Re-Descemet Membrane Endothelial Keratoplasty (DMEK) con preservación del injerto original tras free roll en cámara anterior: a propósito de un caso / Re-descemet membrane endothelial keratoplasty (DMEK) with preservation of the original graft after free-roll in the anterior chamber: a case report

Introducción: Las queratoplastias lamelares han supuesto un gran impacto en el manejo del edema corneal por disfunción endotelial. Las técnicas de trasplante mínimamente invasivo como la Descemet Membrane Endothelial Keratoplasty (DMEK) han permitido reducir la morbilidad que suponía la realización de una queratoplastia penetrante en este tipo de pacientes. Aun así, se trata de técnicas complejas que no están exentas de complicaciones, y que requieren una larga línea de aprendizaje quirúrgico y una aún más exigente experiencia en el manejo postoperatorio.Caso clínicoUna mujer de 89 años afecta de distrofia endotelial de Fuchs e intervenida de cirugía combinada de catarata y DMEK, presentó a las 24h de la intervención un edema estromal de predominio inferior y un despegamiento sectorial del injerto. Tras un re-bubbling en consultas y 4 días más tarde, se observó el injerto enrollado y libre en cámara anterior.Se intervino de re-DMEK con preservación del injerto original tras 24h, con desepitelización para optimizar la visualización. Se tiñó el injerto con azul tripán y se protegió el estroma posterior con aire. Se reimplantó el injerto bajo maniobras intraoculares y con burbuja de aire.A las 24h de la cirugía se observó el injerto adherido, con una gran disminución del edema estromal. Un mes después, la paciente presentaba una córnea transparente, una persistente adhesión completa del injerto y una agudeza visual de 0,9.ConclusiónEl hallazgo del free roll en cámara anterior tras cirugía de DMEK constituye la forma más compleja de despegamiento del injerto. El edema corneal, así como la disposición de las diferentes estructuras intraoculares son condicionantes a tener en cuenta para la resolución quirúrgica de esta complicación. En muchos casos el reposicionamiento quirúrgico del injerto es factible, hecho que implica ahorrar costes sin necesidad de utilizar nuevos tejidos corneales donantes. (AU)

Introduction: Lamellar keratoplasties have had a great impact in the management of corneal edema due to endothelial dysfunction. Minimally invasive transplant techniques such as descemet membrane endothelial keratoplasty (DMEK) have helped to reduce the morbidity involved in performing penetrating keratoplasty in this type of patient. Even so, these are complex techniques that are not free of complications and require a long line of surgical learning and an even more demanding experience in postoperative management.Clinical caseAn 89-year-old woman suffering from Fuchs endothelial dystrophy and undergoing combined cataract and DMEK surgery presented stromal edema predominantly inferior and sectoral detachment of the graft 24h after the intervention. After re-bubbling in consultations and 4 days later, the graft was observed rolled and free in the anterior chamber.She underwent re-DMEK with preservation of the original graft after 24h, with de-epithelialization to optimize visualization. The graft was stained with trypan blue and the posterior stroma was protected with air. The graft was reimplanted under intraocular maneuvers and with an air bubble.Twenty four hours after surgery, the adhered graft was observed, with a great decrease in stromal edema. One month later, the patient had a clear cornea, persistent complete graft adhesion, and visual acuity of 0.9.ConclusionThe discovery of free roll in the anterior chamber after DMEK surgery constitutes the most complex form of graft detachment. Corneal edema as well as the arrangement of the different intraocular structures are conditions to be considered for the surgical resolution of this complication. In many cases, surgical repositioning of the graft is feasible, which means saving costs without the need to use new donor corneal tissues. (AU)

Structural Features and Zeolite Stability: A Linearized Equation Approach.

Zeolite stability, in terms of lattice energy, is revisited from a crystal-chemistry point of view. A linearized equation relates the zeolite lattice energy using simple structural data readily available from experiments or modeling. The equation holds for a large range of zeolite energies, up to 3 eV per tetrahedron with respect to quartz, and has been validated internally via two simple machine learning automatic procedures for data fitting/reference partitions and externally using data from recently synthesized zeolites. The approach is certain in locating those recently synthesized zeolites in the energy range of those experimentally known zeolites used in the parametrization of the linearized equation. Hidden intrinsic structural data-energy correlations were found for data sets built from energy-relaxed structures along with energy values computed using the same energy functions employed in the structural relaxation. The asymmetry of the structural features is relevant for an accurate description of the energy.

Re-descemet membrane endothelial keratoplasty (DMEK) with preservation of the original graft after free roll in anterior chamber: A case report.

INTRODUCTION: Lamellar keratoplasties have had a great impact in the management of corneal edema due to endothelial dysfunction. Minimally invasive transplant techniques such as Descemet Membrane Endothelial Keratoplasty (DMEK) have helped to reduce the morbidity involved in performing penetrating keratoplasty in this type of patient. Even so, these are complex techniques that are not free of complications and require a long line of surgical learning and an even more demanding experience in postoperative management. CLINICAL CASE: An 89-year-old woman suffering from Fuchs endothelial dystrophy and undergoing combined cataract and DMEK surgery presented stromal edema predominantly inferior and sectoral detachment of the graft 24 h after the intervention. After re-bubbling in consultations and 4 days later, the graft was observed rolled and free in the anterior chamber. She underwent re-DMEK with preservation of the original graft after 24 h, with de-epithelialization to optimize visualization. The graft was stained with trypan blue and the posterior stroma was protected with air. The graft was reimplanted under intraocular maneuvers and with an air bubble. 24 h after surgery, the adhered graft was observed, with a great decrease in stromal edema. One month later, the patient had a clear cornea, persistent complete graft adhesion, and visual acuity of 0.9. CONCLUSION: The discovery of free roll in the anterior chamber after DMEK surgery constitutes the most complex form of graft detachment. Corneal edema as well as the arrangement of the different intraocular structures are conditions to be considered for the surgical resolution of this complication. In many cases, surgical repositioning of the graft is feasible, which means saving costs without the need to use new donor corneal tissues.

The glymphatic system and cerebral small vessel disease.

OBJECTIVES: Cerebral small vessel disease is a group of pathologies in which alterations of the brain's blood vessels contribute to stroke and neurocognitive changes. Recently, a neurotoxic waste clearance system composed of perivascular spaces abutting the brain's blood vessels, termed the glymphatic system, has been identified as a key player in brain homeostasis. Given that small vessel disease and the glymphatic system share anatomical structures, this review aims to reexamine small vessel disease in the context of the glymphatic system and highlight novel aspects of small vessel disease physiology. MATERIALS AND METHODS: This review was conducted with an emphasis on studies that examined aspects of small vessel disease and on works characterizing the glymphatic system. We searched PubMed for relevant articles using the following keywords: glymphatics, cerebral small vessel disease, arterial pulsatility, hypertension, blood-brain barrier, endothelial dysfunction, stroke, diabetes. RESULTS: Cerebral small vessel disease and glymphatic dysfunction are anatomically connected and significant risk factors are shared between the two. These include hypertension, type 2 diabetes, advanced age, poor sleep, obesity, and neuroinflammation. There is clear evidence that CSVD hinders the effective functioning of glymphatic system. CONCLUSION: These shared risk factors, as well as the model of cerebral amyloid angiopathy pathogenesis, hint at the possibility that glymphatic dysfunction could independently contribute to the pathogenesis of cerebral small vessel disease. However, the current evidence supports a model of cascading dysfunction, wherein concurrent small vessel and glymphatic injury hinder glymphatic-mediated recovery and promote the progression of subclinical to clinical disease.

Differences in excito-repellent behavior between susceptible and permethrin-resistant strains of Aedes aegypti upon exposure to insecticide-treated fabric.

BACKGROUND: An important component of the biological activity of pyrethroids, when used in disease vector control, is excito-repellency. In this study, behavioral differences between insecticide susceptible (Orlando) and pyrethroid resistant (Puerto Rican) strains of Aedes aegypti were explored in a round glass arena using fabrics treated with permethrin, etofenprox, deltamethrin, or DDT. Repellency was evaluated across several variables, including the time to first flight (TFF), number of landings (NOL), total flight time (TFT), and maximum surface contact (MSC), all by video analysis. RESULTS: Results from the Orlando strain indicated they were less likely than the Puerto Rican strain to tolerate tarsal contact with the treated fabrics. All four response variables indicated that the mosquito flight and landing behavior was most affected by pyrethroid resistance [knockdown resistance (kdr)] status. In other experiments, mosquitoes were surgically altered, with antennae ablated bilaterally, and these mosquitoes were more likely to stay on the treated surfaces for longer periods of time, irrespective of any chemical exposure. There were also differences in the responses to antennal ablation between the two strains of mosquitoes, indicating that resistance factors, probably kdr, influence the reactivity of mosquitoes to pyrethroid and DDT treatments, and that it was not completely negated by antennal ablation. CONCLUSIONS: These findings confirm the role of antennal olfactory components in the expression of excito-repellent behaviors, and also support the hypothesis that excito-repellency from pyrethroid/DDT exposure is probably due to a combination of sublethal neurotoxic excitation and interactions with the olfactory system. © 2023 Society of Chemical Industry.

Use of Three-Dimensional Intracardiac Echocardiography Catheter in the Evaluation of Prosthetic Pulmonary Valves after Transcatheter Replacement.

Transcatheter pulmonary valve replacement (TPVR) is commonly performed in patients with congenital heart disease as a safe alternative to replacement via open heart surgery. Intracardiac echocardiography (ICE) is a useful technique for evaluating multiple structures that are difficult to assess by other echocardiographic techniques, particularly the pulmonary valve. To our knowledge, the use of three-dimensional (3D) ICE catheters to evaluate prosthetic valves after TPVR has not been reported. Three-dimensional ICE catheters offer a comprehensive evaluation of transcatheter-deployed pulmonary valves through 3D, 3D color, xPlane, and multiplane reconstruction. The aim of this study is to demonstrate the feasibility of using 3D ICE catheters, outline their role in evaluating post-TPVR deployment success and complications, consider their additive value to two-dimensional ICE, and present our institutional experience with it in 50 cases of TPVR.

Trepanations in non-adults of the 16th to 18th C. The osteological series of the Church of the Assumption of Valdepeñas (Ciudad Real, Spain).

OBJECTIVE: To investigate the presence of trepanations in an early Modern Age, skeletal collection documented in medical treatises but infrequently reported in osteological collections. MATERIALS: Analyses were conducted on 387 non-adult crania from the ossuary in the church of the Assumption of Valdepeñas (16th - 18th C.), Ciudad Real, Spain. METHODS: All complete or semi-complete crania of non-adults (aged 3-20 years) were macroscopically examined. RESULTS: Trepanation was detected in two adolescents aged 14 and 20 years; no evidence of their survival was observed. CONCLUSIONS: These findings suggest that trepanation was carried out in rural areas as Valdepeñas in the 16th-18th centuries, where the selection of instruments indicates knowledge of contemporaneous medical treatises. SIGNIFICANCE: The present study provides new data on trepanation and how it was performed in adolescents during this period. LIMITATIONS: Understanding the motive for these interventions is highly challenging in the absence of bone lesions, and their occurrence is likely underestimated due to the scant research in skeletal remains from the early Modern Age. SUGGESTIONS FOR FUTURE RESEARCH: Further palaeopathological analyses of osteological collections from this period will provide more information about how this surgical technique was perfected.

Effects of Heat Treatment on the Physicochemical Properties and Electrochemical Behavior of Biochars for Electrocatalyst Support Applications.

The present work reports the synthesis and the physicochemical characterization of biochar from the organic wastes of nopal (Opuntia Leucotricha), coffee grounds (Coffea arabica) and Ataulfo mango seeds (Mangifera indica) as alternative electrocatalyst supports to Vulcan XC-72 carbon black. The biochars were prepared using pyrolysis from organic wastes collected at three temperatures, 600, 750 and 900 °C, under two atmospheres, N2 and H2. The synthesized biochars were characterized using Raman spectroscopy and scanning electron microscopy (SEM) to obtain insights into their chemical structure and morphological nature, respectively, as a function of temperature and pyrolysis atmosphere. A N2 adsorption/desorption technique, two-point conductivity measurements and cyclic voltammetry (CV) were conducted to evaluate the specific surface area (SSA), electrical conductivity and double-layer capacitance, respectively, of all the biochars to estimate their physical properties as a possible alternative carbon support. The results indicated that the mango biochar demonstrated the highest properties among all the biochars, such as an electrical conductivity of 8.3 S/cm-1 at 900 °C in N2, a specific surface area of 829 m2/g at 600 °C in H2 and a capacitance of ~300 mF/g at 900 °C in N2. The nopal and coffee biochars exhibited excellent specific surface areas, up to 767 m2/g at 600 °C in N2 and 699 m2/g at 750 °C in H2, respectively; nonetheless, their electrical conductivity and capacitance were limited. Therefore, the mango biochar at 900 °C in N2 was considered a suitable alternative carbon material for electrocatalyst support. Additionally, it was possible to determine that the electrical conductivity and capacitance increased as a function of the pyrolysis temperature, while the specific surface area decreased for some biochars as the pyrolysis temperature increased. Overall, it is possible to conclude that heat treatment at a high temperature of 900 °C enhanced the biochar properties toward electrocatalyst support applications.

Trichoderma as a biological control agent: mechanisms of action, benefits for crops and development of formulations.

Currently, the food and economic losses generated by the attack of phytopathogens on the agricultural sector constitute a severe problem. Conventional crop protection techniques based on the application of synthetic pesticides to combat these undesirable microorganisms have also begun to represent an inconvenience since the excessive use of these substances is associated with contamination problems and severe damage to the health of farmers, consumers, and communities surrounding the fields, as well as the generation of resistance by the phytopathogens to be combated. Using biocontrol agents such as Trichoderma to mitigate the attack of phytopathogens represents an alternative to synthetic pesticides, safe for health and the environment. This work explains the mechanisms of action through which Trichoderma exerts biological control, some of the beneficial aspects that it confers to the development of crops through its symbiotic interaction with plants, and the bioremedial effects that it presents in fields contaminated by synthetic pesticides. Also, detail the production of spore-based biopesticides through fermentation processes and formulation development.

Shortening replacement by emulsion and foam template hydroxypropyl methylcellulose (HPMC)-based oleogels in puff pastry dough. Rheological and texture properties.

Shortening plays an essential function in the formulation of sweet laminated bakery products, but has a potential health risk due to their high percentage of saturated fatty acids. In this paper, the feasibility of hydroxypropyl methylcellulose (HPMC) oleogels prepared with emulsion template (ET) and foam template (FT) approaches as fat sources in a puff pastry dough was investigated. Spreadability and thermal properties of control shortening, 100% ET and FT oleogels and shortening/oleogel (50/50) blends were measured. The different systems were applied as the fat source in a puff pastry dough, and their effect on rheological and texture properties was investigated. Results showed that partial replacement of shortening with oleogels could significantly decrease the firmness values (from 115 to 26 N) (P < 0.05) and increased the spreadability of shortening. The methodology to prepare the oleogel (FT or ET) also significantly affected the texture parameters. FT blends had the highest spreadability with significantly lower firmness values and area under the curve. Thermal values showed that both oleogels could slightly increase the melting point of shortening from 47 to 50 °C. The replacement of shortening with oleogel decreases the viscoelasticity of puff pastry dough and increases its thermal stability but does not significantly change dough viscoelasticity in the shortening/oleogel mixture. These results indicated that both oleogels have promising potential to replace shortening in puff pastry dough formulations, but the ET oleogel showed a more similar behavior to the control shortening than the FT oleogel.

Delayed and Attenuated Antibody Responses to Coronavirus Disease 2019 Vaccination With Poor Cross-Variant Neutralization in Solid-Organ Transplant Recipients-A Prospective Longitudinal Study.

Background: Therapeutically immunosuppressed transplant recipients exhibit attenuated responses to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines. To elucidate the kinetics and variant cross-protection of vaccine-induced antibodies in this population, we conducted a prospective longitudinal study in heart and lung transplant recipients receiving the SARS-CoV-2 messenger RNA (mRNA) 3-dose vaccination series. Methods: We measured longitudinal serum antibody and neutralization responses against the ancestral and major variants of SARS-CoV-2 in SARS-CoV-2-uninfected lung (n = 18) and heart (n = 17) transplant recipients, non-lung-transplanted patients with cystic fibrosis (n = 7), and healthy controls (n = 12) before, during, and after the primary mRNA vaccination series. Results: Among healthy controls, strong anti-spike responses arose immediately following vaccination and displayed cross-neutralization against all variants. In contrast, among transplant recipients, after the first 2 vaccine doses, increases in antibody concentrations occurred gradually, and cross-neutralization was completely absent against the Omicron B.1.1.529 variant. However, most (73%) of the transplant recipients had a significant response to the third vaccine dose, reaching levels comparable to those of healthy controls, with improved but attenuated neutralization of immune evasive variants, particularly Beta, Gamma, and Omicron. Responses in non-lung-transplanted patients with cystic fibrosis paralleled those in healthy controls. Conclusions: In this prospective, longitudinal analysis of variant-specific antibody responses, lung and heart transplant recipients display delayed and defective responses to the first 2 SARS-CoV-2 vaccine doses but significantly augmented responses to a third dose. Gaps in antibody-mediated immunity among transplant recipients are compounded by decreased neutralization against Omicron variants, leaving many patients with substantially weakened immunity against currently circulating variants.

A Novel Patient Selection Tool Is Highly Efficacious at Identifying Candidates for Outpatient Surgery When Applied to a Nonselected Cohort of Patients in a Community Hospital.

BACKGROUND: There is a paucity of validated selection tools to assess which patients can safely and predictably undergo same-day or 23-hour discharge in a community hospital. The purpose of this study was to assess the ability of our patient selection too to identify patients who are candidates for outpatient total joint arthroplasty (TJA) in a community hospital. METHODS: A retrospective review of 223 consecutive (unselected) primary TJAs was performed. The patient selection tool was retrospectively applied to this cohort to determine eligibility for outpatient arthroplasty. Utilizing length of stay and discharge disposition, we identified the proportion of patients discharged home within 23 hours. RESULTS: We found that 179 (80.1%) patients met eligibility criteria for short-stay TJA. Of the 223 patients in this study, 215 (96.4%) patients were discharged home; 17 (7.9%) were on the day of surgery, and 190 (88.3%) within 23 hours. Of the 179 eligible patients for short-stay discharge, 155 (86.6%) patients were discharged home within 23 hours. Overall, the sensitivity of the patient selection tool was 79%, the specificity was 92%, the positive predictive value was 87% and the negative predictive value was 96%. CONCLUSION: In this study, we found that more than 80% of patients undergoing TJA in a community hospital are eligible for short-stay arthroplasty with this selection tool. We found that this selection tool is safe and effective at predicting short-stay discharge. Further studies are needed to better ascertain the direct effects of these specific demographic traits on their effects on short-stay protocols.

Increasing genomic prediction accuracy for unphenotyped full-sib families by modeling additive and dominance effects with large datasets in white spruce.

Introduction: Genomic selection is becoming a standard technique in plant breeding and is now being introduced into forest tree breeding. Despite promising results to predict the genetic merit of superior material based on their additive breeding values, many studies and operational programs still neglect non-additive effects and their potential for enhancing genetic gains. Methods: Using two large comprehensive datasets totaling 4,066 trees from 146 full-sib families of white spruce (Picea glauca (Moench) Voss), we evaluated the effect of the inclusion of dominance on the precision of genetic parameter estimates and on the accuracy of conventional pedigree-based (ABLUP-AD) and genomic-based (GBLUP-AD) models. Results: While wood quality traits were mostly additively inherited, considerable non-additive effects and lower heritabilities were detected for growth traits. For growth, GBLUP-AD better partitioned the additive and dominance effects into roughly equal variances, while ABLUP-AD strongly overestimated dominance. The predictive abilities of breeding and total genetic value estimates were similar between ABLUP-AD and GBLUP-AD when predicting individuals from the same families as those included in the training dataset. However, GBLUP-AD outperformed ABLUP-AD when predicting for new unphenotyped families that were not represented in the training dataset, with, on average, 22% and 53% higher predictive ability of breeding and genetic values, respectively. Resampling simulations showed that GBLUP-AD required smaller sample sizes than ABLUP-AD to produce precise estimates of genetic variances and accurate predictions of genetic values. Still, regardless of the method used, large training datasets were needed to estimate additive and non-additive genetic variances precisely. Discussion: This study highlights the different quantitative genetic architectures between growth and wood traits. Furthermore, the usefulness of genomic additive-dominance models for predicting new families should allow practicing mating allocation to maximize the total genetic values for the propagation of elite material.

Optimizing Sparse Testing for Genomic Prediction of Plant Breeding Crops.

While sparse testing methods have been proposed by researchers to improve the efficiency of genomic selection (GS) in breeding programs, there are several factors that can hinder this. In this research, we evaluated four methods (M1-M4) for sparse testing allocation of lines to environments under multi-environmental trails for genomic prediction of unobserved lines. The sparse testing methods described in this study are applied in a two-stage analysis to build the genomic training and testing sets in a strategy that allows each location or environment to evaluate only a subset of all genotypes rather than all of them. To ensure a valid implementation, the sparse testing methods presented here require BLUEs (or BLUPs) of the lines to be computed at the first stage using an appropriate experimental design and statistical analyses in each location (or environment). The evaluation of the four cultivar allocation methods to environments of the second stage was done with four data sets (two large and two small) under a multi-trait and uni-trait framework. We found that the multi-trait model produced better genomic prediction (GP) accuracy than the uni-trait model and that methods M3 and M4 were slightly better than methods M1 and M2 for the allocation of lines to environments. Some of the most important findings, however, were that even under a scenario where we used a training-testing relation of 15-85%, the prediction accuracy of the four methods barely decreased. This indicates that genomic sparse testing methods for data sets under these scenarios can save considerable operational and financial resources with only a small loss in precision, which can be shown in our cost-benefit analysis.

Pure Aortic Regurgitation Complicated by Membranous Interventricular Septum Aneurysm Treated With Transcatheter Aortic Valve Replacement.

An 89-year-old woman with severe aortic regurgitation and an aneurysmal interventricular membranous septum extending into the aortic annulus underwent successful transcatheter aortic valve replacement. A challenging case because of the risk of valve mispositioning complications attributed to the co-occurrence of pure aortic regurgitation (very low calcium burden) with an aneurysmal interventricular membranous septum. (Level of Difficulty: Intermediate.).

Nucleation of zeolitic imidazolate frameworks: from molecules to nanoparticles.

We have studied the clusters involved in the initial stages of nucleation of Zeolitic Imidazolate Frameworks, employing a wide range of computational techniques. In the pre-nucleating solution, the prevalent cluster is the ZnIm4 cluster (formed by a zinc cation, Zn2+, and four imidazolate anions, Im-), although clusters such as ZnIm3, Zn2Im7, Zn2Im7, Zn3Im9, Zn3Im10, or Zn4Im12 have energies that are not much higher, so they would also be present in solution at appreciable quantities. All these species, except ZnIm3, have a tetrahedrally coordinated Zn2+ cation. Small ZnxImy clusters are less stable than the ZnIm4 cluster. The first cluster that is found to be more stable than ZnIm4 is the Zn41Im88 cluster, which is a disordered cluster with glassy structure. Bulk-like clusters do not begin to be more stable than glassy clusters until much larger sizes, since the larger cluster we have studied (Zn144Im288) is still less stable than the glassy Zn41Im88 cluster, suggesting that Ostwald's rule (the less stable polymorph crystallizes first) could be fulfilled, not for kinetic, but for thermodynamic reasons. Our results suggest that the first clusters formed in the nucleation process would be glassy clusters, which then undergo transformation to any of the various crystal structures possible, depending on the kinetic routes provided by the synthesis conditions. Our study helps elucidate the way in which the various species present in solution interact, leading to nucleation and crystal growth.

Management of Complex Pulmonary Vein Stenosis at Altitude Combining Comprehensive Percutaneous Interventional Treatment with Sirolimus, Pulmonary Hypertension Medications and Intraluminal Imaging with Optical Coherence Tomography.

BACKGROUND: Pulmonary vein stenosis (PVS) is a growing problem for the pediatric congenital heart population. Sirolimus has previously been shown to improve survival and slow down the progression of in-stent stenosis in patients with PVS. We evaluated patients before and after initiation of sirolimus to evaluate its effects on re-intervention and vessel patency utilizing Optical Coherence Tomography (OCT). METHODS: We performed a retrospective study, reviewing the charts of patients with PVS, who had been prescribed sirolimus between October 2020 and December 2021. OCT was performed in the pulmonary vein of interest as per our published protocol. Angiographic and OCT imaging was retrospectively reviewed. Statistical analysis was performed using Chi square and Wilcoxon signed-rank test to compare pre-and post-sirolimus data. RESULTS: Ten patients had been started and followed on sirolimus. Median age at sirolimus initiation was 25 months with median weight of 10.6 kg and average follow-up of 1 year. Median total catheterizations were 7 for patients prior to starting sirolimus and 2 after starting treatment (p = 0.014). Comparing pre- and post-sirolimus, patients were catheterized every 3 months vs every 11 months (p = 0.011), median procedure time was 203 min vs 145 min (p = 0.036) and fluoroscopy time, 80 min vs 57.2 min (p = 0.036). 23 veins had severe in-stent tissue ingrowth prior to SST (luminal diameter < 30% of stent diameter). Post-sirolimus, 23 pulmonary veins had moderate to severe in-stent tissue ingrowth that responded to non-compliant balloon inflation only with stent luminal improvement of > 75%. CONCLUSION: Our study suggests that the addition of sirolimus in patients with moderate-severe PVS helps to decrease disease progression with decrease frequency of interventions. Reaching therapeutic levels for sirolimus is critical and medication interactions and side-effects need careful consideration. OCT continues to be important for evaluation and treatment guidance in this patient population.

One and a Half-Stage Revision With Prosthetic Articulating Spacer for Definitive Management of Knee Periprosthetic Joint Infection.

This paper is a comprehensive review that describes indications, contraindications, clinical outcomes, and pearls and pitfalls of 1.5-stage revision total knee arthroplasty (TKA) utilizing a primary TKA femoral component, all-polyethylene tibial component, and hand-crafted antibiotic cement for the management of chronic periprosthetic joint infection. The 1.5-stage exchange TKA details placement of an articulating spacer for an indefinite period, prolonging revision until reinfection, deterioration of functional status, or construct failure. A 1.5-stage revision TKA technique is a viable option for treatment of chronic periprosthetic knee infections. The inherent advantages of decreased health-care costs, decreased morbidity and mortality, and improved emotional ease from having a single procedure is attractive, especially if reinfection rates are determined to be equivocal to 2-stage revision.

Mr.Bean: a comprehensive statistical and visualization application for modeling agricultural field trials data.

Crop improvement efforts have exploited new methods for modeling spatial trends using the arrangement of the experimental units in the field. These methods have shown improvement in predicting the genetic potential of evaluated genotypes. However, the use of these tools may be limited by the exposure and accessibility to these products. In addition, these new methodologies often require plant scientists to be familiar with the programming environment used to implement them; constraints that limit data analysis efficiency for decision-making. These challenges have led to the development of Mr.Bean, an accessible and user-friendly tool with a comprehensive graphical visualization interface. The application integrates descriptive analysis, measures of dispersion and centralization, linear mixed model fitting, multi-environment trial analysis, factor analytic models, and genomic analysis. All these capabilities are designed to help plant breeders and scientist working with agricultural field trials make informed decisions more quickly. Mr.Bean is available for download at https://github.com/AparicioJohan/MrBeanApp.

Endocardite tardia na valva Melody: experiência multicêntrica no Brasil / Melody valve delayed endocarditis: multicentric experience in Brazil

INTRODUÇÃO E/OU FUNDAMENTOS: A valva Melody, indicada para revalvularização percutânea pulmonar, tem sido usada no Brasil desde 2013. Nos EUA a probabilidade de endocardite (EI) tardia é de 9,5% em 5 anos e 16,9% em 8 anos (mortalidade de 6,7%). Gradientes residuais (GR), faixa etária no implante e história prévia de EI têm sido implicados como fatores de risco. No Brasil, onde encontramos uma população heterogenea, não temos esta informação. Objetivo é determinar a incidência e os desfechos da EI tardia após implante de Melody no Brasil. MÉTODOS: Estudo de coorte observacional, retrospectivo, de pacientes submetidos a implante da Melody. Todos os centros implantadores foram contatados para reportar o número total de implantes e dos casos de EI, incluindo o momento do diagnóstico, manejo e o desfecho final. O diagnóstico de EI foi baseado em critérios clínicos, culturas, ecocardiograma e, por vezes, tomografia. RESULTADOS E CONCLUSÕES: 87 pacientes foram submetidos ao implante em 10 centros no Brasil. Em 9 anos de seguimento, 7 pacientes tiveram EI tardia (8,0%), com 2 óbitos (2,2% do total e 28% dos casos de EI). Em 3 pacientes o quadro foi agudo e em 4 sub-agudo. Um caso acometeu uma criança, sendo o restante em adultos, todos após 1 ano ou mais do implante. Um paciente possuía GR elevado previamente por "mismatch". A EI foi associada a piora importante do gradiente em 3 pacientes: um submetido a dilatação com balão e os outros 2 a troca valvar, com 1 óbito após cirurgia tardia. Os germes identificados foram S. aureus (1), S. viridans (1), Pseudomonas (1) e S. Cristatus (1). Em 3 pacientes as hemoculturas foram negativas. O manejo incluiu, além da antibioticoterapia, explante valvar em 3 (um óbito em paciente crítico, estenose grave e falência do VD), valvoplastia com balão em 1 e tratamento conservador em 3 (com 1 óbito devido a embolia pulmonar). Dos 7 casos de EI, em 4 identificamos fatores de risco que poderiam ter sido evitados: injeção intramuscular de anabolizantes, tratamento dentário sem profilaxia adequada, presença de piercing e tatuagem e história prévia de EI. Nos 4 casos curados nos quais a Melody foi mantida, observou-se estenose e/ou insuficiência discreta a moderada da valva. CONCLUSOES: A incidência de EI tardia na valva Melody no Brasil é significativa, mas não difere significativamente dos dados de literatura. Encontramos fatores de risco diferentes dos relatados previamente, muitos deles evitáveis. Além da incidência significativa, a EI pode se apresentar de forma aguda e ser letal.