomes symptomatic, has not been a commonly studied issue. Due to the lack of research on this matter, the impact of interhospital transfer on mortality is ambiguous. OBJECTIVE: Evaluate the influence of the geographic location of patients with symptomatic AAA or rAAA on AAA mortality. METHODS: Retrospective review of all cases of symptomatic AAA and rAAA submitted to surgery in a tertiary institution, between January 2011 and August 2017. The main outcome was in-hospital mortality. Secondary outcomes were admission to intensive care unit (ICU), length of ICU and hospital stay, type of repair and anesthesia and weekend presentation. Data was submitted to univariable analysis and logistic regression. Statistical significance was considered if the p value was <0.05. RESULTS: During the defined period of 80 months, a total of 135 patients were admitted with the diagnosis of symptomatic or rAAA and submitted to surgery. Most patients had a ruptured AAA (90.4%, n=122), while symptomatic AAA represented a minority (9.6%, n=13). All patients (91.1% male gender, mean age 74±10 years) were submitted to surgery, 83 (61.5%) by endovascular repair and 52 (38.5%) by open repair, 30.4% with local anesthesia and sedation (n=41), all in the endovascular group. 92 patients (68.1%) were transferred from other hospitals, with a mean distance of 113±88 km. In this cohort, in-hospital mortality was 31.5% in transferred patients and 34.9% in not transferred patients. Subgroup analysis revealed that there were no significant differences between transferred and not transferred patients' groups concerning main outcome (p=0.35), baseline characteristics (age and gender), type of surgery and anesthesia, weekend presentation, ICU admission, length of ICU and hospital stay. Logistic regression analysis revealed that the variables associated with mortality were female gender (odds ratio [OR] 2.28; 95% confidence interval [CI] 1.40-3.70; p<0.01), open repair (OR 2.79; 95% CI 1.68-4.63; p<0.01) and general anesthesia (OR 9.16; 95% CI 2.33-36.06; p<0.01). CONCLUSION: Our study revealed that transfer of patients for urgent repair of AAA was not associated with an increased mortality. The hypothetical increased mortality due to transfer might have been compensated by endovascular treatment and local anesthesia in some cases. Further studies must be carried out, particularly comparing endovascular and open repair in emergency setting.

Infrarenal Abdominal Penetrating Aortic Ulcer, an Atypical Location of a Rare Disease.

INTRODUCTION: Penetrating aortic ulcer (PAU) is classically included in acute aortic syndromes, together with aortic dissection and intramural hematoma. These three disorders are considered different stages of the same disease. PAU is the result of medial degeneration with disruption of the intima, mainly due to atherosclerotic risk factors. Most of them are located on descending thoracic aorta and only a few small series and case reports demonstrate location on infrarenal abdominal aorta. Clinical presentation varies in spectrum, from asymptomatic to fatal aortic rupture. Treatment options include medical therapy, particularly strict blood pressure control, and surgical approach. Nowadays endovascular exclusion is commonly performed, although open surgical reconstruction remains the gold standard. METHODS: Report a case of endovascular repair of an infrarenal abdominal PAU. RESULTS: A 72-year-old man, with hypertension, type 2 diabetes, hypercholesterolemia, lumbar osteoarthrosis, was referred to Vascular Surgery outpatient clinic with the diagnosis of infrarenal abdominal PAU on a Computed Tomography Angiography (CTA). This exam was performed due to chronic lumbar complaints from lumbar osteoarthrosis. The patient denied any other complaint. Physical examination was normal. A thoraco-abdomino-pelvic CTA revealed two sites of PAU in the infrarenal aorta with 10mm and 21mm of depth and associated aortic enlargement of 39mm maximum diameter. This exam revealed an enlargement of the depth of the PAU and the aorta diameter in 2 and 3mm, respectively, in the course of 2 months. An EVAR was performed, in a standard aorto-biiliac fashion. The post-operative period was uneventful and the patient discharged 3 days later. 1 month after the surgery, patient remained asymptomatic and the follow-up CTA demonstrated exclusion of both PAU, no endoleaks and stability of aortic diameter. A long term follow-up should be maintained, as for regular EVAR. CONCLUSION: PAU is a rare clinical entity, with infrarenal abdominal aorta location even scarcer. Asymptomatic patient must be regularly followed and threshold to treatment low, bearing in mind the possible catastrophic evolution of the disease. Endovascular approach should be considered as a first approach, considering the technical feasibility and the comorbidities associated with this elderly population.

The implications of recurrent disturbances within the world's hottest coral reef.

Determining how coral ecosystems are structured within extreme environments may provide insights into how coral reefs are impacted by future climate change. Benthic community structure was examined within the Persian Gulf, and adjacent Musandam and northern Oman regions across a 3-year period (2008-2011) in which all regions were exposed to major disturbances. Although there was evidence of temporal switching in coral composition within regions, communities predominantly reflected local environmental conditions and the disturbance history of each region. Gulf reefs showed little change in coral composition, being dominated by stress-tolerant Faviidae and Poritidae across the 3 years. In comparison, Musandam and Oman coral communities were comprised of stress-sensitive Acroporidae and Pocilloporidae; Oman communities showed substantial declines in such taxa and increased cover of stress-tolerant communities. Our results suggest that coral communities may persist within an increasingly disturbed future environment, albeit in a much more structurally simple configuration.

DEFECTIVE KERNEL 1 promotes and maintains plant epidermal differentiation.

During plant epidermal development, many cell types are generated from protodermal cells, a process requiring complex co-ordination of cell division, growth, endoreduplication and the acquisition of differentiated cellular morphologies. Here we show that the Arabidopsis phytocalpain DEFECTIVE KERNEL 1 (DEK1) promotes the differentiated epidermal state. Plants with reduced DEK1 activity produce cotyledon epidermis with protodermal characteristics, despite showing normal growth and endoreduplication. Furthermore, in non-embryonic tissues (true leaves, sepals), DEK1 is required for epidermis differentiation maintenance. We show that the HD-ZIP IV family of epidermis-specific differentiation-promoting transcription factors are key, albeit indirect, targets of DEK1 activity. We propose a model in which DEK1 influences HD-ZIP IV gene expression, and thus epidermis differentiation, by promoting cell adhesion and communication in the epidermis.

Epidermal identity is maintained by cell-cell communication via a universally active feedback loop in Arabidopsis thaliana.

The transcription factors ARABIDOPSIS THALIANA MERISTEM L1 (ATML1) and PROTODERMAL FACTOR2 (PDF2) are indispensable for epidermal cell-fate specification in Arabidopsis embryos. However, the mechanisms of regulation of these genes, particularly their relationship with cell-cell signalling pathways, although the subject of considerable speculation, remain unclear. Here we demonstrate that the receptor kinase ARABIDOPSIS CRINKLY4 (ACR4) positively affects the expression of ATML1 and PDF2 in seedlings. In contrast, ATML1- and PDF2-containing complexes directly and negatively affect both their own expression and that of ACR4. By modelling the resulting feedback loop, we demonstrate a network structure that is capable of maintaining robust epidermal cell identity post-germination. We show that a second seed-specific signalling pathway involving the subtilase ABNORMAL LEAFSHAPE1 (ALE1) and the receptor kinases GASSHO1 (GSO1) and GASSHO2 (GSO2) acts in parallel to the epidermal loop to control embryonic surface formation via an ATML1/PDF2-independent pathway. Genetic interactions between components of this linear pathway and the epidermal loop suggest that an intact embryo surface is necessary for initiation and/or stabilization of the epidermal loop, specifically during early embryogenesis.

Critical research needs for identifying future changes in Gulf coral reef ecosystems.

Expert opinion was assessed to identify current knowledge gaps in determining future changes in Arabian/Persian Gulf (thereafter 'Gulf') coral reefs. Thirty-one participants submitted 71 research questions that were peer-assessed in terms of scientific importance (i.e., filled a knowledge gap and was a research priority) and efficiency in resource use (i.e., was highly feasible and ecologically broad). Ten research questions, in six major research areas, were highly important for both understanding Gulf coral reef ecosystems and also an efficient use of limited research resources. These questions mirrored global evaluations of the importance of understanding and evaluating biodiversity, determining the potential impacts of climate change, the role of anthropogenic impacts in structuring coral reef communities, and economically evaluating coral reef communities. These questions provide guidance for future research on coral reef ecosystems within the Gulf, and enhance the potential for assessment and management of future changes in this globally significant region.

Embryonic cuticle establishment: the great (apoplastic) divide.

The plant cuticle, a dynamic interface between plants and their environment, is formed by the secretion of hydrophobic lipids and waxes into the outer wall of aerial epidermal cells. Cuticle formation is such a ubiquitous feature of epidermal cells, and is of such fundamental importance for plant survival, that identifying and understanding specific developmental roles for this structure has been a major challenge for plant scientists. In recent work, we have tried to understand the functional relationships between a signaling feedback loop required for epidermal cell specification in developing plant embryos, and a seed specific signaling cascade, involving components localized both in the embryo and in the embryo surrounding endosperm, and necessary for embryo cuticle function. Analysis of the strongly synergistic genetic relationships between these 2 independent pathways, combined with mathematical simulations of the behavior of the signaling feedback loop, have allowed us to propose an important, and hitherto unsuspected, role for the embryonic cuticle as an apoplastic diffusion barrier, necessary for preventing the excessive diffusion of developmentally important signaling molecules away from developing embryo into surrounding tissues.

Implementation of communication-mediating domains for non-ribosomal peptide production in Saccharomyces cerevisiae.

Saccharomyces cerevisiae has in several cases been proven to be a suitable host for the production of natural products and was recently exploited for the production of non-ribosomal peptides. Synthesis of non-ribosomal peptides (NRPs) is mediated by NRP synthetases (NRPSs), modular enzymes, which are often organized in enzyme complexes. In these complexes, partner NRPSs interact via communication-mediating domains (COM domains). In order to test whether functional interaction between separate NRPS modules is possible in yeast we constructed a yeast strain expressing two modules with compatible COM domains from two plasmids. Successful production as well as secretion of the expected dipeptide was detected. This opens the possibility of using yeast as a eukaryotic platform for fast assessment of new module combinations for the development of novel NRP compounds.