Gentianamopanshanensis (Gentianaceae), a new species from Yunnan, southwest China.

Gentianamopanshanensis, a new species of the family Gentianaceae is here described and illustrated. This species is presently known only from the Mopanshan Mountain, Yunnan Province, southwest China. Phylogenetic analysis based on ITS sequence data has shown that this new species is a member of the series Fimbriatae of the section Chondrophyllae. Morphologically, it mostly resembles G.mairei and G.panthaica, but differs clearly from the latter two species in the shape and size of the leaves, and the characters of the corolla throat and plicae.

ACETYL-COA PRODUCTION BY OCTANOIC ACID ALLEVIATES ACUTE COMPARTMENT SYNDROME-INDUCED SKELETAL MUSCLE INJURY THROUGH REGULATING MITOPHAGY.

ABSTRACT: Background: Treatment of acute compartment syndrome (ACS)-induced skeletal muscle injury remains a challenge. Previous studies have shown that octanoic acid is a promising treatment for ACS owing to its potential ability to regulate metabolic/epigenetic pathways in ischemic injury. The present study was designed to investigate the efficacy and underlying mechanism of octanoic acid in ACS-induced skeletal muscle injury. Methods: In this study, we established a saline infusion ACS rat model. Subsequently, we assessed the protective effects of sodium octanoate (NaO, sodium salt of octanoic acid) on ACS-induced skeletal muscle injury. Afterward, the level of acetyl-coenzyme A and histone acetylation in the skeletal muscle tissue were quantified. Moreover, we investigated the activation of the AMP-activated protein kinas pathway and the occurrence of mitophagy in the skeletal muscle tissue. Lastly, we scrutinized the expression of proteins associated with mitochondrial dynamics in the skeletal muscle tissue. Results: The administration of NaO attenuated muscle inflammation, alleviating oxidative stress and muscle edema. Moreover, NaO treatment enhanced muscle blood perfusion, leading to the inhibition of apoptosis-related skeletal muscle cell death after ACS. In addition, NaO demonstrated the ability to halt skeletal muscle fibrosis and enhance the functional recovery of muscle post-ACS. Further analysis indicates that NaO treatment increases the acetyl-CoA level in muscle and the process of histone acetylation by acetyl-CoA. Lastly, we found NaO treatment exerts a stimulatory impact on the activation of the AMPK pathway, thus promoting mitophagy and improving mitochondrial dynamics. Conclusion: Our findings indicate that octanoic acid may ameliorate skeletal muscle injury induced by ACS. Its protective effects may be attributed to the promotion of acetyl-CoA synthesis and histone acetylation within the muscular tissue, as well as its activation of the AMPK-related mitophagy pathway.

Isodonxiaoluzhiensis (Lamiaceae, Nepetoideae), a new species from Yunnan, southwest China.

Isodonxiaoluzhiensis, a new species of the tribe Ocimeae in family Lamiaceae, is described and illustrated. The new species is known only from the type locality, Xiaoluzhi village in Luzhijang dry-hot valley of Yimen County, central Yunnan, southwest China. It is characterized by having a procumbent habit, gracile stems and branches, relatively small leaves and flowers, and the phenology of flowering in winter. The morphological comparisons with its putative closest relatives (I.adenanthus and I.hsiwenii) are also presented.

Bronchiole adenoma/pulmonary ciliated mucinous nodular papillary tumor: Case series and literature review.

OBJECTIVE: To analyze the clinical-pathological characteristics of 3 cases of bronchiolar adenoma/pulmonary ciliary mucinous nodular papillary tumors, and to improve the understanding of bronchiolar adenoma (BA)/ciliated muconodular papillary tumors (CMPT) (bronchiolar adenoma/ciliated muconodular papillary tumor). METHODS: Retrospective analysis was done on the clinical information, diagnosis, and treatment of 3 instances of BA/CMPT at the Second People's Hospital of Weifang City. By scanning the CNKI, Wanfang, VIP database, and Pubmed database using the English key words "bronchiolar adenoma, ciliated muconodular papillary tumor," respectively patients with comprehensive clinical data were gathered, and studies from January 2002 to August 2021 that were relevant to the patients were examined. RESULTS: A total of 35 articles and 71 instances were found, including 3 cases in our hospital, for a total of 74 cases. There were 31 males and 43 females among them, ranging in age from 18 to 84 years (average 63 years), and 15 cases had a smoking history. The majority of them were discovered by physical examination and had no clinical symptoms. The majority of the imaging revealed solid nodules with variable forms, with some ground-glass nodules displaying vacuole and bronchial inflation signs. BA/CMPT are generally gray-white, gray-brown solid nodules with obvious boundaries but no envelope with a maximum dimension of 4 to 45 mm (average 10.6 mm) on gross examination. Acinar, papillary, and lepidic formations can be seen under the microscope at high magnification; the majority of these structures are made up of tripartite epithelial components, including basal cells, mucous cells, ciliated columnar cells, and alveolar epithelial cells, demonstrating a variety of combinations. An important basis for diagnosis in immunohistochemistry is the continuous positive basal cell layer that is shown by p63, p40, and CK5/6. BRAF and epidermal growth factor receptor are the genes that are most frequently mutated. All of the patients showed no signs of metastasis or recurrence during follow-up period. CONCLUSION: BA/CMPT is a rare benign tumor of lung epithelium. Because imaging and intraoperative cryosection diagnosis are easy to be misdiagnosed as malignant, it is necessary to further improve understanding and improve immunohistochemistry and genetic examination.

Hemilophiacardiocarpa (Brassicaceae), a new species from Yunnan, southwest China.

Hemilophiacardiocarpa (Brassicaceae), the sixth species of the Chinese endemic genus Hemilophia, is described and illustrated. This plant is found in the Jiaozishan Mountains in Dongchuan District, northern Yunnan, southwest China. Morphologically, it shows close relationships with H.rockii and H.pulchella, but differs from it in the leaf shape and size, inflorescence, flower size, shape of fruit and length of its pedicel. An updated key to the taxa of Hemilophia is provided.

High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study.

BACKGROUND: We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO2) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days. METHODS: During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO2. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO2 therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation. RESULTS: In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups. CONCLUSIONS: Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO2 protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.

Automated pupillometry helps monitor the efficacy of cardiopulmonary resuscitation and predict return of spontaneous circulation.

BACKGROUND: We investigated the effectiveness of automated pupillometry on monitoring cardiopulmonary resuscitation (CPR) and predicting return of spontaneous circulation (ROSC) in a swine model of cardiac arrest (CA). METHODS: Sixteen male domestic pigs were included. Traditional indices including coronary perfusion pressure (CPP), end-tidal carbon dioxide (ETCO2), regional cerebral tissue oxygen saturation (rSO2) and carotid blood flow (CBF) were continuously monitored throughout the experiment. In addition, the pupillary parameters including the initial pupil size before constriction (Init, maximum diameter), the end pupil size at peak constriction (End, minimum diameter), and percentage of change (%PLR) were measured by an automated quantitative pupillometer at baseline, at 1, 4, 7 min during CA, and at 1, 4, 7 min during CPR. RESULTS: ROSC was achieved in 11/16 animals. The levels of CPP, ETCO2, rSO2 and CBF were significantly greater during CPR in resuscitated animals than those non-resuscitated ones. Init and End were decreased and %PLR was increased during CPR in resuscitated animals when compared with those non-resuscitated ones. There were moderate to good significant correlations between traditional indices and Init, End, and %PLR (|r| = 0.46-0.78, all P < 0.001). Furthermore, comparable performance was also achieved by automated pupillometry (AUCs of Init, End and %PLR were 0.821, 0.873 and 0.821, respectively, all P < 0.05) compared with the traditional indices (AUCs = 0.809-0.946). CONCLUSION: The automated pupillometry may serve as an effective surrogate method to monitor cardiopulmonary resuscitation efficacy and predict ROSC in a swine model of cardiac arrest.

Establishment of a swine model of traumatic cardiac arrest induced by haemorrhage and ventricular fibrillation.

OBJECTIVE: To establish and evaluate a swine model of traumatic cardiac arrest (TCA) induced by haemorrhage and ventricular fibrillation. METHODS: Thirteen male pigs were divided into a sham group (n = 5) and TCA group (n = 8). Animals in the sham-operated group underwent intubation and monitoring but not haemorrhage and resuscitation, while animals in the TCA group underwent 40% blood volume haemorrhage over 20 min followed by 5 min of ventricular fibrillation and 5 min of cardiopulmonary resuscitation with fluid resuscitation. RESULTS: Restoration of spontaneous circulation was achieved in seven of eight animals in the TCA group. After resuscitation, the heart rate was significantly increased while the mean arterial pressure and ejection fraction were significantly decreased in the TCA group. The TCA group had significant cardiac and neurological injuries post-resuscitation and had higher serum creatinine and blood lactic acid levels and lower PaO2 than the sham group. Animals in the TCA group also exhibited significantly higher apoptotic indices and caspase-3 protein levels in the heart, brain and kidney than the sham group. CONCLUSION: Animals in this swine model of TCA exhibited high rates of successful resuscitation, significant vital organ injury and prolonged survival. The model is suitable for use in further TCA research.

Effect of a feedback system on the quality of 2-minute chest compression-only cardiopulmonary resuscitation: a randomised crossover simulation study.

OBJECTIVE: We evaluated the quality of 2-minute continuous chest compressions (CCCs) performed by emergency staff in 30-second intervals to determine the effect of a feedback system on maintaining the quality of CCCs. METHODS: Two hundred three physicians and nurses were randomised into two groups. Each participant performed 2-minute CCCs both with and without feedback. Group A performed CCCs under the guidance of a feedback device followed by performance without feedback, and Group B performed these tasks in reverse order. The primary outcome was the proportion of optimal compressions; i.e., compressions at both the correct rate (100-120 beats/minute) and correct depth (5-6 cm). RESULTS: During 2-minute CCCs, the proportion of optimal compressions was poor in personnel without feedback. The proportion of optimal compressions was unchanged and low from 2.4% (interquartile range, 0.0%-32.8%) in the first 30 seconds to 3.3% (0.0%-47.7%) in the last 30 seconds of the 2-minute period. Use of the feedback device significantly improved and maintained the quality of compressions from the first 30 seconds (53.3%; 29.2%-70.4%) to the last 30 seconds (82.8%; 50.8%-96.2%). CONCLUSION: Use of the feedback device was helpful for maintaining the quality of CCCs.

Hypothermia Inhibits Cerebral Necroptosis and NOD-Like Receptor Pyrin Domain Containing 3 Pathway in a Swine Model of Cardiac Arrest.

BACKGROUND: Targeted temperature management (TTM) is commonly used in hypothermia after cardiopulmonary resuscitation (CPR), and its mechanism to improve cerebral function is complex. This study aimed to investigate the effects of TTM on necroptosis and the NOD-like receptor pyrin domain containing 3 (NLRP3) inflammasome in the brain tissue of pigs after CPR. MATERIALS AND METHODS: Ventricular fibrillation was induced, and CPR was performed 10 min later in nine pigs in the normothermia group and nine pigs in the TTM group. The body temperature in the TTM group was dropped to 33°C after CPR and maintained for 24 h, whereas in the normothermia group, it was maintained at 38°C. Before CPR and at 30 h after CPR, serum neuron-specific enolase and S-100ß were measured. At 30 h after CPR, pigs were euthanized, and brain tissues were collected for measurement of receptor-interacting protein kinase (RIPIK) 1, RIPK3, mixed lineage kinase domain-like (MLKL), NLRP3, cysteinyl aspartate-specific proteinase (caspase)-1, interleukin (IL)-1ß, and IL-18. RESULTS: Serum neuron-specific enolase and S-100ß were increased significantly (P < 0.05) in the two CPR-treated groups compared with the sham group and more obviously in the normothermia group. In addition, the expression of RIPK3, phosphorylated MLKL, and NLRP3 in brain tissues was increased. The expression of RIPK3, phosphorylated MLKL, NLRP3, and caspase-1 as well as the levels of IL-1ß and IL-18 were lower (P < 0.05) in the TTM group compared with the normothermia group. CONCLUSIONS: Necroptosis and the NLRP3 pathway were activated after CPR. TTM may attenuate postresuscitation brain injury through the regulation of necroptosis and the NLRP3 pathway.

Use of a Doppler-Based Pulsatility Index to Evaluate Cerebral Hemodynamics in Neurocritical Patients After Hemicraniectomy.

OBJECTIVES: As a noninvasive method for evaluation of cerebral hemodynamics, the correct interpretation of transcranial Doppler or transcranial imaging (TCI) data remains a major challenge. We explored how to interpret the pulsatility index (PI) derived via TCI during evaluations of cerebral hemodynamics in posthemicraniectomy patients. METHODS: We included patients who underwent invasive arterial pressure and intracranial pressure (ICP) monitoring and simultaneous TCI examinations after hemicraniectomy. We classified the PI of the middle cerebral artery (MCA) into ipsilateral (craniectomy side) and contralateral (opposite side) and analyzed both data sets. The statistical analysis was performed by the Bland-Altman approach, by calculating intraclass correlation coefficients and Spearman correlations, and by drawing receiver operating characteristic curves. Pulsatility index probability charts were created for ICPs exceeding 20, 25, and 30 mm Hg and cerebral perfusion pressures (CPPs) lower than 70, 60, and 50 mm Hg; we thus explored defined ICP and CPP values. RESULTS: The ipsilateral and contralateral MCA PI data differed. Only the ipsilateral MCA PI showed a weak correlation with ICP (r = 0.378; P < .001). The receiver operating characteristic curve analysis revealed limited diagnostic utility of bilateral MCA PIs for ICP and CPP assessments. An extremely elevated MCA PI indicated that patients were at high risk of a dangerous ICP elevation or CPP reduction. However, MCA PI values within the normal range did not effectively rule out an ICP of 20 mm Hg or higher but effectively eliminated a CPP lower than 50 mm Hg. CONCLUSIONS: In posthemicraniectomy patients, the Doppler-based MCA PI value was ineffectively for quantitative ICP and CPP evaluations but a useful index for assessment of cerebral hemodynamics in terms of the probability of an ICP elevation or a CPP reduction.

The Effects of the Duration of Aortic Balloon Occlusion on Outcomes of Traumatic Cardiac Arrest in a Porcine Model.

Aortic balloon occlusion (ABO) facilitates the success of cardiopulmonary resuscitation (CPR) in non-traumatic cardiac arrest, and is also effective in controlling traumatic hemorrhage; however, a prolonged occlusion results in irreversible organ injury and death. In this study, we investigated the effects of ABO on CPR outcomes and its optimal duration for post-resuscitation organ protection in a porcine model of traumatic cardiac arrest (TCA).Twenty-seven male domestic pigs weighing 33 ±â€Š4 kg were utilized. Forty percent of estimated blood volume was removed within 20 min. The animals were then subjected to 5 min of untreated ventricular fibrillation and 5 min of CPR. Coincident with the start of CPR, the animals were randomized to receive either 30-min ABO (n = 7), 60-min ABO (n = 8) or control (n = 12). Meanwhile, fluid resuscitation was initiated by the infusion of normal saline with 1.5 times of hemorrhage volume in 1 h, and finished by the reinfusion of 50% of the shed blood in another 1 h. The resuscitated animals were monitored for 6 h and observed for an additional 18 h.During CPR, coronary perfusion pressure was significantly increased followed by a higher rate of resuscitation success in the 30 and 60-min ABO groups compared with the control group. However, post-resuscitation cardiac, neurologic dysfunction, and injuries were significantly milder accompanied with less renal and intestinal injuries in the 30-min ABO group than in the other two groups.In conclusion, ABO augmented the efficacy of CPR after TCA, and furthermore a 30-min ABO improved post-resuscitation cardiac and neurologic outcomes without exacerbating the injuries of kidney and intestine.

Diagnostic and prognostic value of the optic nerve sheath diameter with respect to the intracranial pressure and neurological outcome of patients following hemicraniectomy.

BACKGROUND: In cases showing cerebrospinal fluid (CSF) redistribution as a compensatory mechanism in acute intracranial hypertension, the optic nerve sheath diameter (ONSD) can be used to estimate intracranial pressure (ICP). However, it remains unclear whether the ONSD can be applied in patients with skull defects after a craniectomy, because the primary injury or surgical craniectomy may alter the dynamics of the CSF circulation or structure of the optical nerve sheath. This study explored the value of the ONSD in patients after a hemicraniectomy. METHODS: This prospective observational study enrolled patients after a hemicraniectomy. All patients underwent invasive ICP monitoring and ocular ultrasound within 6 h postoperatively. We followed the patients for 6 months and evaluated them using the Glasgow Outcome Score (GOS), classifying the outcome as favorable (GOS 4-5) or unfavorable (GOS 1-3). We evaluated the ONSD in both according to the ICP and neurological outcome. RESULTS: Of the 33 enrolled patients, 20 (60.6%) had an unfavorable outcome at 6 months. Disagreement was seen in the ONSD measurements between the eyes [craniectomy side (ONSDips) and opposite side (ONSDcon)]. The intraclass correlation coefficient between ONSDips and ONSDcon was 0.745 (p < 0.001). ONSD had no significant correlation with ICP in Spearman correlation analysis (ONSDips r = 0.205, p = 0.252; ONSDcon r = 0.164, p = 0.362). Receiver operator characteristic (ROC) curve analysis revealed that the GCS, Helsinki computed tomography (CT) score, pupil reaction, and ONSDcon measured after the craniectomy were significantly associated with a poor outcome. ONSDcon > 5.5 mm predicted a poor outcome, with an area under the ROC curve of 0.717 (95% confidence interval, 0.534-0.860, p = 0.02), 70% sensitivity, and 69.2% specificity. CONCLUSIONS: After hemicraniectomy, the ONSD measured on ultrasound was unreliable for evaluating ICP, but showed potential prognostic value for a poor neurological outcome.

Multi-organ protection of ulinastatin in traumatic cardiac arrest model.

Background: Post-cardiac arrest syndrome, which has no specific curative treatment, contributes to the high mortality rate of victims who suffer traumatic cardiac arrest (TCA) and initially can be resuscitated. In the present study, we investigated the potential of ulinastatin to mitigate multiple organ injury after resuscitation in a swine TCA model. Methods: Twenty-one male pigs were subjected to hemodynamic shock (40% estimated blood loss in 20 min) followed by cardiac arrest (electrically induced ventricular fibrillation) and respiratory suspension for 5 min, and finally manual resuscitation. At 5 min after resuscitation, pigs were randomized to receive 80,000 U/kg ulinastatin (n = 7) or the same volume of saline (n = 9) in the TCA group. Pigs in the sham group (n = 5) were not exposed to bleeding or cardiac arrest. At baseline and at 1, 3, and 6 h after the return of spontaneous circulation, blood samples were collected and assayed for tumor necrosis factor-alpha, interleukin 6, and other indicators of organ injury. At 24 h after resuscitation, pigs were sacrificed and apoptosis levels were assessed in samples of heart, brain, kidney, and intestine. Results: One pig died in the ulinastatin group and one pig died in the TCA group; the remaining animals were included in the final analysis. TCA and resuscitation caused significant increases in multiple organ function biomarkers in serum, increases in tumor necrosis factor-alpha, and interleukin 6 in serum and increases in the extent of apoptosis in key organs. All these increases were lower in the ulinastatin group. Conclusion: Ulinastatin may attenuate multiple organ injury after TCA, which should be explored in clinical studies.

The chronergy of recombinant streptokinase thrombolysis in acute myocardial infarction.

The aim of this study was to explore the chronergy of intravenous recombinant streptokinase (r-SK) in patients with acute myocardial infarction (AMI). A total of 114 patients were divided into two groups according to the time of AMI onset: the morning onset (6:01-12:00, n=53) and non-morning onset (12:01-06:00, n=61) groups. The recanalization rate was recorded, as well as anticoagulant and fibrinolytic indices. Statistical analysis was performed to evaluate the recanalization rate following thrombolysis, as well as the anticoagulant and fibrinolytic activities. The recanalization rates following thrombolysis in the morning onset and non-morning onset groups were 60.4 and 82.0%, respectively (P<0.05). The level of plasminogen activator inhibitor-1 (PAI-1) antigen was significantly higher in the morning onset group compared with that in the non-morning onset group (P<0.05). This indicated a resistance to r-SK thrombolysis in the morning at the early stage of AMI, which possibly correlates with increased PAI-1 antigen levels and activity.

[Comparative study on hypoglycemic effects of different traditional Chinese medicine treatments in rats with diabetes mellitus induced by alloxan].

OBJECTIVE: To observe hypoglycemic effects of Yunu Decoction, Zuogui Pill and Shenqi Pill, three compound traditional Chinese herbal medicines, in treatment of diabetes mellitus induced by alloxan in rats, and to compare the therapeutic effects among the three recipes for nourishing yin, clearing away heat, and nourishing yin and warming yang. METHODS: Diabetes mellitus was induced in rats with alloxan at a dose of 60 mg/kg via tail vain injection. The diabetic rats were randomly divided into four groups: alloxan model group, Yunu Decoction-treated group, Zuogui Pill-treated group and Shenqi Pill-treated group. Rats in the three recipe groups were administered intragastrically with water extraction of Yunu Decoction, Zuogui Pill, and Shenqi Pill accordingly for 10 days. Then the level of blood glucose was measured by glucose oxidase method and the glucose tolerance was determined. RESULTS: Compared with the normal rats, blood glucose level in the alloxan model group was obviously increased (P<0.05). Glucose levels in the three recipe groups were obviously decreased as compared with the alloxan model group (P<0.05), and glucose level in the Yunu Decoction-treated group after treatment was significant lower than before treatment (P<0.05). The glucose tolerance test indicated that rats in the alloxan model and three recipe groups revealed impaired glucose tolerance as compared with the normal rats, and there were no significant differences between the alloxan model group and the three recipe groups. CONCLUSION: Yunu Decoction, Zuogui Pill and Shenqi Pill can effectively decrease the glucose level of the rats with diabetes mellitus induced by alloxan, and Yunu Decoction showed the best therapeutic effects. The glucose tolerance test shows that the three recipes cannot correct the abnormal metabolism of glucose.

[Amniotic membrane transplantation and limbal autograft transplantation for patients with recurrent pterygium].

OBJECT: To evaluate the effect of amniotic membrane transplantation and limbal autograft transplantation for recurrent pterygium. METHODS: Patients with recurrent pterygium underwent pterygia excision with amniotic membrane transplantation and limbal auto-graft transplantation. The condition of grafts, the corneal surface and the recurrent rate were observed. RESULTS: Twenty-eight patients (32 eyes) with recurrent pterygium underwent pterygia excision with amniotic membrane transplantation and limbal auto-graft transplantation. The mean time of corneal epithelial healing was 4.4 +/- 1.5 days. The recurrent rate was 12.5% with the mean follow-up of 7.6 months. CONCLUSION: Amniotic membrane transplantation and limbal auto-graft transplantation can reduce the recurrence in patients with recurrent pterygium. The decompensation of the limbal stem cells should be considered to the severe patients.