Effects of daily versus weekly teriparatide for medication-related osteonecrosis of the jaw: A case-control study.

INTRODUCTION: Medication-related osteonecrosis of the jaw (MRONJ) is uncommon but can result in severe destruction of the jaw. This case-control study investigated the therapeutic effects of daily or weekly administration of teriparatide in the management of MRONJ using a cohort for osteonecrosis of the jaw. METHODS: Patients who were diagnosed with MRONJ and consented to teriparatide administration were assigned either to a group of daily injection or of weekly injection and completed a 4-week course of injection preoperatively and at least an 8-week course postoperatively. The control group received either the intraoperative rhBMP treatment (CG_BMP) or no additional perioperative treatment (CG_noBMP). The state of MRONJ was evaluated 2 months (T1) and 6 months (T2) postoperatively for all participants. RESULTS: Either group of daily injection (8.35 weeks ± 1.58; n = 17) or weekly injection (9.17 ± 3.79; n = 12) showed significantly faster healing than those of CG_BMP (14.40 ± 6.08; n = 25) or CG_noBMP (15.79 ± 9.79; n = 39). MRONJ was resolved completely in 24 out of 29 participants who completed the course of teriparatide injections, whereas 46.9% of CG showed delayed resolution. Multiple regression analysis indicated 7.50 times (95% CI, 1.77-31.82) more likelihood of complete resolution of MRONJ for participants with teriparatide injections. CONCLUSION: A course of daily or weekly administration of teriparatide injections may improve treatment outcomes for patients with MRONJ.

Delayed ischemic events with low-dose prasugrel medication for stent-assisted coil embolization in intracranial aneurysm patients.

OBJECTIVE: Much emphasis has been put on the use of antiplatelet medication for the prevention of ischemic events in the treatment of cerebral aneurysms with stent assistance. In this regard, the effectiveness and safety of a low-dose prasugrel regimen during the periprocedural period was recently reported. The purpose of this study was to present the outcomes of patients on low-dose prasugrel regimens during the follow-up period after stent-assisted coil embolization (SACE) of cerebral aneurysms. METHODS: For the 396 consecutive patients undergoing SACE procedures, low-dose prasugrel therapy (5 mg of prasugrel and 100 mg of aspirin) was recommended for 3 months after the endovascular treatment. The authors performed a retrospective review of a single-center experience focusing on delayed ischemic events beyond 1 month after treatment. The mean follow-up period was 24.6 ± 11.3 months. RESULTS: In this cohort of patients on a low-dose prasugrel regimen, cerebral infarction occurred in 1 patient (0.3%, 95% CI 0%-1.8%) beyond 1 month after SACE. No intracranial hemorrhage occurred. Overall ischemic events occurred in 14 patients (3.5%, 95% CI 2.1%-5.9%), all within 6 months of the coiling procedure. All patients had transient symptoms. The events occurred within 2 months after cessation of prasugrel in 11 patients (78.6%). Prasugrel maintenance for 6 months was found to result in lower ischemic events compared with maintenance for 3 months. CONCLUSIONS: For patients undergoing SACE, a low-dose prasugrel regimen was a safe and reliable treatment option for the prevention of delayed ischemic events. Transient ischemic events often occurred within 2 months of stopping prasugrel medication.

An Accurate Deep Learning-Based System for Automatic Pill Identification: Model Development and Validation.

BACKGROUND: Medication errors account for a large proportion of all medical errors. In most homes, patients take a variety of medications for a long period. However, medication errors frequently occur because patients often throw away the containers of their medications. OBJECTIVE: We proposed a deep learning-based system for reducing medication errors by accurately identifying prescription pills. Given the pill images, our system located the pills in the respective pill databases in South Korea and the United States. METHODS: We organized the system into a pill recognition step and pill retrieval step, and we applied deep learning models to train not only images of the pill but also imprinted characters. In the pill recognition step, there are 3 modules that recognize the 3 features of pills and their imprints separately and correct the recognized imprint to fit the actual data. We adopted image classification and text detection models for the feature and imprint recognition modules, respectively. In the imprint correction module, we introduced a language model for the first time in the pill identification system and proposed a novel coordinate encoding technique for effective correction in the language model. We identified pills using similarity scores of pill characteristics with those in the database. RESULTS: We collected the open pill database from South Korea and the United States in May 2022. We used a total of 24,404 pill images in our experiments. The experimental results show that the predicted top-1 candidates achieve accuracy levels of 85.6% (South Korea) and 74.5% (United States) for the types of pills not trained on 2 different databases (South Korea and the United States). Furthermore, the predicted top-1 candidate accuracy of our system was 78% with consumer-granted images, which was achieved by training only 1 image per pill. The results demonstrate that our system could identify and retrieve new pills without additional model updates. Finally, we confirmed through an ablation study that the language model that we emphasized significantly improves the pill identification ability of the system. CONCLUSIONS: Our study proposes the possibility of reducing medical errors by showing that the introduction of artificial intelligence can identify numerous pills with high precision in real time. Our study suggests that the proposed system can reduce patients' misuse of medications and help medical staff focus on higher-level tasks by simplifying time-consuming lower-level tasks such as pill identification.

Endocrine-Disrupting Chemicals and Their Adverse Effects on the Endoplasmic Reticulum.

There is growing concern regarding the health and safety issues of endocrine-disrupting chemicals (EDCs). Long-term exposure to EDCs has serious adverse health effects through both hormone-direct and hormone-indirect ways. Accordingly, some EDCs can be a pathogen and an inducer to the susceptibility of disease, even if they have a very low affinity on the estrogen receptor, or no estrogenic effect. Endoplasmic reticulum (ER) stress recently attracted attention in this research area. Because ER and ER stress could be key regulators of the EDC's adverse effects, such as the malfunction of the organ, as well as the death, apoptosis, and proliferation of a cell. In this review, we focused on finding evidence which shows that EDCs could be a trigger for ER stress and provide specific examples of EDCs, which are known to cause ER stress currently.

Combined Exposure to Diazinon and Nicotine Exerts a Synergistic Adverse Effect In Vitro and Disrupts Brain Development and Behaviors In Vivo.

A real-life environment during pregnancy involves multiple and simultaneous exposures to toxic chemicals. Perinatal exposures to toxic chemicals have been reported to exert an inhibitory effect on mouse neural development and behaviors. However, the effect of combined exposures of organophosphate and nicotine has not been previously reported. In this study, we investigated whether a combined exposure of diazinon and nicotine can have a synergistic effect. The effects of the combined chemical exposure on cell viability and neuronal differentiation were examined using mouse Sox1-GFP cells. Additionally, mice were maternally administered 0.18 mg/kg diazinon, a no adverse effect level (NOAEL) dose, combined with 0.4, 1, and 2 mg/kg nicotine. Mice offspring underwent behavior tests to assess locomotor, depressive, cognitive, and social behaviors. Morphological change in the brain was investigated with immunolocalization. We revealed that the combined exposure to diazinon and nicotine can have a synergistic adverse effect in vitro. In addition, the chemical-treated mouse offspring showed abnormalities in motor learning, compulsive-like behaviors, spatial learning, and social interaction patterns. Moreover, 0.18 mg/kg diazinon and 2 mg/kg nicotine co-exposure resulted in an increase in tyrosine hydroxylase (TH)-positive dopaminergic neurons. Thus, the findings suggest that perinatal co-exposure to nicotine and diazinon can result in abnormal neurodevelopment and behavior, even at low-level administration.

Preparation of Carbon Nanowall and Carbon Nanotube for Anode Material of Lithium-Ion Battery.

Carbon nanowall (CNW) and carbon nanotube (CNT) were prepared as anode materials of lithium-ion batteries. To fabricate a lithium-ion battery, copper (Cu) foil was cleaned using an ultrasonic cleaner in a solvent such as trichloroethylene (TCE) and used as a substrate. CNW and CNT were synthesized on Cu foil using plasma-enhanced chemical vapor deposition (PECVD) and water dispersion, respectively. CNW and CNT were used as anode materials for the lithium-ion battery, while lithium hexafluorophosphate (LiPF6) was used as an electrolyte to fabricate another lithium-ion battery. For the structural analysis of CNW and CNT, field emission scanning electron microscope (FE-SEM) and Raman spectroscopy analysis were performed. The Raman analysis showed that the carbon nanotube in composite material can compensate for the defects of the carbon nanowall. Cyclic voltammetry (CV) was employed for the electrochemical properties of lithium-ion batteries, fabricated by CNW and CNT, respectively. The specific capacity of CNW and CNT were calculated as 62.4 mAh/g and 49.54 mAh/g. The composite material with CNW and CNT having a specific capacity measured at 64.94 mAh/g, delivered the optimal performance.

Revisiting the plant growth-promoting rhizobacteria: lessons from the past and objectives for the future.

Plant beneficial rhizobacteria (PBR) is a group of naturally occurring rhizospheric microbes that enhance nutrient availability and induce biotic and abiotic stress tolerance through a wide array of mechanisms to enhance agricultural sustainability. Application of PBR has the potential to reduce worldwide requirement of agricultural chemicals and improve agro-ecological sustainability. The PBR exert their beneficial effects in three major ways; (1) fix atmospheric nitrogen and synthesize specific compounds to promote plant growth, (2) solubilize essential mineral nutrients in soils for plant uptake, and (3) produce antimicrobial substances and induce systemic resistance in host plants to protect them from biotic and abiotic stresses. Application of PBR as suitable inoculants appears to be a viable alternative technology to synthetic fertilizers and pesticides. Furthermore, PBR enhance nutrient and water use efficiency, influence dynamics of mineral recycling, and tolerance of plants to other environmental stresses by improving health of soils. This report provides comprehensive reviews and discusses beneficial effects of PBR on plant and soil health. Considering their multitude of functions to improve plant and soil health, we propose to call the plant growth-promoting bacteria (PGPR) as PBR.

Rational Design of Efficient Amine Reductant Initiators for Amine-Peroxide Redox Polymerization.

Amine-peroxide redox polymerization (APRP) has been highly prevalent in industrial and medical applications since the 1950s, yet the initiation mechanism of this radical polymerization process is poorly understood so that innovations in the field are largely empirically driven and incremental. Through a combination of computational prediction and experimental analysis, we elucidate the mechanism of this important redox reaction between amines and benzoyl peroxide for the ambient production of initiating radicals. Our calculations show that APRP proceeds through SN2 attack by the amine on the peroxide but that homolysis of the resulting intermediate is the rate-determining step. We demonstrate a correlation between the computationally predicted initiating rate and the experimentally measured polymerization rate with an R2 = 0.80. The new mechanistic understanding was then applied to computationally predict amine reductant initiators with faster initiating kinetics. This led to our discovery of N-(4-methoxyphenyl)pyrrolidine (MPP) as amine reductant, which we confirmed significantly outperforms current state-of-the-art tertiary aromatic amines by ∼20-fold, making it the most efficient amine-peroxide redox initiator to date. The application of amines with superior kinetics such as MPP in APRP could greatly accelerate existing industrial processes, facilitate new industrial manufacturing methods, and improve biocompatibility in biomedical applications conducted with reduced initiator concentrations yet higher overall efficiency.

Multi-phased internalization of murine norovirus (MNV) in Arabidopsis seedlings and its potential correlation with plant defensive responses.

Norovirus is a highly infectious human pathogen that causes acute foodborne diseases worldwide. As global diet patterns have begun to incorporate a higher consumption of fresh agricultural products, the internalization of norovirus into plants has emerged as a potential threat to human health. Here, we demonstrated that murine norovirus (MNV1) was internalized into Arabidopsis in multiple phases, and this internalization was correlated with Arabidopsis innate immunity responses. Under hydroponic conditions, continuous treatment of MNV1 retarded root growth and facilitated flower development of Arabidopsis without causing necrotic lesions. Examination of viral titers and RNA levels revealed that MNV1 was internalized into Arabidopsis in at least three different phases. In response to MNV1 treatment, the Arabidopsis defensive marker PR1 (a salicylic acid signaling marker) was transiently up-regulated at the early stage. PDF1.2, a jasmonic acid signaling marker, exhibited a gradual induction over time. Noticeably, Arabidopsis RNS1 (T2 ribonuclease) was rapidly induced by MNV1 and exhibited anti-correlation with the internalization of MNV1. Exposure to recombinant Arabidopsis RNS1 protein reduced the viral titers and degraded MNV1 RNA in vitro. In conclusion, the internalization of MNV1 into Arabidopsis was fluctuated by mutual interactions that were potentially regulated by Arabidopsis immune systems containing RNS1.

Ghost probiotics with a combined regimen: a novel therapeutic approach against the Zika virus, an emerging world threat.

The Zika virus (ZIKV) used to be an obscure flavivirus closely related to dengue virus (DENV). Transmission of this epidemic pathogen occurs mainly via mosquitoes, but it is also capable of placental and sexual transmission. Although the characteristics of these viruses are well defined, infections are unpredictable in terms of disease severity, unusual clinical manifestations, unexpected methods of transmission, long-term persistence, and the development of new strains. Recently, ZIKV has gained huge medical attention following the large-scale epidemics around the world, and reported cases of congenital abnormalities associated with Zika virus infections which have created a public health emergency of international concern. Despite continuous research on ZIKV, no specific treatment or vaccine has been developed, excepting a preventive strategy for congenital ZIKV infection. Probiotics, known as GRAS, are bacteria that confer various health beneficial effects, and have been shown to be effective at curing a number of viral diseases by modulating the immune system. Furthermore, probiotic preparations consisting of dead cells and cellular metabolites, so-called "Ghost probiotics", can also act as biological response modifiers. Here, we review available information on the epidemiology, transmission, and clinical features of ZIKV, and on treatment and prevention strategies. In addition, we emphasize the use of probiotics and plant-based natural remedies and describe their action mechanisms, and the green technologies for microbial conversion, which could contribute to the development of novel therapies that may reduce the pathogenicity of ZIKV. Accordingly, we draw attention to new findings, unanswered questions, unresolved issues, and controversies regarding ZIKV.

Amine Induced Retardation of the Radical-Mediated Thiol-Ene Reaction via the Formation of Metastable Disulfide Radical Anions.

The effect of amines on the kinetics and efficacy of radical-mediated thiol-ene coupling (TEC) reactions was investigated. By varying the thiol reactant and amine additive, it was shown that amines retard thiyl radical-mediated reactions when the amine is adequately basic enough to deprotonate the thiol affording the thiolate anion, e.g., when the weakly basic amine tetramethylethylenediamine was incorporated in the TEC reaction between butyl 2-mercaptoacetate and an allyl ether at 5 mol %, the final conversion was reduced from quantitative to <40%. Alternatively, no effect is observed when the less acidic thiol butyl 3-mercaptopropionate is employed. The thiolate anion was established as the retarding species through the introduction of ammonium and thiolate salt additives into TEC formulations. The formation of a two-sulfur three-electron bonded disulfide radical anion (DRA) species by the reaction of a thiyl radical with a thiolate anion was determined as the cause for the reduction in catalytic radicals and the TEC rate. Thermodynamic and kinetic trends in DRA formations were computed using density functional theory and by modeling the reaction as an associative electron transfer process. These trends correlate well with the experimental retardation trends of various thiolate anions in TEC reactions.

Right sizes of nano- and microstructures for high-performance and rigid bulk thermoelectrics.

In this paper, we systematically investigate three different routes of synthesizing 2% Na-doped PbTe after melting the elements: (i) quenching followed by hot-pressing (QH), (ii) annealing followed by hot-pressing, and (iii) quenching and annealing followed by hot-pressing. We found that the thermoelectric figure of merit, zT, strongly depends on the synthesis condition and that its value can be enhanced to ∼ 2.0 at 773 K by optimizing the size distribution of the nanostructures in the material. Based on our theoretical analysis on both electron and thermal transport, this zT enhancement is attributed to the reduction of both the lattice and electronic thermal conductivities; the smallest sizes (2 ∼ 6 nm) of nanostructures in the QH sample are responsible for effectively scattering the wide range of phonon wavelengths to minimize the lattice thermal conductivity to ∼ 0.5 W/m K. The reduced electronic thermal conductivity associated with the suppressed electrical conductivity by nanostructures also helped reduce the total thermal conductivity. In addition to the high zT of the QH sample, the mechanical hardness is higher than the other samples by a factor of around 2 due to the smaller grain sizes. Overall, this paper suggests a guideline on how to achieve high zT and mechanical strength of a thermoelectric material by controlling nano- and microstructures of the material.

Termitarium-inhabiting Bacillus endophyticus TSH42 and Bacillus cereus TSH77 colonizing Curcuma longa L.: isolation, characterization, and evaluation of their biocontrol and plant-growth-promoting activities.

Bacillus strains were isolated from termitarium soil and screened for their antifungal activity through the production of diffusible and volatile metabolites. Further, the bacterial strains that showed antifungal activity were evaluated for their biocontrol potential on the basis of their plant-growth-promoting attributes. Termitarium-inhabiting Bacillus strains TSH42 and TSH77 significantly reduced the growth of pathogenic fungus Fusarium solani, controlled the symptoms of rhizome rot in turmeric (Curcuma longa L.), and demonstrated various plant-growth-promoting traits in different in vitro assays. On the basis of morphological, physiological, biochemical, and 16S rDNA characteristics, isolates TSH42 and TSH77 were identified as Bacillus endophyticus (KT379993) and Bacillus cereus (KT379994), respectively. Through liquid chromatography - mass spectrometry analysis, acidified cell-free culture filtrate (CFCF) of B. cereus TSH77 was shown to contain surfactin and fengycin, while CFCF of B. endophyticus TSH42 contained iturin in addition to surfactin and fengycin. Treatment of the turmeric (C. longa L.) plants with TSH42 and TSH77 significantly reduced the percentage incidence of rhizome rot disease caused by F. solani. The same treatment also increased the fresh rhizome biomass and plant growth in greenhouse conditions.

Design and Development of Layered Security: Future Enhancements and Directions in Transmission.

Today, security is a prominent issue when any type of communication is being undertaken. Like traditional networks, supervisory control and data acquisition (SCADA) systems suffer from a number of vulnerabilities. Numerous end-to-end security mechanisms have been proposed for the resolution of SCADA-system security issues, but due to insecure real-time protocol use and the reliance upon open protocols during Internet-based communication, these SCADA systems can still be compromised by security challenges. This study reviews the security challenges and issues that are commonly raised during SCADA/protocol transmissions and proposes a secure distributed-network protocol version 3 (DNP3) design, and the implementation of the security solution using a cryptography mechanism. Due to the insecurities found within SCADA protocols, the new development consists of a DNP3 protocol that has been designed as a part of the SCADA system, and the cryptographically derived security is deployed within the application layer as a part of the DNP3 stack.

The Development of Simple Methods for the Maintenance and Quantification of Polymyxa graminis.

Polymyxa graminis, a root endoparasite of several cereal species, is considered to be non-pathogenic but serves as a vector of various plant viruses belonging to the genera Bymovirus, Furovirus, and Pecluvirus. Specifically, it reduces barley productivity by transmitting the Barley Yellow Mosaic Virus (BaYMV). To date, due to its obligate biotrophic property, no artificial culturing of P. graminis was reported and its quantification was also technically challenging. Here, we developed a novel and simple method to infect P. graminis within sterile barley roots in contamination free by preparing nearly pure zoospore inoculum. Such artificial maintenance of P. graminis was verified based on the presence of various developmental stages in infected barley roots under microscope. In addition, the population of resting spores in host tissue was determined by establishing standard curve between manually counted number of spores and Ct values of 18S rDNA amplification using quantitative real-time PCR. Furthermore, it was validated that standard curve generated was also applicable to estimate the abundance of P. graminis in soil environments. In conclusion, the present study would help to generate a system to investigate the etiological causes as well as management of plant diseases caused by P. graminis and BaYMV in tissue and soil.

Antiviral potential of a diterpenoid compound sugiol from Metasequoia glyptostroboides.

This research reports first time antiviral activity of sugiol, a diterpenoid isolated from Metasequoia glyptostroboides in terms of its ability to inhibit in vitro growth of H1N1 influenza virus. Antiviral potential of sugiol was evaluated through hcytopathogenic reduction assay using Madin-Darby canine kidney (MDCK) cell line. Sugiol (500 µg/ml) was found to exhibit considerable anti-cytopathic effect on MDCK cell line confirming its antiviral efficacy against H1N1 influenza virus. These findings strongly reinforce the suggestion that sugiol could be a candidate of choice in combinational regimen with potential antiviral efficacy.

Protective effect of heat-treated cucumber (Cucumis sativus L.) juice on alcohol detoxification in experimental rats.

In this study, heat-treated cucumber juice was assessed for its protective effect on blood alcohol levels and hepatic alcohol metabolic enzyme system in experimental rats. Initially, during detoxification of alcohol, all groups were orally dosed to 22% alcohol (6ml/kg body weight) along with different concentrations of heat-treated cucumber juice (10, 100 and 500mg/kg) and commercial goods for hangover-removal on sale (2ml/kg). Cucumber juice was dosed before 30 min, and simultaneously after 30min of alcohol administration, and its hepatoprotective effect on blood alcohol levels and hepatic alcohol metabolic enzyme system in experimental rats was evaluated. As a result, after 7h, remarkable reduction was found in the blood alcohol levels for all concentrations of cucumber juice treatment. Treatment with cucumber juice resulted in increasing dehydrogenase (ADH) and acetaldehyde dehydrogenase (ALDH) enzymatic activities in rat liver at 9h after alcohol administration thereby stimulated blood alcohol metabolism as compared with control group. The effect of heat-treated cucumber juice on alcohol detoxification was observed only in the rats treated before 30min from alcohol administration. These findings indicate that heat-treated cucumber juice has significant protective effect on alcohol detoxification in experimental rats, suggesting its usefulness in the treatment of liver injury caused by alcohol consumption.

BAT1, a putative acyltransferase, modulates brassinosteroid levels in Arabidopsis.

Brassinosteroids (BRs) are essential for various aspects of plant development. Cellular BR homeostasis is critical for proper growth and development of plants; however, its regulatory mechanism remains largely unknown. BAT1 (BR-related acyltransferase 1), a gene encoding a putative acyltransferase, was found to be involved in vascular bundle development in a full-length cDNA over-expressor (FOX) screen. Over-expression of BAT1 resulted in typical BR-deficient phenotypes, which were rescued by exogenously applied castasterone and brassinolide. Analyses of BR profiles demonstrated that BAT1 alters levels of several brassinolide biosynthetic intermediates, including 6-deoxotyphasterol, typhasterol and 6-deoxocastasterone. BAT1 is mainly localized in the endoplasmic reticulum. BAT1 is highly expressed in young tissues and vascular bundles, and its expression is induced by auxin. These data suggest that BAT1 is involved in BR homeostasis, probably by conversion of brassinolide intermediates into acylated BR conjugates.

Simulation of a Multistaggered Baffle Scrubber to Enhance the Efficiency of Simultaneous Desulfurization and Denitrification.

In this study, we conduct simulation research on simultaneous desulfurization and denitrification in a multistaggered baffle spray scrubber. By employing two-phase flow simulations within the Euler-Lagrange framework and calculating the gas-liquid mass transfer rate with user-defined functions, we comprehensively analyzed the effects of various operational parameters. Initially, we validated our simulation model by comparing the simulation results with experimental data. Under conditions of a 0.2 mm droplet diameter, a liquid-to-gas ratio (L/G) of 12 L/m3, and a gas flow rate of 5 CMM using a full cone nozzle, the simulation indicated a desulfurization efficiency of 99.90 versus 99.84% obtained experimentally and a denitrification efficiency of 92.01 versus 90.67% obtained experimentally. This comparison confirmed the reliability of the simulation model. Our findings indicate that a droplet size of 2 mm is optimal, enhancing the desulfurization efficiency from 99.90 to 99.98% and the denitrification efficiency from 92.01 to 99.76%. However, when the droplet size exceeds 2 mm, efficiencies marginally decrease. Increasing the liquid-to-gas ratio to 16 L/m3 further improves desulfurization and denitrification efficiencies to 99.98 and 99.80%, respectively. In contrast, higher inlet flue gas flow rates reduce these efficiencies, with a decline observed from 100% to as low as 93.90% for denitrification with 2 mm droplets. Additionally, the use of a swirl cone nozzle, compared to full or hollow cone nozzles, better disperses droplets, enhancing the gas-liquid contact and achieving efficiencies of 99.99% for desulfurization and 99.81% for denitrification with 2 mm droplets. These insights are valuable for optimizing operational conditions in industrial-scale spray scrubbers, significantly contributing to mitigating the environmental impacts of industrial emissions.

Natural course of hemodynamically stable hemispheres contralateral to operated hemispheres in adult patients with ischemic moyamoya diseases.

The necessity of bilateral bypass in adult moyamoya disease (MMD) remains unclear despite its recommendation for pediatric and hemorrhagic cases. We aimed to investigate the natural course of hemodynamically stable unoperated hemispheres after bypass surgery for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD. Among 288 patients, the mean age at the first operation of the unstable hemispheres was 40.8 ± 12.2 years. The mean follow-up period was 62.9 ± 46.5 months. 45 patients (15.6%) experienced stroke events in the unoperated hemisphere, consisting of hemorrhagic stroke in 8 (2.8%) and ischemic stroke in 37 (12.8%), including progressive transient ischemic attack in 25 (8.7%) and infarction in 12 (4.2%). Among them, 39 patients (13.5%) underwent bypass surgery. The annual risk of total stroke is 3.0%/patient-year, with 2.5% for ischemic stroke and 0.5% for hemorrhagic stroke. The 5- and 10-year cumulative risks of ischemic stroke were 13.4% and 18.3%, respectively, and those of hemorrhagic stroke were each 3.2%. The natural course of hemodynamically stable hemispheres contralateral to the operated ones appeared fairly good. Additional bypass surgery on the unoperated hemispheres should be considered for symptomatic and hemodynamically unstable hemispheres in adult patients with ischemic MMD during the follow-up.