Outcomes of endovascular therapy for Stanford type B aortic dissection in patients with sleep apnea syndrome.

OBJECTIVE: This study aimed to determine the influences of varying severity of sleep apnea syndrome (SAS) on the outcomes after thoracic endovascular aorta repair (TEVAR) in patients with Stanford type B aortic dissection (TBAD). METHODS: This observational study focused on individuals with TBAD plus SAS who received TEVAR between January 2018 and December 2022. Patients were divided into groups according to the results of the portable sleep-breathing monitoring systems: mild SAS (MSAS) and moderate-to-severe SAS (MSSAS). Clinical profiles were collected and analyzed. RESULTS: A total of 121 cases with TBAD plus SAS who underwent TEVAR were enrolled in this study. Two groups were formed by stratifying these cases: MSAS (74 cases) and MSSAS (47 cases). The MSSAS cases were found to be older relative to MSAS cases (51.7 ± 8.3 years vs 57.1 ± 12.8 years; P = .012) and had a higher body mass index (BMI; 25.7 ± 2.3 kg/m2vs 27.0 ± 2.3 kg/m2; P = .038). The investigation did not find any appreciable differences between the MSAS and MSSAS groups in terms of complications (endoleak, P = .403; stent-induced new entry, P >.999; and stent displacement: P >.999). However, the MSSAS group exhibited a significantly higher overall mortality rate compared with the MSAS group (log-rank P = .027). The tendency continued when examining cases with Marfan syndrome combined with MSSAS, where the overall mortality rate was significantly greater compared with Marfan syndrome cases with MSAS (log-rank P = .037). The absence of a significant difference was noteworthy in the freedom from reintervention between the MSAS and MSSAS groups (log-rank P = .278). The overall mortality rate was significantly higher in MSSAS group even after adjusting for varying potential confounders in the multivariate cox regression analysis (hazard ratio [HR], 1.875; 95% confidence interval [CI], 1.238-2.586; P = .012). A markedly higher rate of distal stent dilation in the MSSAS group was also observed compared with the MSAS group (HR, 2.5 mm/year [95% CI, 2-3 mm/year] vs HR, 4 mm/year [95% CI, 2.0-5.5 mm/year]; P = .029). CONCLUSIONS: MSSAS is associated with a significantly higher risk of overall mortality and dilation rate of the distal stent after TEVAR for TBAD patients. Hence, aggressive efforts to reverse the severity of SAS in time in these individuals seem to be necessary.

Effect of dietary concentrate level on digestibility of nutrients in each region of the gastrointestinal tract and rumen fermentation in goats.

This study evaluated the effects of high concentrate diets (HCD) on the rumen fermentation and the digestibility of nutrients in different sites of the gastrointestinal tract (GIT) in goats. Four goats were used in a crossover design. The goats were fitted with a ruminal cannula and flexible T-cannulae proximal duodenum and terminal ileum. Treatments were as follows: low concentrate group (LCG) and high concentrate group (HCG). Duodenal flow and forestomach digestibility of starch were significantly higher in the HCG than those in the LCG (p < 0.05); There was no significant difference in ileum flow and digestibility of starch in the small intestine, large intestine and total GIT (p > 0.05). The digestibility of crude protein (CP) in the forestomach was significantly higher in the HCG than in the LCG (p < 0.05); the flow of the duodenum and ileum of CP, and the CP digestibility of the small intestine, large intestine and total GIT were not significantly different between groups (p > 0.05). The duodenal and ileal flow of neutral detergent fiber (NDF), the NDF digestibility of the different segments and total GIT were not significantly different between groups (p > 0.05). Compared to the LCG, the ruminal pH of the HCG was significantly lower (p < 0.05). The HCG concentrations of microbial crude protein, ammonia nitrogen and isovaleric acid were significantly higher (p < 0.05) than the LCG. The foam strength, foam production and viscosity of the rumen fluid in the HCG were higher than the LCG (p < 0.01). These results showed that when the goats were fed with HCD, the digestibility of nutrients was not significantly impaired, but the risk of frothy rumen bloat increased. ImplicationsDue to a serious shortage of high-quality roughage in China, producers commonly used a high-concentrate diet in ruminants, which can improve animal production performance.Gastrointestinal digestive function plays a vital role in the absorption of nutrients and the healthy growth of animals.Therefore, this research evaluated the digestibility of various nutrients in different segments of the gastrointestinal tract (GIT) under HCD feeding by using three-site cannula goats as experimental animals.The results indicated that the GIT of goats could fully digest nutrients such as starch and protein under HCD feeding conditions.

The factors related to failure of Enhanced Recovery after Surgery (ERAS) in colon cancer surgery.

PURPOSE: Enhanced Recovery after Surgery has been proven effective for patients with gastrointestinal cancer. But radical enhanced recovery could also lead to adverse clinical outcomes. Compared with reports on the estimation of successful implementation of enhanced recovery, studies on risk factors of enhanced recovery failure are still lacking. METHODS: A retrospective analysis was carried out on 102 patients in ERAS who underwent elective colon cancer surgery. This study included 102 patients with colon cancer between 2015 and 2019, defining enhanced recovery failure as postoperative length of stay over 10 days, stay in ICU over 24 h after surgery, reoperation, death, or unplanned readmission within 30 days after surgery. Univariate and multivariate analyses were performed to explore potential risk factors of failure. RESULTS: Aged ≥ 75, open operation, number of drainage tube over 1, re-urethral catheterization, and Clavien-Dindo grade over 2 were associated with ERAS failure, according to univariate analysis. Multivariate analysis showed that age ≥ 75 [OR 7.231; P = 0.009]; open operation (OR 3.599; P = 0.021); and number of drainage tube over 1 (OR 3.202; P = 0.020) were independent risk factors for ERAS failure. CONCLUSIONS: We found age ≥ 75, open operation, and number of drainage tube over 1 are independent risk factors associated with ERAS failure after colon cancer surgery.

[Construction and immunogenicity analysis of the attenuated recombinant Salmonella typhimurium strains expressing Echinococcus granulosus Eg95 antigen].

OBJECTIVE: To study the feasibility of using attenuated Salmonella typhimurium as carrier for oral immunization of Eg95 antigen of Echinococcus granulosus. METHODS: The recombinant plasmid pYA3341-Eg95 was constructed by inserting the Eg95 gene into expression vector pYA3341, and identified by the methods of PCR and enzyme digestion. The recombinant plasmid pYA3341-Eg95 was electro-transformed into attenuated S. typhimurium strains X3730 and X4550 one by one to construct the recombinant strain St-Eg95. The expression of recombinant Eg95 protein in the recombinant strains St-Eg95 was analyzed by Western blotting. The strains of St-Eg95 were passaged 10 times in vitro and the recombinant plasmids were extracted at one generation interval. The genetic stability of recombinant plasmids was identified by PCR. BALB/c mice were randomly divided into six groups (five mice per group) and inoculated orally with St-Eg95, 100 µl/mouse, at dosage of 1 x 10(9), 1 x 10(10), 1 x 10(11), and 1 x 10(12) cfu/ml, wild-type S. typhimurium strain(l x l0(7)cfu/ml), and PBS, respectively. The survival rate was monitored daily for 30 days. Another 15 mice were divided into three groups and inoculated orally with St-Eg95(5 x 10(5) cfu/ml), X4550(pYA3341)(5 x 10(5) cfu/ml), and PBS, respectively, for 2 times, 0.5 ml/mouse/time, at biweekly intervals. On weeks 0, 2, 4, and 6 after the second immunization, sera were collected and tested for the presence of Eg95 antibody titers using commercially Eg antibody detection ELISA kit. The splenic lymphocyte proliferation was detected by MTT assay at 6 weeks after the second immunization. RESULTS: The constructed recombinant plasmid pYA3341-Eg95 was identified by enzyme digestion and PCR identification. The Eg95 protein (M, 18000) was expressed in the recombinant strains St-Eg95. After the recombinant strains St-Eg95 were passaged 10 times, the Eg95 gene (about 486 bp) was still amplified from St-Eg95. Safety results showed that mice inoculated orally with the St-Eg95 or PBS were all survival on the 30th day after immunization. However, all mice taking wild virulent S. typhimurium strain diedr within 4 days. The Eg95-specific antibodies examined by indirect ELISA were significantly higher in mice immunized with St-Eg95 than that of mice immunized with X4550 (pYA3341) or PBS at 2 weeks after the second immunization (P<0.05). The average Eg95-specific antibody titers reached up to the highest value of 1:1700 in mice immunized with St-Eg95 at 4 weeks after the second immunization. The lymphocyte proliferation test showed that the stimulation index value was significantly higher(P<0.05) in mice immunized with the St-Eg95(reached up to 1.94±0.15) than that in mice immunized with X4550 (pYA3341) or PBS at 6 weeks after the second immunization. CONCLUSION: The recombinant oral attenuated S. typhimurium St-Eg95 was successfully constructed, and has a good safety and immunogenicity profile in mouse.

Baculovirus virions displaying infectious bursal disease virus VP2 protein protect chickens against infectious bursal disease virus infection.

Infectious bursal disease (IBD) is an acute and contagious viral infection of young chickens caused by IBD virus (IBDV). The VP2 protein of IBDV is the only antigen for inducing neutralizing antibodies and protective immunity in the natural host. In the current study, we have succeeded in construction of one recombinant baculovirus BacSC-VP2 expressing His6-tagged VP2 with the baculovirus envelope protein gp64 transmembrane domain (TM) and cytoplasmic domain (CTD). The His6-tagged recombinant VP2 was expressed and anchored on the plasma membrane of Sf-9 cells, as examined by western blot and confocal microscopy. Immunogold electron microscopy demonstrated that the VP2 protein of IBDV was successfully displayed on the viral surface. Vaccination of chickens with the VP2-pseudotyped baculovirus vaccine (BacSC-VP2) elicited significantly higher levels of VP2-specific enzyme-linked immunosorbent assay antibodies and neutralizing antibodies than the control groups. IBDV-specific proliferation of lymphocytes was observed in chickens immunized with the recombinant BacSC-VP2. An in vivo challenge study of the recombinant baculovirus BacSC-VP2 showed effective protection against a very virulent (vv) IBDV infection in chickens. In addition, mortality and gross and histopathological findings in the bursa demonstrated the efficacy of the vaccine in reducing virulence of the disease. These results indicate that the recombinant baculovirus BacSC-VP2 can be a potential vaccine against IBDV infections.

High prevalence of blaCTX-M and blaSHV among ESBL producing E. coli isolates from beef cattle in China's Sichuan-Chongqing Circle.

Enterobacteria that produce extended-spectrum ß-lactamase (ESBL) such as Escherichia coli (E. coli) are common in our environment and known to cause serious health implications in humans and animals. ß-lactam antibiotics such as penicillins, cephalosporins and monobactams are the most commonly used anti-bacterials in both humans and animals, however, Gram negative bacteria (such as E. coli) that produces extended-spectrum ß-lactamases (ESBLs) have the ability to hydrolyze most ß-lactams therefore making them resistant to ß-lactam antibiotics. Recent extensive researches on the epidemiology and genetic characteristics of extended-spectrum ß-lactamase (ESBL)-producing E. coli reported the existence of ESBL-producing E. coli in humans, companion animals and poultry. Therefore, this experiment was performed to investigate the prevalence and genetic characteristics of ß-lactamase producing E. coli isolated from beef cattle farms in the Sichuan-Chongqing circle of China. Phenotypic confirmation of ESBL-producing E. coli was performed using the double disk synergy test. Polymerase Chain Reaction (PCR) was used to detect blaCTX-M, blaSHV and blaTEM gene codes, then after, isolates were divided into different phylogenetic groups and multi-locus sequence typing (MLST). The results showed that out of the 222 E. coli strains isolated from the beef cattle, 102 strains showed ESBL phenotypes. The PCR results showed that blaCTX-M was the predominant ESBL gene identified among the E. coli strains with 21 (9.5%) isolates having this gene, followed by blaSHV which was found in 18 (8.1%) isolates. The majority of these ESBL positive isolates were assigned to phylogroup A (19.8%) followed by phylogroup B1 (13.5%). In addition, from the MLST results on ESBL positive isolates (n = 30) we identified 19 STs, ST398 (ST398cplx) and ST7130 which were the prevalent population (20%). In conclusion, the high prevalence of CTX-M, and SHV in the study confirmed its association with E. coli infection; therefore, this calls for health concerns on ESBL-producing E. coli. As far as we know, this is the first comprehensive research report relating to ESBL-producing E. coli incidence in Chinese beef cattle.

Draft Genome Sequence of Serratia marcescens Strain ZZCCN01, Isolated from the Cardiac Blood of a Beef Cow.

Serratia marcescens strain ZZCCN01 was isolated from the cardiac blood of a dead beef cow with a lung infection and a foam-like secretion from the nostril. Here, we introduce the 5.1-Mb draft genome sequence, which comprises 105 scaffolds, and the corresponding annotation.

Comparison of Single-Incision and Conventional Laparoscopic Sleeve Gastrectomy for Morbid Obesity: a Meta-Analysis.

BACKGROUND: Single-incision laparoscopic sleeve gastrectomy (SILSG) has been proposed as an alternative to conventional laparoscopic sleeve gastrectomy (CLSG) in obese patients. This study aims to compare the surgical outcomes of these two techniques. METHODS: A meta-analysis of existing literature obtained through a systematic literature search in the PubMed, EMBASE, and Cochrane Library CENTRAL databases from 2009 to 2019 was conducted. RESULTS: Eleven articles including 1168 patients were analyzed. Patients in the SILSG group reported greater satisfaction with cosmetic scar outcomes than those in the CLSG group (SMD = 2.47, 95% CI = 1.10 to 3.83, P = 0.00). There was no significant difference between the SILSG group and the CLSG group regarding operative time, intraoperative estimated blood loss, conversion rate, intraoperative complications, length of hospital stay, postoperative analgesia, postoperative complications, excess weight loss (EWL), and improvements in comorbidities (P > 0.05). CONCLUSIONS: Compared to CLSG, SILSG resulted in improved cosmetic satisfaction and showed no disadvantages in terms of surgical outcomes; thus, SILSG can serve as an alternative to CLSG for obese patients. Nonetheless, high-quality randomized controlled trials (RCTs) with large study populations and long follow-up periods are needed.

[A multi-factorial correlation analysis of deep vein thrombosis after trauma to lower extremities].

OBJECTIVE: To investigate the multiple correlation factors of deep vein thrombosis after trauma to lower extremities. METHODS: A total of 2727 patients with traumas from pelvis to ankle were admitted from August 2006 to March 2008 and detected by Color Doppler ultrasound for DVT of bilateral lower extremities before operation. Emergency internal fixation or external fixation was not used for all patients before operation. Seventeen clinical factors were examined in order to analyze their influences upon DVT occurrence after trauma. RESULTS: DVT occurred in 351 patients after trauma. The incidence of DVT in all patients was 12.9%. The analysis of logistic regression demonstrated a definite correlation with the increment of age, the length of presentation time and the gender of female. No associated injury lowered the odds ratio of DVT down to 1.484, 1.816, 0.637 and 0.671 respectively. Other clinical factors had no statistically significant correlation with DVT. CONCLUSION: Both the increment of age and the length of presentation time are risk factors for DVT after trauma to lower extremities. It is best to perform conventional ultrasound examinations in patients with these risk factors so as to timely treat a possible DVT.

The underlying microbial mechanism of epizootic rabbit enteropathy triggered by a low fiber diet.

Epizootic rabbit enteropathy (ERE) is reproduced successfully in the present study by feeding rabbits a low-fibre diet, and high-throughput sequencing and quantitative real-time PCR (qPCR) analysis were applied to examine the microbial variations in the stomach, small intestine and caecum. The evenness was disturbed and the richness was decreased in the ERE groups. When the rabbits were suffering from ERE, the abundance of the Firmicutes was decreased in three parts of the digestive tract, whereas the Proteobacteria was increased in the stomach and caecum, the Bacteroidetes and Verrucomicrobia were increased in the small intestine. Correlation analysis showed that the reduced concentrations of TVFA and butyrate in the caeca of the ERE group were attributed to the decreased abundances of genera such as Lactobacillus, Alistipes and other fibrolytic bacteria and butyrate- producing bacteria such as Eubacterium and Faecalibacterium. It is concluded that, in terms of microorganisms, the overgrowth of Bacteroides fragilis, Clostridium perfringen, Enterobacter sakazakii and Akkermansia muciniphila and inhibition of Bifidobacterium spp. and Butyrivibrio fibrisolvens in the stomach, small intestine and caecum resulted in a decrease in butyrate yield, leading to the incidence of ERE, and the probability of developing ERE could be manipulated by adjusting the dietary fibre level.

Dietary supplements during the cold season increase rumen microbial abundance and improve rumen epithelium development in Tibetan sheep.

Livestock on the Qinghai-Tibetan Plateau are faced with extreme harsh winters and are often in negative energy balance during this period. Dietary supplementation can improve growth performance of Tibetan sheep and, consequently, we hypothesized that it would also increase microbial abundance and rumen epithelium development. To test this hypothesis, we examined the effect of feed supplementation during the cold season on rumen microbes, fermentation, epithelium development, and absorptive capability in Tibetan sheep. Eighteen 1-yr-old ewes (BW = 29.4 ± 1.79, kg) were offered oat hay ad libitum for 60 d and divided randomly into three groups: 1) no supplement; control group (CON); 2) urea-molasses lick block supplement (BS); and 3) concentrate feed supplement (CS). The ADG of CS ewes (143.3, g/d) was greater (P < 0.05) than BS ewes (87.9, g/d), which was greater (P < 0.05) than CON ewes (44.5, g/d). Serum concentrations of GH, IGF-1, and IGF-2 in the CS and BS groups were greater than in the CON group (P < 0.05). Greater relative abundance of protozoa, Ruminococcus albus, Fibrobacter succinogenes, Streptococcus bovis, and Ruminobacter amylophilus was observed in the CS and BS groups than in the CON group (P < 0.05), and relative abundances of rumen fungi, Butyrivibrio fibrisolvens, and Prevotella ruminicola in the CS group were greater than in the BS and CON groups (P < 0.05). Ruminal total VFA, ammonia, and microbial protein concentrations in the CS and BS groups were greater than in the CON group (P < 0.05), and in the CS group were greater than in the BS group (P < 0.05). Ruminal papillae width and surface area in the CS and BS groups were greater than in the CON group (P < 0.05), while in the CS group were greater than in the BS group (P < 0.05). The mRNA expressions of IGFBP5, NHE1 (sodium/hydrogen antiporter, isoform 1), DRA (downregulated in adenoma), and Na+/K+-ATPase (sodium/potassium ATPase pump) in ruminal epithelium were greater in the CS and BS groups than in the CON group (P < 0.05), and in the CS group was greater than in the BS group (P < 0.05), while NHE3 (sodium/hydrogen antiporter, isoform 3), MCT1 (monocarboxylate transporter 1), and MCT4 (monocarboxylate transporter 4) mRNA expressions in the CS group were greater than in the BS and CON groups (P < 0.05). It was concluded that supplementing Tibetan sheep during the cold season increases rumen microbial abundance and improves fermentation parameters, rumen epithelium development, and absorptive capability.

Effects of different levels of protein supplementary diet on gene expressions related to intramuscular deposition in early-weaned yaks.

This study was conducted to estimate different levels of protein supplementary diet on gene expressions related to intramuscular deposition in early-weaned yaks. Results showed that supplementary dietary protein significantly increased final weight, average daily gain (ADG), intramuscular fat (IMF), serum free fatty acid (FFA), total triglycerides, total cholesterol (Ch), low-density lipoprotein cholesterol (LDL) and high-density lipoprotein cholesterol (HDL) content. There was a quadratic response of ADG, IMF, FFA, Ch, HDL and LDL to dietary crude protein (CP) level. Lipoprotein lipase (LPL), fatty acid synthase (FAS) and acetyl-CoA carboxylase (ACC) enzyme activities were significantly increased by supplementary dietary CP, while hormone-sensitive lipase (HSL) and carnitine palmitoyltransferase-1 (CPT-1) activities were significantly decreased. LPL, ACC and FAS enzyme activities showed quadratic increase as dietary CP increased. Peroxisome proliferator-activated receptor γ (PPARγ), LPL, FAS, sterol regulatory element binding protein 1 (SREBP-1), ACC, stearoyl-CoA desaturase (SCD) and heart fatty-acid binding protein (H-FABP) gene expression were significantly increased by supplementary dietary CP, while HSL and CPT-1 gene expression were significantly decreased. PPARγ, LPL, SREBP-1, ACC and H-FABP gene expression showed quadratic increase as dietary CP increased. These results indicated that supplementary dietary protein increased IMF accumulation mainly to increased intramuscular lipogenic gene expression and decreased lipolytic gene expression.

Comparison of drip, pipe and surge spring root irrigation for Jujube (Ziziphus jujuba Mill.) fruit quality in the Loess plateau of China.

Loess Plateau is a typical rain-fed farming region, facing the threat of drought. Irrigation method is among the most important factors affecting jujube quality. This study investigated the response of Ziziphus jujuba Mill. cv. Lizao quality to three different irrigation methods (drip-, pipe- and surge spring root irrigation) combining two water levels (20 m(3)/hm(2) and 120 m(3)/hm(2)). The effects of the trials were evaluated by taking into account the physical-chemical characteristics of jujubes and the antioxidant activity. Concomitant to this, the concentration of some taste-related (viz. glucose, fructose, TSS and malic acid) and health-related compounds/parameters (viz. catechin and epicatechin) were generally much greater in jujube fruit treated with drip irrigation (120 m(3)/hm(2)). Different irrigation treatments had no significant effects on antioxidant capacity, total phenolics and proanthocyanidins (except for pipe irrigation 20 m(3)/hm(2)). The best compromise between quality and irrigation of jujube fruit was achieved with drip irrigation (120 m(3)/hm(2)).

Baculovirus as a PRRSV and PCV2 bivalent vaccine vector: baculovirus virions displaying simultaneously GP5 glycoprotein of PRRSV and capsid protein of PCV2.

The GP5 glycoprotein of PRRSV is the main target for inducing neutralizing antibodies and protective immunity in the natural host. The capsid (Cap) protein is the major immunogenic protein and associated with the production of PCV2-specific neutralizing antibodies. In the present study, one genetic recombinant baculovirus BacSC-Dual-GP5-Cap was constructed. This virus displays simultaneously histidine-tagged GP5 and Cap proteins with the baculovirus glycoprotein gp64 TM and CTD on the virion surface as well as the surface of the virus-infected cells. After infection, the GP5 and Cap proteins were expressed and anchored simultaneously on the plasma membrane of Sf-9 cells, as revealed by Western blot and confocal microscopy. This report demonstrated first that both GP5 and Cap proteins were displayed successfully on the viral surface, revealed by immunogold electron microscopy. Vaccination of swine with recombinant baculovirus BacSC-Dual-GP5-Cap elicited significantly higher GP5 and Cap ELISA antibody titers in swine than the control groups. Virus neutralization test also showed that serum from the BacSC-Dual-GP5-Cap treated swine had significant levels of virus neutralization titers. Lymphocyte proliferation responses could be induced in swine immunized with BacSC-Dual-GP5-Cap than the control groups. These findings demonstrate that the BacSC-Dual-GP5-Cap bivalent subunit vaccine can be a potential vaccine against PRRSV and PCV2 infections.

Baculovirus surface display of E envelope glycoprotein of Japanese encephalitis virus and its immunogenicity of the displayed proteins in mouse and swine models.

Japanese encephalitis virus (JEV), an important pathogen in humans and animals, is capable of causing febrile syndrome, encephalitis and death. The E glycoprotein of JEV is the main target for inducing neutralizing antibodies and protective immunity in the natural host. In this work, we have succeeded in construction of one recombinant baculovirus BacSC-E expressing His6-tagged E with the baculovirus envelope protein gp64 TM and CTD. After infection, E was expressed and anchored on the plasma membrane of Sf-9 cells, as demonstrated by Western blot and confocal microscopy. Immunogold electron microscopy demonstrated that the E glycoprotein was successfully displayed on the viral surface. Vaccination of mouse and swine with recombinant baculovirus BacSC-E successfully induced neutralizing antibody response and protective immunity toward a lethal challenge of the JEV. Taken all findings together, our results indicate that the recombinant baculovirus BacSC-E can be a potential vaccine against JEV infections. This finding provides valuable information for establishing subunit vaccines for JEV antigenic complex viruses. This is a fresh research demonstrating the potential of E-pseudotyped baculovirus as a JEV vaccine.

[Current study on classification of bone deficiency in the revision of total hip replacement].

In the revisions of total hip replacement, the classification of the bone deficiency includes both the acetabular and the femur. That classification of the acetabular bone deficiency includes the classification of Paprosky, Engh, Gross, Gustilo and Pasternak, Chongqing, and so on. That classification of the femoral bone deficiency includes AAOS, Paprosky, Mallory, and modified Mallory. All of the classification is not consistent for peroperative evaluation. As to the confusion, it is necessity to do more researches.