The anatomic placement of anterior cruciate ligament (ACL) grafts is often assessed with postoperative imaging. In clinical practice, graft angles are measured to indicate anatomic placement on magnetic resonance imaging, whereas grid measurements are performed on computed tomography (CT). Recently, a study indicated that graft angle measurements could also be assessed on CT. No consensus has yet been reached on which measurement method is best suited to assess anatomic graft placement.To compare the ability of grid measurements and angle measurements to identify anatomic versus nonanatomic tunnel placement on CT performed in patients undergoing ACL reconstruction.Case series; Level of evidence, 4.A total of 100 knees undergoing primary reconstruction with a hamstring graft (HAM group), 91 undergoing reconstruction with a bone–patellar tendon–bone graft (BPTB group), and 117 undergoing revision ACL reconstruction (REV group) were assessed with CT. Grid measurements of the femoral and tibial tunnels and angle measurements of grafts were performed. Graft placement, rated as anatomic or nonanatomic, was assessed with both methods. Pearson chi-square, analysis of variance, Kruskal-Wallis, and weighted kappa tests were performed as appropriate.P < .001). The angle assessment classified 37% of the HAM group, 54% of the BPTB group, and 47% of the REV group as nonanatomic. The weighted kappa between angle measurements and grid measurements was low in all groups .The grid assessment classified 10% of the HAM group, 4% of the BPTB group, and 17% of the REV group as nonanatomic (The agreement between grid measurements and angle measurements was very low. The angle measurements seemed to overestimate nonanatomic tunnel placement. Grid measurements were better in identifying malpositioned grafts. The matter is further complicated by the fact that different measurement methods are used on the various radiological modalities for the assessment of femoral graft placement.34 The Bernard and Hertel grid is commonly used on radiographs and 3-dimensional computed tomography (3D-CT), with accurate measurements of graft placement in the high-low direction only possible on 3D-CT.31 There is less controversy regarding tibial graft placement, as measurements are performed in a similar manner in all modalities.42 The angle measurements of graft inclination or obliquity are mostly performed on magnetic resonance imaging (MRI).46Anterior cruciate ligament (ACL) reconstruction has evolved constantly since it was implemented in clinical practice more than 3 decades ago.35 Several studies have also examined the normal angles of the native ACL.36 In clinical practice, it is common to perform MRI before primary surgery and revision to assess the soft tissues to detect/identify concomitant meniscal injuries and other ligament injuries. However, some also suggest the use of CT and 3D-CT to aid surgery planning before revision.37 In the clinical setting, it is not common to measure graft angles on CT or grids on MRI, and the methods are not used interchangeably. Recent studies show that there is little difference between angle measurements performed on MRI and CT and grid measurements performed on CT and 3D-MRI.14 However, it is not known if both methods are equally adept in identifying the nonanatomic placement of grafts.Studies have examined the normal anatomic locations of ACL insertions, which are used to judge postoperative placement as either “in” or “out” of the anatomic range.The purpose of this study was to compare the angle and grid measurements of identifying anatomic versus nonanatomic tunnel placement on CT performed in patients undergoing ACL reconstruction. We hypothesized that the rate of nonanatomic placement would be higher in patients undergoing revision surgery compared with primary ACL reconstruction and aimed to assess the ability of the measurement methods to follow this hypothesis.The study was approved by a regional ethics board, and informed consent was waived. From January 2011 to the end of December 2017, all patients who were evaluated for revision ACL reconstruction and who underwent preoperative CT at a single institution were initially included retrospectively. Revision surgery was planned in patients who had an unsatisfactory function in the knee joint; examples of underlying causes were nonanatomic placement of graft tunnels, impingement due to grafts that were too long, or stretching of grafts during a new injury. Potential patients were identified through a manual search in our PACS system. From January 2011 to December 2015, we also included 100 postoperative CT scans obtained after primary reconstruction with either a hamstring graft or bone–patellar tendon–bone (BPTB) graft consecutively as separate groups. Postoperative CT was performed within 1 to 3 days after ACL reconstruction with the knee in full extension. Exclusion criteria were cases with multiple ligament reconstructions, known graft ruptures, or cases with previous revision. Graft ruptures were excluded, as graft angle measurements were not possible to perform without visible fibers on CT.In all cases, sex, age, and knee laterality were recorded. In addition, the type of surgical technique  and type of graft used (hamstring or BPTB) were recorded. In the revision group, months since primary ACL reconstruction were also recorded. All CT examinations were performed in our institution on either a 64- or 512-detector CT machine . All images were acquired at a tube voltage of 100 kV and tube current of 80 mA with a 0.625-mm slice thickness and reconstructed in 3 planes in soft kernel and bone algorithms with 2 mm–thick slabs.42 and ACL graft angles were measured in the coronal and sagittal planes. All measurements were performed and recorded by an experienced radiologist   . Normal 36 The normal coronal angle ranged from 66° to 74°, and the normal sagittal angle ranged from 47° to 59°. Graft placement in the coronal and sagittal planes was dichotomously recorded as “in” or “out” of the anatomic range. Within the revision group, the abovementioned analyses were also performed comparing the anteromedial portal and transtibial surgical approach.The normal ranges for ACL coronal and sagittal angles were calculated from weighted means from the literature, as presented in 48P < .05 was considered significant, but the Bonferroni adjustment was used for multiple comparisons . All statistical analyses were performed with SPSS .Dichotomous variables were assessed with the Pearson chi-square test. The combined assessments of grid in 2 directions or angles in 2 planes were classified in ordered categories , which were assessed with the weighted kappa. Continuous variables were assessed with the analysis of variance or Kruskal-Wallis test according to an assumed normality of data.All of the primary ACL reconstructions were performed with the anteromedial portal approach. Within the study period, 137 patients were reviewed for revision surgery, of whom 6 were excluded from our study because of a ruptured graft and 14 were excluded because of multiple revisions. The final total of included revisions was 117 cases (REV group). Within the study period for primary ACL reconstruction, 100 cases of reconstruction with a hamstring graft (HAM group) and 91 cases of reconstruction with a BPTB graft (BPTB group) met the inclusion criteria.P = .01) and BPTB  groups. There was no difference between laterality and age between groups  compared with the HAM , in which the mean graft placement in the REV group was shallower than in the HAM and BPTB groups . The nonanatomic rate in the HAM group was significantly worse than in the BPTB and REV groups (P ≤ .002 for both) . In the femoral high-low direction, for both the measurement and the rate of anatomic placement, there were significant differences between the HAM and REV groups and between the BPTB and REV groups . A significant difference was seen in the tibial measurement between the HAM and REV groups but not in the comparison of the rate of tibial nonanatomic versus anatomic placement. The rate of anatomic placement according to the combined grid assessment  differed significantly between the BPTB and REV groups but not between the HAM and BPTB groups or between the HAM and REV groups  and between the BPTB and REV groups (P = .010), while the rate of anatomic versus nonanatomic placement differed between the HAM and BPTB groups (P = .001) and between the HAM and REV groups (P < .001). The sagittal angle measurement did not differ between the 3 groups, but the rate of anatomic placement differed significantly between the BPTB and REV groups. The combined angle assessment  did not differ significantly between groups . The rate of anatomic graft placement according to the combined grid assessment also differed between the surgical approaches. However, no differences were observed in the combined angle assessment with regard to anatomic versus nonanatomic placement . Pairwise comparisons showed no difference between the HAM and BPTB groups, as was expected. However, there was also no difference between the HAM and REV groups. This may be explained by the high rate of nonanatomic placement in the HAM group in the femoral deep-shallow direction, influencing the overall anatomic rate in the grid measurements. There was a significant difference in the combined grid assessment between the BPTB and REV groups.47 In the coronal measurements, we found significant differences between the HAM and BPTB groups and between the BPTB and REV groups. In general, in the BPTB group, we observed a steeper (nonanatomic) coronal angle than in the other groups. The reason for this may again be the bony attachment of the BPTB graft, which when placed caudally in the tunnel will cause a more cranial exit for the tendon, causing it to run a steep slope in the coronal view. There were no differences in the sagittal angle measurements or in the combined angle assessment for anatomic placement between groups. The highest rate of overall nonanatomic placement was seen in the BPTB group (54% in BPTB vs 37% in HAM and 47% in REV).Angle measurements for assessing postoperative graft placement are often recommended in the literature.45 However, it is known that flexion affects the ACL angle in the sagittal plane. A study showed that the sagittal angle of the ACL ranges from 45° to 20° with increasing knee joint flexion.16 This factor affects the measurements in a clinical setting, as even the slightest flexion during CT or MRI will change the angle of the ACL graft. Furthermore, even if the angle is correct, the placement may still be faulty if the graft is placed too anteriorly or too posteriorly.32 The grid measurements were devised so that the measurements in the femur and tibia are independent of the degree of knee flexion. Thus, methodological discrepancies relating to knee flexion may explain the poor agreement between the 2 measurement methods. CT is the more robust modality if one chooses to measure graft placement.The 2 grid and the angle methods yielded significantly different rates of nonanatomic placement in the same patients. The explanation for this is a fundamental difference in measurement methods. The angle measurements were devised in the era of the transtibial surgical technique. Technical failure with the transtibial technique was related to “too high” placement of the femoral tunnel and was easily assessed on sagittal images, and a too steep graft angle was introduced as an imaging criterion.45 The transtibial technique is known to cause too high placement in the grid measurements, which was confirmed in our study.43 The combined grid assessment differed significantly between the surgical techniques (P = .004), with no anatomic cases in the transtibial technique group. In addition, the sagittal angle differed between the surgical techniques (P = .002), while the coronal angle measurements and combined angle assessment did not differ within the REV group. Thus, the lack of agreement between the grid and angle measurement methods was also observed within the REV group.Considering revision ACL reconstruction, previous studies have shown that the anteromedial portal technique yields higher rates of anatomic placement compared with the transtibial technique.49 MRI undoubtedly has a role in planning revision surgery for identifying recurrent ACL graft ruptures and missed concomitant lesions in other ligaments, menisci, or articular cartilage.37 Ducouret et al10 found that angle measurements did not differ between CT and MRI and suggested that MRI can be used to replace CT for identifying tunnel placement. Grasso et al14 performed grid measurements on CT and MRI; however, the measurements were conducted on computer-generated models after adding digitized information acquired during revision surgery, not on actual CT or MRI scans. In our view, the clinical usefulness of angle and grid measurements on MRI has not been sufficiently established to date. No studies have examined the clinical benefit of angle measurements in reconstruction using the anteromedial portal technique. Furthermore, our results show that graft angles do not correlate with grid measurements, and they overestimate nonanatomic placement in ACL reconstruction with the anteromedial portal technique. Therefore, MRI currently cannot replace CT to identify anatomic graft placement in ACL reconstruction.The clinical usefulness of (1) postoperative CT in primary reconstruction to improve a surgeon’s learning curve and to serve as a baseline examination and (2) preoperative CT for planning revision surgery has been established.46 This makes a comparison of surgical results difficult, as we now know that the reported rate of nonanatomic tunnel placement varies depending on the method used.This study highlights the problems that arise because of the lack of consensus on which measurement method to use when assessing ACL graft placement. Several studies have compared graft placement between the transtibial and anteromedial portal techniques, but the studies used several different measurement methods to assess graft placement.23 The normal ranges of grid and angle measurements are based on a relatively high number of anatomic and imaging cases (>200-300).36 This limits bias in identifying the appropriate cutoff in our study. As the purpose of our study was to compare 2 methods used for assessing anatomic tunnel placement on imaging, we did not correlate graft placement with clinical or functional assessments of graft laxity and cannot determine whether nonanatomic tunnel placement affects graft laxity.This is the first study comparing grid and angle measurement methods after ACL reconstruction. We have laid bare the major discrepancy between these methods. As previous studies have shown low interrater and intrarater variability in both methods used in our study, we did not assess interrater variability and do not consider this a major limitation.The agreement between angle and grid measurements to identify anatomic ACL graft placement was very low. Compared with grid measurements, angle measurements tended to overestimate nonanatomic tunnel placement. Grid measurements were better in identifying malpositioned ACL grafts. Orthopaedic surgeons and radiologists ought to be aware of the pitfalls of the angle measurement method when assessing ACL graft placement on imaging.


All patients underwent routine liver MRI pre-treatment and 6w after RE. Two readers assessed index tumor response at 6 months after RE in consensus, using mRECIST criteria. vADC histogram parameters of index tumors at baseline and 6w, and changes in vADC (ΔvADC) histogram parameters were calculated. The predictive value of ADC metrics was assessed by logistic regression with stepwise parameter selection and ROC analyses.n = 6), partial response , stable disease  and progression . vADC median/mode at 6w (1.81–1.82 vs. 1.29–1.35 × 10− 3 mm2/s) and ΔvADC median/max (27–44% vs. 0–10%) were significantly higher in CR/PR vs. SD/PD (p = 0.011–0.036), while there was no significant difference at baseline. Logistic regression identified vADC median at 6w as an independent predictor of response (CR/PR) with odds ratio (OR) of 3.304  and AUC of 0.77. ΔvADC mean was identified as an independent predictor of CR with OR of 4.153  and AUC of 0.91.Twenty two HCC lesions  were assessed. Response at 6 months was as follows: complete response (CR, Diffusion histogram parameters obtained at 6w and early changes in ADC from baseline are predictive of subsequent response of HCCs treated with RE, while pre-treatment vADC histogram parameters are not. These results need confirmation in a larger study.This retrospective study was IRB-approved and the requirement for informed consent was waived. A vADC median threshold of 1.901 × 10− 3 mm2/s at 6w had a sensitivity of 67% and a specificity of 100% for prediction of PR/CR, while a ΔvADC mean threshold of 19.2% had a sensitivity of 100% and a specificity of 81% for prediction of CR  3.304, In this preliminary study, we have evaluated the potential of vADC histogram measurements obtained pre- and early (6w) post-treatment for prediction of HCC response to RE. Volumetric histogram parameters vADC median, mode, ΔvADC median and ΔvADC max obtained at 6w post-treatment were significantly different between patients with PR/CR vs. those with SD/PD. Furthermore, ΔvADC mean was an independent predictor of complete response at 6 m, while vADC median was an independent predictor of any response  at 6 m. Pre-treatment vADC did not have any predictive value for response at 6 m.mRECIST is currently proposed as the standard method to assess radiological response of HCC  and has Two MRI-pathological correlation studies , 43 from− 3 mm2/s is an independent predictor of poorer immediate complete or partial response and index lesion specific progression free survival in patients with HCC undergoing TACE or RE. The discrepancy with our results may be due to different locoregional therapies (TACE+RE in their study vs. RE only in our study). On the other hand, Vouche et al. [DWI provides information on cell membrane integrity and cellular density. Several studies have suggested that ADC can be used as earlier surrogate of response compared to size criteria in HCC treated by RE –17. Kokae et al. , howeverRecent studies demonstrated ADC changes in the index tumor volume rather than in a single axial plane , 24. A s2/s × 10− 3) mean and standard deviation (SD) values of 0.185 and 0.041 at baseline and 1.91 and 0.201 at 4 weeks. In line with their results we observed a significant increase in vADC 6w post RE, however our vADC mean and SD values were higher with 1.288 and 0.325 mm2/s × 10− 3 at baseline and 1.534 and 0.423 mm2/s × 10− 3 at 6w. An explanation might be related to differences in b-values used for DWI acquisition .There is limited data on the role of vADC in HCC post RE, with only one study from Vouche et al. . The autMost prior studies have reported mean ADC values from a single slice, which do not account for the underlying tumor heterogeneity. Histogram analysis (i.e. first order radiomics) is a new approach for quantifying tumor heterogeneity using routine MRI data. Radiomics, which is defined as the conversion of images to higher-dimensional data and the subsequent mining of these data for improved decision support, appears to offer a nearly limitless supply of imaging biomarkers that could potentially aid cancer detection, diagnosis, assessment of prognosis, prediction of response to treatment, and monitoring of disease status . HistogrThe assessment of treatment response with imaging techniques plays a critical role in the management of HCC. Tumor response criteria may be used as a surrogate marker of efficacy in clinical trials in HCC, and as predictors of survival following RE. It has been suggested that DWI is an earlier surrogate of response compared to size criteria in HCC treated by RE –17. vADCOur study had several limitations. First, this was a retrospective study. Second, our study population was slightly underpowered showing an overall power of 75% for presence of type II error , reflecting our preliminary experience. Third, the qualitative image analysis was performed by two readers in consensus, which precluded the evaluation of interobserver variability. Interobserver reproducibility for mRECIST was shown to be excellent (ICC of 0.77–0.84) in a recent publication . Fourth,Our preliminary results indicate that volumetric ADC measurements obtained at 6 weeks and early changes in ADC from baseline are predictive of subsequent response in HCCs treated with RE, while pre-treatment vADC did not have any predictive value.


In the article titled “Efficacy and Safety of Sipjeondaebo-Tang for Anorexia in Patients with Cancer: A Pilot, Randomized, Double-Blind, Placebo-Controlled Trial” , there wThis error in the reporting was brought to the attention of the journal by Professor Edzard Ernst, Emeritus Professor of Complementary Medicine, University of Exeter. The journal and the authors apologize for this misreporting of the conclusions.


Article submissions to The Gerontological Society of America’s high impact scientific journals continue to increase each year which has led to editors becoming more selective about which articles are accepted for publication. The purpose of this session is to describe how to efficiently and successfully navigate the process of determining which journal is the best fit for your manuscript. The specific objectives are to: (1) increase understanding the differences in scope and features of each journal; (2) inform how to determine which journal is most appropriate for the topic and methods of your manuscript; and (3) describe how to convey the scientific contribution of your article to the journal.


Vibrio cholerae may protect against cholera; however, little is known about this immune response in infected immunologically naïve humans.Antibodies targeting O-specific polysaccharide (OSP) of V. cholerae O1 Inaba El Tor N16961. We also measured vibriocidal and anti-cholera toxin B subunit (CtxB) antibodies and compared responses to those in matched cholera patients in Dhaka, Bangladesh, an area endemic for cholera.We measured serum anti-OSP antibodies in adult North American volunteers experimentally infected with We found prominent anti-OSP antibody responses following initial cholera infection: these responses were largely IgM and IgA, and highest to infecting serotype with significant cross-serotype reactivity. The anti-OSP responses peaked 10 days after infection and remained elevated over baseline for ≥ 6 months, correlated with vibriocidal responses, and may have been blunted in blood group O individuals (IgA anti-OSP). We found significant differences in immune responses between naïve and endemic zone cohorts, presumably reflecting previous exposure in the latter.Our results define immune responses to O-specific polysaccharide in immunologically naive humans with cholera, find that they are largely IgM and IgA, may be blunted in blood group O individuals, and differ in a number of significant ways from responses in previously humans. These differences may explain in part varying degrees of protective efficacy afforded by cholera vaccination between these two populations.NCT01895855.ClinicalTrials.gov  Vibrio cholerae O1. There is a growing body of evidence that immune responses targetting the O-specific polysaccharide (OSP) of V. cholerae are associated with protecton against cholera. Despite this, little is known about immune responses targeting OSP in immunologically naive individals. Cholera affects populations in severely resource-limited areas. To address this, we assessed anti-OSP immune responses in North American volunteers experimentally infected with wild type V. cholerae O1 El Tor Inaba strain N16961. We found that antibody responses were largely IgM and IgA, cross-reacted to both Inaba and Ogawa serotypes, and correlated with vibriocidal responses. We found no association of responses to severity of disease, but did find that blood group O individuals mounted lower IgA fold-changes to OSP than did non-blood group O individuals. Individuals with blood group O are at particular risk for severe cholera, and are less well protected against cholera following oral vaccination. We also compared anti-OSP responses in previously unexposed individuals to responses in matched endemic zone patients, and found a number of significant differences. Such differences may explain in part the varying degrees of protective efficacy afforded by cholera vaccination between these two populations.Cholera is an acute, secretory diarrheal disease caused by  Vibrio cholerae serogroups O1 or (rarely) O139 and occurs most commonly among people living in low and middle income countries [V. cholerae has over 200 serogroups, but only the O1 and O139 serogroups cause epidemic and endemic cholera. The O1 serogroup is further divided into El Tor and classical biotypes and subdivided into two major serotypes, Inaba and Ogawa, on the basis of a number of genotypic and phenotypic characteristics [O-methyl group in the non-reducing terminal sugar of the O-specific polysaccharide (OSP) portion of the lipopolysaccharide (LPS); the methyl group is not present in the Inaba serotype [Cholera is a diarrheal disease caused by serotype .V. cholerae LPS [V. cholerae O1 infection confers no cross-protection from V. cholerae O139 infection and vice versa [V. cholerae O1 OSP [OSP is a component of erae LPS . Importace versa –8. Howeve O1 OSP  and preve O1 OSP . We foune O1 OSP . Similare O1 OSP . We havee O1 OSP .Vibrio cholerae O1. We also assessed vibriocidal and immune responses targeting the B subunit (CtxB) of cholera toxin (CT). Interestingly, immune responses that target CT and CtxB have not been highly correlated with protection against cholera [V. cholerae O1-infected cholera patients in Dhaka, Bangladesh, an area endemic for cholera. Immunogenicity and protective efficacy of oral cholera vaccines have varied when evaluated in cholera endemic zone versus naïve populations, and we hypothesized that a direct comparison of responses in these cohorts might identify possibly relevant differences.As such, there is a growing body of evidence that immune responses targeting OSP are involved in mediating protection against cholera; however, little is known about this immune response in immunologically naïve humans. To assess anti-OSP responses in such individuals, we measured serum anti-OSP immune responses in adult North American volunteers experimentally infected with  cholera –23. We ahttp://clinicaltrials.gov/show/NCT01895855) [This study used anonymized samples from a previously reported clinical trial (1895855)  and samp1895855) , 24.North American healthy adult volunteers (18–45 years of age) were enrolled in a previously described randomized, double blind, placebo-controlled phase 3 clinical trial , 24, 25 5 CFU of V. cholerae O1 El Tor Inaba strain N16961 and blood samples were collected before infection (designated as day 0) and at days 10, 28, and 90 or 170 after infection [V. cholerae 10-days after placebo ingestion; samples from day 170 were available from the remaining 22 participants who were infected 3 months after placebo ingestion. Each subject was treated with ciprofloxacin (500 mg twice daily for 5 days) if they reached 5.0 L of cumulative diarrheal stool volume or on day 4 post experimental infection, whichever occurred first [These volunteers were experimentally infected with 1x10nfection , 24, 25.V. cholerae O1 Inaba and were further selected from the icddr,b hospital by 1:1 matching gender, age (± 2.5 year of the paired mean age) and blood group with the North American volunteers. Patients with severe acute watery diarrhea, stool culture positive for V. cholerae O1 Inaba, and negative for other pathogens were eligible, as previously described [All the 38 Bangladeshi patients included in this study were adults 18 to 45 years of age . All 38 escribed , 21. Allescribed , 21. BloV. cholerae OSP purified from PIC018 (Inaba) and PIC158 (Ogawa), and CtxB, as previously described [Stored serum or plasma specimens were used to measure Inaba and Ogawa vibriocidal responses against PIC018 (Inaba) and PIC158 (Ogawa) strains, and IgM, IgA and IgG immune responses against escribed , 12, 14.2) using Pearson’s correlation coefficient. We used LOESS smoothing, as implemented in the ggplot2 package in R, to visualize trajectories of antibody responses and relationships between responses and diarrhea volume. We used linear regression and generalized additive models to characterize the association between specific antibody responses and diarrhea volume. We used linear regression models to estimate adjusted effect of O-blood group on antibody response. All P values were two-tailed, and we used P ≤ 0.05 as the threshold for statistical significance. We used GraphPad Prism, version 5.0  and the R statistical computing language (3.5.2) for all analyses and illustrations.We estimated the geometric mean at each study time point within each population and accompanying asymptotic 95% confidence intervals for IgM, IgA and IgG anti-OSP and anti-CtxB titers in addition to vibriocidal responses. We compared responses between two time points within each cohort using Wilcoxon signed-rank tests and compared responses between populations using Mann-Whitney U tests. We characterized the linear relationship between OSP responses (log) and vibriocidal titers .We found significant increases of IgM antibody responses to Inaba OSP at day 10 and the responses remained significantly elevated compared to baseline up to day 170 after experimental infection in North Americans , started to decrease by the next sampled time point (day 28), but remained significantly elevated compared to baseline through the last sampling point (day 170) after experimental infection  following infection, started to decrease at the next sampling (day 21), and had returned to baseline by days 90 and 180  and total diarrhea volume within the first four days after experimental infection in North American subjects. We identifed no strong relationships through visual inspection –S9 Figs,P = 0.048).Although we did not find a difference in mean immune response to OSP by blood group (O versus non-O), we did find that fold-change IgA responses to Inaba OSP were higher in non-O blood group North Americans (median 3.01) than in O group individuals . In comparison, we found that Bangladeshi patients had higher correlation coefficients than matched North Americans for all antibody isotypes, and that Ogawa correlations were comparable to Inaba correlations, despite the patients being infected with Inaba serotype V. cholerae, it is possible that some may have been exposed to enterotoxigenic E. coli (ETEC) that expresses heat labile toxin (LT) that shares structural similarities and immunologic cross-reactivity with CT [Antibody responses to CtxB in North American volunteers was largely IgG, with a lower level IgA response, and a minimal IgM response. Although it is unlikely that North American volunteers would have been previously exposed to wild type epidemic  with CT , 30. As in vitro  [V. cholerae OSP/LPS, perhaps through the impact of initial innate immune handling, and that these lower mucosal IgA responses lead to the observed lower protective efficacy following killed OCV in blood group O individuals compared to non-O individuals.With regard to severity of disease resulting from experimental infection, we did not find that it correlated with peak, fold-change, or duration of any of the immune responses that we assessed, although there was a trend toward lower fold increases in anti-OSP IgA responses and volume of diarrhea. These observations may suggest that other factors may impact the clinical and immune variability seen during cholera. Such factors might include host genetic or nutritional variability, the microbiota or blood grouping , 31–35.  system) . We therV. cholerae O1 Inaba also developed prominent anti-OSP, vibriocidal, and anti-CtxB antibody responses, we detected important differences in these responses between these two cohorts. Interestingly, the magnitude of the vibriocidal responses, the percent responder frequency, and the duration of elevation were all higher in immunologically naïve North Americans experimentally infected with wild type V. cholerae than matched Bangladeshi controls. This is despite the fact that baseline vibriocidal values were comparable between the two groups. One possible explanation is that Bangladeshi adults had pre-existing mucosal immunity not reflected by baseline plasma vibriocidal assessment in this highly cholera endemic area, and that this pre-existing mucosal immunity blunted immunological processing and subsequent serum responses [5 CFU administered to North American volunteers. Our findings of blunted vibriocidal responses in endemic zone residents mirror those seen when attenuated live oral cholera vaccine strains have been administered in low resource setting [In this study we also had a unique opportunity to compare immune responses between North American immunologically naïve volunteers and matched Bangladeshi adults residing in a cholera endemic urban setting. Although we found that Bangladeshi patients naturally infected with esponses , 45. Altesponses , 46, or  setting , 48.V. cholerae Inaba and Ogawa in the Bangladeshi study participants.We found that although anti-OSP IgM and IgA responses occurred in Bangladeshi adults, the magnitude and duration of these responses were higher in North American volunteers, mirroring the vibriocidal responses. We also found that Bangladeshi adults recovering from cholera developed much more prominent IgG responses to OSP than did North American volunteers. Indeed, in Bangladeshi adults, the vibriocidal response highly correlated with IgG as well as IgM and IgA anti-OSP responses to both Inaba and Ogawa serotypes, while in North Americans, it only weakly correlated to IgG targeting Inaba, but not Ogawa OSP. Presumably this reflects previous exposure in Bangladeshis. We also found that Bangladeshis developed anti-Ogawa OSP and vibriocidal responses that were very comparable to anti-Inaba responses, and these anti-Ogawa responses were much more prominent than those detected in North Americans. These differences would also all be consistent with previous exposure to V. cholerae O1 in adults, and immune responses in children may well be quite different. Although children in a endemic zone may be immunologically naïve, they also respond less prominently to T cell-independent antigens, especially young children. Second, we did not include direct assessment of mucosal immune responses. Third, North American volunteers were experimentally infected with a fixed number of bacteria (1x105 CFU of V. cholerae O1 El Tor Inaba strain N16961), while the infectious dose of naturally infected patients in Bangladesh may differ from patient to patient and circulating strains may vary [V. cholerae infection, that cross-serotype antibody responses develop, that anti-OSP IgM and IgA responses most highly correlate with vibriocidal responses following initial exposure, and that blood group O correlates with lower anti-OSP IgA responses. We also found a number of prominent differences in immune responses following cholera in immunological naïve North Americans versus in individuals residing in a highly endemic cholera region in Bangladesh. Whether such differences might impact protection following oral cholera vaccination is currently uncertain.Our study has a number of limitations. We focused on immune responses to may vary . Fourth,S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 FigP values represent statistical differences of the mean between the country groups. Asterisks represent statistically significant differences of immune responses within the country group compared to baseline . Responder frequencies (defined in text) are shown in parentheses below the X-axes.In the two cohorts, the numbers of patients with sample measurements are shown below the x axes. (1A) Inaba OSP-specific IgM antibody responses and (1B) Ogawa OSP-specific IgM antibody responses. X axis indicates the time points of samples, and the Y-axis denotes IgM antibody responses. Each single dot indicates an individual antibody response, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals. (TIF)Click here for additional data file.S2 FigP values represent statistical differences of the mean between the country groups. Asterisks represent statistically significant differences of immune responses compared to baseline within the country group . Responder frequencies (defined in text) are shown in parentheses below the X-axes.In the two cohorts, the numbers of patients with sample measurements are shown below the x axes. (2A) Inaba OSP-specific IgA antibody responses and (2B) Ogawa OSP-specific IgA antibody responses. X axes indicate the time points of samples, while the Y-axes denote IgA antibody responses. Each single dot indicates an individual antibody response, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals. (TIF)Click here for additional data file.S3 FigP values represent statistical differences of the mean between the country groups. Asterisks represent statistically significant differences of immune responses compared to baseline within country group . Responder frequencies (defined in text) are shown in parentheses below the X-axes.In the two cohorts, the numbers of patients with sample measurements are shown below the x axes. (3A) Inaba OSP-specific IgG antibody responses and (3B) Ogawa OSP-specific IgG antibody responses. X axes indicate the time points of samples, while the Y-axes denote IgG antibody responses. Each single dot indicates an individual antibody response, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals. (TIF)Click here for additional data file.S4 FigP values represent statistical differences of the mean between the country groups. Asterisks represent statistically significant differences of immune responses compared to baseline within country group . Responder frequencies (defined in text) are shown in parentheses below the X-axes.In the two cohorts, the numbers of patients with sample measurements are shown below the x axes. (4A) CtxB-specific IgM antibody responses, (4B) CtxB-specific IgA antibody responses and (4C) CtxB-specific IgG antibody responses. X axes indicate the time points of samples, while the Y-axes denote antibody responses. Each single dot indicates an individual antibody response, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals. (TIF)Click here for additional data file.S5 FigP values represent statistical differences of the mean vibriocidal responses between the two country groups. Asterisks represent statistically significant differences of vibriocidal responses compared to the baseline time point within a country group . Responder frequencies (defined in text) are also presented in parentheses below the X-axes.The time points of samples are plotted on the X axis while vibriocidal antibody responses are plotted on the Y-axis. (5A) Inaba vibriocidal antibody responses and (5B) Ogawa vibriocidal antibody responses. Each single dot indicates an individual vibriocidal antibody reciprocal end-dilution titer. Horizontal bars indicate the Geometric Mean (GM) and error bars indicate 95% Confidence Intervals (CI). (TIF)Click here for additional data file.S6 FigLines represent simple linear regression lines with asymptotic 95% confidence intervals shown as grey envelopes. Pearson’s correlation coefficient and corresponding p-values are shown in each panel. Left panels compare Inaba OSP-specific IgM, IgA, and IgG to Inaba vibriocidal responses; Right panels compare Ogawa OSP-specific IgM, IgA, and IgG to Ogawa vibriocidal responses.(TIF)Click here for additional data file.S7 FigBlue lines show smoothed LOESS estimates and 95% confidence intervals.(TIF)Click here for additional data file.S8 FigBlue lines show smoothed LOESS estimates and 95% confidence intervals.(TIF)Click here for additional data file.S9 FigBlue lines show smoothed LOESS estimates and 95% confidence intervals.(TIF)Click here for additional data file.S10 FigX axis indicates the time points of samples, while Y-axis denotes OSP-specific antibody responses. Each single dot indicates an individual OSP antibody value, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals.(TIF)Click here for additional data file.S11 FigX axis indicates the time points of samples, while Y-axis denotes OSP-specific antibody responses. Each single dot indicates an individual OSP antibody value, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals.(TIF)Click here for additional data file.S12 FigX axis indicates the time points of samples, while Y-axis denotes CtxB-specific antibody responses. Each single dot indicates an individual CtxB antibody value, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals.(TIF)Click here for additional data file.S13 FigX axis indicates the time points of samples, while Y-axis denotes Inaba vibriocidal antibody responses. Each single dot indicates an individual vibriocidal antibody titer, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals.(TIF)Click here for additional data file.S14 FigX axis indicates the time points of samples, while Y-axis denotes Ogawa vibriocidal antibody responses. Each single dot indicates an individual vibriocidal antibody titer, horizontal bars indicate the geometric mean (GM), and error bars indicate 95% confidence intervals.(TIF)Click here for additional data file.


In this study potato and corn starch were subjected to oxidation, using sodium periodate, to obtain dialdehyde starch (DAS) containing different amount of aldehyde groups. The obtained modified starch samples have been characterized with chemical analysis, scanning electron microscopy (SEM) and ATR-FTIR spectroscopy. Then, the samples were exposed to polychromatic UV radiation and the course of photochemical reaction has been monitored with ATR-FTIR spectroscopy. The surface properties of the native and dialdehyde starch before and after UV-irradiation have been determined by contact angle measurements and calculation of surface free energy. The crystallinity of the samples has been estimated with X-ray diffraction (XRD). It has been proved that the dialdehyded corn starch contained a higher amount of functional groups was more photostable than the oxidized potato starch. Sodium iodide(V), firmly bound to DAS macromolecules, has been found to have a significant effect on the photooxidative degradation of the tested systems. In addition, the mechanism of photoinduced reactions in the dialdehyde starch has been proposed. Polysaccharides are of great interest to scientists owing to the ease of modifications, which raises the possibility of their use in numerous new sectors of the industry ,2,3,4,5.Oxidation of starch with efficient oxidizing agent, such as periodate, i.e., metaiodate (VII), is the way to change significantly the properties of native starch. Periodate oxidation is an extremely specific reaction to transform vicinal di-hydroxyl (glycol) groups to paired aldehyde groups without significant side products. The selectively oxidized polysaccharide contains two aldehyde groups in each repeating unit of macromolecule. These aldehyde groups are formed by the opening of the glycosidic ring as a result of preferential C2–C3 bond cleavage ,9,10.4−), is reduced to iodate (V) (IO3−) and can be re-used after oxidation.In the middle of the last century, the oxidation reaction became the industrial method of obtaining dialdehyde starch ,12. The Such modified starch is insoluble in cold water but soluble in hot water, however, its solubility (dependent on oxidation degree) in organic solvents is changed. DAS does not form characteristic complexes with iodine. The aldehyde groups in DAS are present as hemiacetals or hemialdals rather than free aldehydes.A further modification of starch may lead to a cross-linked system, which results in a complete lack of solubility and simultaneously in improvement of mechanical properties ,14. The The presence of highly reactive aldehyde groups in the oxidized starch is desired for potential medical and biomedical applications. In fact, application of the oxidized starch in tissue engineering  and as a drug delivery carrier has been described . RecentlAlthough a lot of research was dedicated to the structure and characteristics of the physicochemical properties of DAS ,16,17,18Moreover, the second objective was to estimate the ability to modify DAS surface by UV radiation. Thus, special attention was paid to the study of the surface properties of the films based on the oxidized starches which are very important for biomedical applications. It should be pointed out that radiation action on starch is considered as a more safe and environmentally friendly modification method compared to chemical methods . FurtherThe native starch (ST) samples in the form of powders were characterized by SEM and ATR-FTIR spectroscopy. Both types of the starch form agglomerates consisting of loosely-bound grains . The aveOne can notice that the shape of CST grains is close to spherical, while the PST objects take spherical and ellipsoidal shape. However, the surfaces of PST grains are smoother than that of CST. Pinholes and cavities are also observed in individual CST grains b.−1 (attributed to OH stretching vibrations), 2800–3000 cm−1 (CH stretching), 900–1200 cm−1 (C–O–C stretching), 400–900, and 1200–1500 cm−1  confirm characteristic polysaccharide structure ..37].Both starches: CST and PST have similar crystallinity degree (about 20%). UV radiation causes a gradual disappearance of these signals with simultaneous increase in amorphous halo. It clearly indicates that the destruction occurs not only in amylose but also in more ordered fraction of amylopectin, however, the observed changes are small. It confirms that photodegradation occurs mainly in the amorphous phase. XRD studies were also conducted for the dialdehyde starches. It was expected that the amorphous structure was formed as a result of the random oxidation of some glucose units. This was also suggested by other authors ,7,38. ThPhotochemical reactions occur in systems containing chromophores absorbing the incident radiation. Although pure starch does not contain typical chromophoric moieties in its structure, but it undergoes photochemical changes due to the presence of contamination form the plant material from which it was obtained. Lipids (including phospholipids) and proteins were found in starch granules .It is known that the presence of a small amount of chromophores can initiate the photochemical decomposition of polysaccharides. Quanta of UV radiation carry large enough energy to break chemical bonds of the starch. Macromolecules undergo excitation and then break down into free radicals of various types. As stated ,27, UV-iThe situation is different in the case of dialdehyde starch which contains a large number of carbonyl groups able to absorb UV radiation and undergo excitation . Thus, tPhotochemical processes in DAS can be proposed by analogy with the processes for starch. Primary photochemical reactions in DAS-C and DAS-P include the main chain scission at α-1,4 glycosidic bond, abstraction of side groups, including hydrogen atoms and opening of a glucopyranose ring . Free ra⋅OH, ⋅CHO, ⋅CH2OH are formed. These radicals are characterized by high mobility and reactivity and they can abstract adjacent substituents (mostly hydrogen atoms). In these sites, macroradicals are formed, next, in air atmosphere these macroradicals react with O2 to form peroxy radicals (Regardless of the starch component (amylose or amylopectin), small radicals such as radicals . As showFTIR spectra of the exposed samples indicate that the reaction of macroradicals with oxygen is dominant. Even if oxygen partially quenches the excited states of macromolecules by direct contact with them, producing oxygen in a singlet state. The singlet oxygen is an active oxidizing agent during further polymer exposure to UV.Another typical process, during UV-treatment of polysaccharides, is the loss of physically loosely adsorbed water as well as water more strongly bound to macromolecules (due to hydrogen bonding). The process is also observed in the case of the dialdehyde starch. Dehydration leads to the formation of double bonds in glucose units . Such unSchemes in It is seen that UV radiation is responsible for the changes in the chemical structure of macromolecules and formation of low molecular weight degradation products rich in functional groups. The oxidation of pyranose rings during UV exposure in the presence of atmospheric oxygen can also result in the creation of the dialdehyde structures, as noted earlier . In othe3) on photochemical processes in DAS. NaIO3 has still oxidative properties and can even be reduced to free iodine, which is possible during UV-irradiation (this is confirmed by the yellow or brown color of the photooxidized products). Therefore, in the presence of the oxidizer, production of the aldehyde groups can still increase as a result of the opening of glucose rings as well as other non-selective oxidation of hydroxyl groups in C6 position. Nevertheless, according to our knowledge, there is no publications taking into account the effect of the oxidizer residue , purchased from Sigma-Aldrich , were the raw materials for preparation of the dialdehyde starch. Both starches were white odorless powders. Sodium hydroxide and concentrated hydrochloric acid (35%) were obtained from POCh, Gliwice, Poland. Sodium periodate (SP) was purchased from Budapest . The glycerol and diiodomethane  have been purchased from Sigma-Aldrich.4, abbreviation SP) according to the recipe in [The dialdehyde starch (DAS) was obtained by oxidation with sodium periodate (NaIOecipe in . 1.5 g oC1 (mol/L) and V1 (dm3) are the concentration and volume of NaOH solution, C2 (mol/L) and V2 (dm3) are the concentration and volume of HCl solution, respectively; m—mass of the sample (g), M—molecular weight of the repeated unit in dialdehyde starch (M = 160 g/mol).The number of the aldehyde groups has been determined by acid-base titration of the modified starch solutions . The conDAS (0.1 g) and NaOH solution  were added to the Erlenmeyer flask and heated in 70 °C (water bath) until the sample was dissolved. After cooling the HCl solution  and distilled water (15 mL) were added. Then phenolophthalein solution was added and the sample was titrated with NaOH solution (0.25 M). Procedure was triplated for each sample.CST—native corn starchPST—native potato starchDAS-C1–5—a sample of corn starch oxidized at different reagent ratio CST: SPDAS-P1–5—a sample of potato starch oxidized at different reagent ratio (PST: SP), in particular, a subscript 1, 2, 3, 4, and 5 means PST:SP = 1:0.5, 1:0.7, 1:0.9, 1:1, and 1:1.1, respectively. 0.2 g of DAS powder was dissolved in 20 mL of distilled water and stirred with a magnetic stirrer at 40 °C during 3 h. Then, this solution was poured onto the leveled glass plates (microscope slides or Petri dishes) to allow the solvent to evaporate. The samples are marked as follows: 2-UVA, 55 W/cm2-UVB, 18,7 W/cm2-UVC, and was measured with an electronic radiometer HD 9021 . Maximal time of exposure was 8 h. The procedure was triplated.The dialdehyde starch and native starch films or powders were exposed to high-pressure mercury vapor lamp HPK 125 W , emitting polychromatic radiation in the range of 248–578 nm. The intensity of the emitted radiation was equal to 72 W/cmTM  equipped with an ATR tool with diamond crystal. Spectra was recorded on over the region from 4000 to 400 cm−1, at a resolution 4 cm−1, 32 scans at room temperature.Infrared spectra have been obtained using Spectrum TwoThe morphology of DAS-C and DAS-P has been studied with Zeiss HamburgLEO Scanning Electron Microscope 1430 VP  without sputtering, using an adjustable vacuum mode.The hydrophilic/hydrophobic properties of starch were analyzed by contact angle measurements using a DSA G10 goniometer . A drop of glycerin or diiodomethane was placed on the polymer film surface. The sessile drop image was recorded and digitized by camera. The drop shape analysis and determination of contact angle have been done with help of instrument software . The reported contact angle value is an average at least 10 measurements for each specimen and solvent (glycerin or diiodomethane). All measurements were carried out at constant temperature (22 °C). The surface free energy was calculated by the Owens–Wendt method  which isX-ray diffraction pattern (XRD) were recorded with X’PertPRO diffractometer  using a CuKα radiation  and High Score software. Crystallinity degree in XRD was calculated using the formula: % Crystallinity =  × 100/.The dialdehyde starch with different content of the dialdehyde groups was obtained by chemical oxidation of the native corn or potato starch. It was found that the corn starch was more susceptible to selective oxidation than the potato starch. During this process, the formation of the aldehyde groups on C2 and C3 carbon atoms takes place as a result of the cleavage of glycosidic rings. 3−) have been observed, which was leading to complex formation. The oxidant residue in the sample may be an additional factor accelerating the photo-oxidation. It was proved that photochemical reactions in the studied dialdehyde starches are different from that occurring in both native starches. Spectroscopic results showed a systematic increase in the amount of functional groups in DAS during UV exposure, whereas the decomposition processes were dominant for the native starches. Moreover, the strong interactions between the dialdehyde starch and the residue of oxidant  is less photostable than that obtained from CST , that may be caused by the differences in the structure and chemical composition of the native polysaccharides. The main explanation for the observed differences in the photochemical stability of the oxidized starches results from different chemical structure of the native polysaccharides. The original structure of the polysaccharides may be also partially preserved in the dialdehyde starches. A higher amount of branched amylopectin in the potato starch can be responsible for its higher resistance to UV radiation. By analogy with typical synthetic polymers , branching points are prone to UV cracking. It was reported that the polymer chains became shorter in amylose and amylopectin as a result of photoinduced depolymerisation, while amylose underwent photocrosslinking . Thus, tMoreover, the ordered structure of A type dominates in CST, in contrast to PST in which the structure of B type was found. It seems that incompact packing of the double helices in crystallities B facilitates the penetration of oxygen, free radicals as well as active low molecular products into the interior of the helices, thus enhance their activity and simultaneously diminish starch photostability.3−, according to our knowledge, has not been described in the literature.This study allowed us to compare the photostability of the dialdehyde starches obtained by oxidation in the same conditions. The polysaccharides studied came from two different botanical raw materials. The dialdehyde corn starch may be recommended for practical applications as more resistant to UV and characterized by a higher content of functional groups in comparison to the potato dialdehyde starch. Finally, it should be pointed out that the creation of the permanent interactions between DAS and IO


A saphenous vein complicated with varicose veins is generally thought to be unsuitable for bypass grafting.A patient who developed sepsis due to lower limb gangrene was successfully treated by endovascular treatment and bypass surgery using a varicose vein graft. There were no complications, such as occlusion or aneurysm, of the varicose vein graft during the 2-year follow-up period.We herein report a case in which bypass surgery with a varicose vein graft was used to avoid major amputation of the lower limb, and the patient recovered markedly from sepsis. If there are no other appropriate autologous veins for revascularization of lower limb gangrene, a varicose vein graft may be useful as a conduit for bypass surgery at risk of graft infection. It is generally recommended that varicose vein grafts not be used, and few prospective case studies have been reported, with evidence insufficient to draw conclusions at this point –4. We suAn 80-year-old female patient was admitted for severe pain in the left foot. She had injured the sole of the left toes a few days before admission, and the area had become ulcerated. She had a history of diabetes, coronary artery disease, and renal disfunction that did not require dialysis; however, all of her diseases were being controlled with medication. On admission, the left foot was swollen red, and the first toe was gangrenous Fig. . She hadA laboratory examination showed that the white blood cell (WBC) count and C-reactive protein (CRP) level were increased at 21900/μl and 28.51 mg/dl, respectively. The left lower limb pulse was not palpable, the ankle-brachial index (ABI) was 0.36, and the skin perfusion pressure (SPP) of the foot was 14 mmHg. A duplex scan showed no flow in the left external iliac artery (EIA) and a poor flow below the left femoral artery. We clinically diagnosed her with severely ischemic limbs with sepsis due to foot gangrene.Staphylococcus aureus was detected in culture of the pus. Subsequent angiography of the left lower limb revealed the presence of an occlusive lesion of the EIA and below the distal superficial femoral artery (SFA); however, the dorsal artery was enhanced via the collateral circulation. Endovascular angioplasty of the EIA was performed with a bare metal stent . The gangrenous area had gradually been confined to the toes. Three days later, metatarsal amputation was performed under sciatic nerve block anesthesia , and there were no other appropriate autologous veins for femorotibial artery bypass. There was no contralateral great saphenous vein, probably due to her history of varicose vein surgery (details unknown). In addition, since the bilateral short saphenous veins and arm veins were small in diameter, bypass surgery without using a varicose vein graft was impossible. Therefore, we decided to use the varicose vein graft for the bypass in order to salvage the limb instead of a prosthetic graft at the risk of infection. When the vein graft was gently distended with saline containing heparin using a syringe for preparation, the saccular venous aneurysm was partially resected Fig. b, arrow.After the bypass surgery, the blood flow of the left lower limb improved significantly, and the ABI and SPP increased to 0.88 and 60 mmHg, respectively. Several debridement operations were required; finally, the stump of the amputated toes had completely healed by 6 months after the bypass surgery Fig. a. The paThe immediate removal of the necrotic tissue and complete revascularization are believed to have led to the recovery from sepsis and limb salvage in the present case. In bypass surgery, varicose vein grafts played an important role in achieving complete revascularization. In general, a varicose vein graft is considered unsuitable for bypass surgery –4, but iIn previous studies, minor dilatation of varicose vein was found able to be corrected by plication, tuck stitching, or prosthetic reinforcement and was able to be used as an autologous vein bypass graft. However major extensive dilatation of varicose veins and unfavorable flow dynamics predispose these veins to aneurysm formation and rupture. Furthermore, varicose vein grafts are likely to undergo increased intimal hyperplasia and long-term risk of thrombosis compared with normal vein grafts when exposed to arterial pressure –11.However, there is not enough evidence concerning the long-term outcomes of varicose vein grafts. In our case, the use of a prosthetic graft had to be avoided because of the risk of graft infection. Therefore, we resected part of the saphenous vein with the saccular venous aneurysm under compression with saline containing heparin at the preparation of the vein graft, although most of the tortuous and dilatated varicose vein graft was still used. No increased intimal hyperplasia or thrombosis of the graft has been observed in the follow-up period.Ultrasonography is usually used for the prevalence of a saphenous vein graft and is the most important evaluation method on diagnosis of varicose vein; however, we additionally performed a new technique  wherein the image was manually adjusted for the window width and level setting in order to visualize the saphenous veins using plain CT reconstructed in 3D  Fig. b. This mWe herein report a rare case of sepsis developing due to lower limb gangrene that was successfully treated by endovascular treatment and bypass surgery using a varicose vein graft.


The authors wish to add the following corrections to their paper published in the International Journal of Environmental Research and Public Health . When caLines 10–12 on page 1880 should be replaced with the following text:The T-score was used for the analysis of the POMS test.The lines 24–27 in page 1883 should be changed as follows:p < 0.05), D , A–H , V , F , and C . However, no significant differences were observed in the baseline period values between the rural and urban environments, respectively: T–A , D , A–H , V , F , and C .In the POMS analysis , signifiWe apologize for any inconvenience caused to the readers by this error.


There is no consensus as to the choice of grafts for primary anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to compare the clinical and second-look arthroscopic outcomes after ACL reconstruction by use of autograft, hybrid graft, and γ-irradiated allograft.Ninety-seven patients who underwent second-look arthroscopy after ACL reconstruction with autografts , hybrid grafts , or γ-irradiated allografts  were included in this study. The clinical outcomes were compared by using Lysholm score, International Knee Documentation Committee (IKDC) score, and Tegner activity score, and the side-to-side differences of KT-1000 measurement. Second-look arthroscopic findings were compared in terms of synovial coverage and graft tension.P > 0.05). The KT-1000 examination showed more anterior laxity in the γ-irradiated allograft group than in the autograft or hybrid graft groups . Two patients in the autograft group, 2 patients in the hybrid graft group and 4 patients in the allograft group were evaluated as graft failure on second-look arthroscopy. The synovial coverage was superior in the autograft group than that in the hybrid graft group or the allograft group , and was comparable between the hybrid graft group and allograft group (P = 0.876). With regard to graft tension, the autograft group and hybrid group were comparable (P = 0.883) but showed better results than the allograft group .There were no statistical significances among the three groups in Lysholm score, IKDC score, or Tegner activity score (The hamstring autografts and hybrid grafts used for ACL reconstruction produced equal efficacy but provided better knee stability than allografts. In addition, the hamstring autografts showed better synovial coverage than the other two graft types. Anterior cruciate ligament (ACL) reconstruction is currently regarded as the best treatment for physically active patients with ACL rupture. A variety of autograft, hybrid graft, and allograft tissues are used for primary ACL reconstruction. Hamstring autograft is a popular choice due to the advantages of low donor site morbidity, early graft incorporation, and no risks of immune reactions and disease transmission , 2. HoweAll biological tissues, whether allograft or autograft, undergo a similar ligamentization process when implanted as an ACL substitute . PreviouThe purpose of this study was to compare the patient-reported outcomes, knee stability, and second-look arthroscopic findings of patients who underwent ACL reconstruction with hamstring autograft, hybrid graft, or soft-tissue allograft. We hypothesized that the outcomes of ACL reconstruction with hamstring tendon autograft would have better results compared with those with hybrid grafts or allografts, and similar outcomes would be seen in the patients with hybrid grafts and allografts.This study was carried out with the approval of the ethics committee of our institution. Patients who underwent second-look arthroscopy after anatomic single-bundle ACL reconstruction were retrospectively reviewed, and signed informed consent was obtained from each participant. The inclusion criteria were (1) primary ACL tears with single-bundle reconstruction; (2) the grafts with diameters equal to or more than 8 mm including hamstring autografts (combined gracilis and semitendinosus tendons), hybrid grafts , or γ-irradiated tibialis anterior allografts; (3) unilateral knee with no history of previous surgery; (4) skeletally mature patients aged more than 16 years old; (5) no signs of cartilage lesion and osteoarthritis; and (6) no combined ligament injury that requires surgical intervention. The exclusion criteria were (1) revision ACL reconstruction, (2) multiple knee ligaments requiring surgical intervention, (3) serious meniscal tear requiring total meniscectomy, and (4) patients who were unable to comply with the treatment protocol, or could not finish at least 12 months follow-up.For the autograft reconstruction, the semitendinosus and gracilis tendons were harvested and prepared as a 4-stranded or 6-stranded hamstring autograft. If the combined diameter of the autograft tendons was less than 8 mm, the γ-irradiated tibialis anterior allograft was used as augmentation to achieve a minimum desired diameter of 8 mm. In the allograft group, the γ-irradiated tibialis anterior allograft was prepared as a 2-stranded or 4-stranded graft. All the allografts were irradiated at a dose of 2.5 Mrad, and supplied by a certified tissue bank .Diagnostic arthroscopy was performed to identify the ACL tear. The combined meniscal injuries were addressed as needed before ACL reconstruction. The ACL remnant was generally preserved. All patients underwent anatomic single-bundle ACL reconstruction, with the femoral and tibial tunnel placed in the center of the femoral and tibial ACL insertion sites. The tunnel diameter was equal to the graft tendon diameter. The graft was then pulled into both tunnels from tibia to femur. The femoral side was fixed with a TightRope device , and the tibial side was fixed with an interference screw .All patients followed the same rehabilitation protocol. The knee was immobilized with a long hinge brace immediately postoperatively for up to 8 weeks. Isometric quadriceps training was started immediately after surgery. Range-of-motion (ROM) exercise was started 2 days after the operation, with the goal of gaining normal ROM within 6 weeks. Partial weight bearing was allowed in the first 4 weeks, and full weight bearing was started at 8 weeks. Patients were allowed to run after 6 months, and return to sports activities gradually at 9 months after surgery. The patients were routinely followed up at 1, 3, 6, 9, 12 and 24 months, and clinical outcomes and second-look arthroscopic evaluation were recorded at the final follow-up postoperatively.Subjective functional assessment included Lysholm score, subjective International Knee Documentation Committee (IKDC) score, and Tegner activity score. Knee stability was evaluated by the side-to-side differences of KT-1000 arthrometer measurement at 30-lb. force . The complications due to surgery were also recorded.Second-look arthroscopy was performed only in patients who requested femoral fixation device removal at least 12 months after ACL reconstruction. The purpose and risk of second-look arthroscopy were explained, and the informed consents were provided by all the patients. Graft failure was defined as a failure in the completion of the ligamentization process, leading to an atonic, disorganized, and non-viable graft  U test were used to test differences of the synovial coverage and graft tension among the three groups. Comparison of the knee functional scores and differences in KT-1000 were analyzed by ANOVA and LSD test. The level of significance was set at P < 0.05. SPSS software  was used for data analysis.The baseline characteristics of the three groups were compared using chi-square test for nominal variables, and analysis of variance (ANOVA) and least significant difference (LSD) test were conducted for continuous variables. The Kruskal-Wallis test and Mann-Whitney P = 0.000 and 0.012, respectively), but there was no significant difference between the autograft and allograft groups (P = 0.086).From January 2013 to February 2018, 97 patients who met the inclusion criteria and underwent second-look arthroscopy were enrolled, including 28 with autograft ACL reconstruction, 32 with hybrid graft ACL reconstruction, and 37 with allograft ACL reconstruction. There was no statistically significant difference in demographics at the time of initial ACL reconstruction among the groups   Table .Table 2P = 0.006 and 0.013, respectively). Additionally, no significant difference was found between the autograft group and hybrid group (P = 0.748) ; however, there was no significant difference between hybrid graft group and allograft group (P = 0.876). With respect to graft tension, both the autograft and hybrid graft groups showed statistically significant differences compared with the allograft group , but no statistically significant difference was found between the autograft group and hybrid graft group (P = 0.883) (Table Two patients in the autograft group, 2 patients in the hybrid graft group, and 4 patients in allograft group were evaluated as graft failure on second-look arthroscopy. There were 1 patient with failed autograft, 1 patient with failed hybrid grafts, and 3 patients with failed allografts, and they underwent revision ACL reconstruction. The other patients did not received revision surgery because there was no feeling of instability during daily activities. With respect to synovial coverage over the graft, the autograft group showed significantly better results than the other two groups (The most important finding of our study was that the synovial coverage was significantly superior in the hamstring autograft group when compared with hybrid graft and γ-irradiated allograft groups. In addition, there was no difference between hybrid graft and allograft groups. Concerning the knee laxity evaluated by KT-1000 measurement and subjective graft tension under second-look arthroscopy, both the autograft and hybrid graft groups were significantly superior to those for patients in the allograft group. There were no significant differences in the Lysholm score, IKDC score, or Tegner activity score among the 3 groups during the short-term follow-up.Hamstring autografts are commonly used for ACL reconstruction, with successful clinical results and low donor site morbidities , 26. HowIt has been reported that the ACL grafts undergo a continuous remodeling process of ligamentization consisting of necrosis, revascularization, cellular repopulation, and collagen remodeling , and theOne interesting finding of our second-look arthroscopy was that the hybrid group did not show better synovialization than the allograft types, although autograft tissues acted as the main component in hybrid ACL graft. The possible explanation could be that the allograft portion in the hybrid implant was associated with increased inflammation, enhanced immunologic reaction, and slower histologic incorporation, which would slow down the synovialization and the graft remodeling process. Even at approximate 2 years after surgery, the allograft tendons might have inferior graft maturity than autograft tendons in ACL reconstruction , 22. TheThe failure rates of hybrid grafts and allografts were reported to be higher than that of autografts after primary ACL reconstruction , 38, 39.There were several limitations in our study. First, the main areas that can be improved on in our future studies include the retrospective design, the limited sample size, and the short-term follow-up. Second, not all the patients who underwent the primary ACL reconstruction were included in our study. We conducted the analysis only on patients who underwent second-look arthroscopy after ACL reconstruction. Therefore, the selection bias could not be avoided. Third, it is quite difficult to evaluate the back of the ACL graft during arthroscopic surgery because it is located deeply in the knee joint. Forth, the assessment on synovial coverage and graft tension depended on the subjective judgment since no standard quantification method has been developed.There was no difference in patient-reported knee function among the outcomes of ACL reconstruction with hamstring autografts, hybrid grafts, and allografts in short-term follow-up. However, the hamstring autografts and hybrid grafts produced comparable knee stability and they both outperformed the allografts. The second-look arthroscopy revealed that hamstring autografts resulted in better synovial coverage than the other two graft types.


The best performance corresponded to particleboard with a density of 318 kg/m3, an internal bond strength of 0.67 N/mm2, and a thickness swelling of 8.7%. These values meet the standard requirements of general purpose lightweight boards for use in dry conditions. Heat post-treatment (24 h at 80 °C) led to lower internal bond strength, due to retrogradation  causing higher rigidity of the starch binder. However, it showed to have a significant effect on decreasing the thickness swelling.This work investigates the feasibility of producing low density particleboards using an adhesive system based on sour cassava starch, taking advantage of its adhesive and self-expansion properties. Relevant properties of the produced particleboards were evaluated according to European Standards including: density, internal bond, moisture content and thickness swelling. Low density particleboards were produced with densities between 207 kg/m BiomateS 16368) . One wayS 16368) . HoweverSynthetic formaldehyde-based resins are currently used to produce wood-based particleboards, due to their low cost and good binder performance. Natural-based alternatives have been reported, such as adhesives based on tannins, lignin and their combinations ,7,8, soyStarch is one of the most abundant natural polymers and is relatively inexpensive. Cereal grains (such as corn and wheat), tubers (such as potato), and roots (such as cassava) are some of the commercial sources of starch for industrial exploitation. Starch consists of two major molecular components, amylose and amylopectin , which cStarch has excellent affinity towards polar materials such as cellulose, because of the many hydroxyl groups, forming strong adhesive bonds . It is e3 [Cassava sour starch is a traditional food ingredient made by fermentation and sun drying of native cassava starch. It shows good expansion upon heating, which makes it widely used in baking. Expansion occurs after starch gelatinization, as a consequence of water vaporization combined with appropriate paste fluidity, swelling and solubilization. Presence of carboxylate functional groups, formed during fermentation/sun drying, has been correlated with expansion performance . Some au3 .The world’s largest producers of cassava are Africa with 57% and Asia with 31%. Latin America and the Caribbean provide 12% of the world’s supply . ApproxiPopulus L. fibers, commonly used in medium density fiber panels (MDF) production, was provided by Valbopan-Fibras de Madeira S.A . Glycerol (≥95%) was supplied by Sigma-Aldrich . Wood particles with a moisture content of 4% used for the production of particleboards were supplied by Sonae Indústria PCDM .Native and sour cassava starch was purchased at a local supermarket in Porto, Portugal. Chitosan  was supplied by Golden-Shell Pharmaceutical Co. Ltd . 2 (from iodate). This procedure is based on the method described by Banks et al. [The amylose content determination was performed by Eurofins . Sample was first defatted with dichloromethane/methanol and 75% of propanol, and then the starch was solubilized in 2 M sodium hydroxide solution. The amylose content was determined by potentiometric titration with in-situ formed Is et al. .The interior morphology of particleboards was observed by scanning electron microscopy, using a high resolution (Schottky) Environmental Scanning Electron Microscope with X-ray Microanalysis and Electron Backscattered Diffraction analysis: Quanta 400 FEG ESEM/EDAX Genesis X4M . Samples were coated with a Au/Pd thin film, by sputtering, using the SPI Module Sputter Coater equipment. The analysis were performed at CEMUP .−1 at 4 cm−1 resolution. Symmetrical interferograms on 66 scans were co-added for each spectrum.FTIR spectra of the native and sour cassava starch were recorder with a Vertex 70 spectrometer . The absorbance spectra were computed between 4000 and 500 cmPopulus fibers and glycerol were added and stirring was maintained for 5 min. The adhesive system is a brownish viscous liquid with a solid content of 38%.The formulation of the adhesive system is shown in Two formulations were prepared with each starch, as described in 3. A computer-controlled laboratory scale hot-press (homemade at our laboratory), equipped with a linear variable displacement transducer (LVDT), a pressure transducer and thermocouples, was used for producing the panels. The platen temperature was set to 190 °C. The adhesive/wood mixture was placed on the bottom platen, and the top platen was positioned at 25 mm height, during 30 min. Afterwards the top platen was slowly lifted until 28 mm thickness, over a 6 min period, and the final position maintained for 5 min.Wood particles were manually blended with the adhesive. The adhesive/wood ratio was 1:1, based on weight of solid adhesive content and oven dry wood. Single layer mats were hand formed in square aluminum foil deformable containers , with initial dimensions of 220 × 220 × 80 mmAbout 12 h after production, part of the particleboards were subjected to heat post-treatment (HPT) in an oven, at 80 °C for 24 h. The remaining boards were not subjected to any kind of post-treatment. All boards were conditioned at 20 °C and a relative humidity of 65% until testing. The mass of wood/binder mixture used to produce the panels with different densities was between 276 g and 725 g.The boards were tested according to the European standards for density (D) (EN 323), internal bond strength (IB) (EN 319), moisture content (MC) (EN 322) and thickness swelling (TS) (EN 317). In order to evaluate the variability of the measurements, 5 particleboards were produced from the same binder formulation and their properties measured. The coefficient of variation  obtained for each property were: density—4.0%, internal bond strength—2.7%, thickness swelling—10.7%, moisture content—7.5%.The ability of native and sour cassava starches to expand during baking was compared. The formulation containing sour cassava starch increased about 700% in volume , while t−1 and 2930.7 cm−1 can be attributed to O–H and C–H bond stretching, respectively [−1 was assigned as C–O–C stretching and the absorption peak at 1455.4 cm−1 was attributed to C–H bending.−1 and 1077.2 cm−1 are both assigned as the coupling of C–O, C–C and O-H bond stretching, bending and asymmetric stretching of the C–O–C glycosidic bridge [−1 can be attributed to the C–O–H bending and H–C–H related modes. The peak at 860.1 cm−1 can be assigned to C–O–C symmetrical stretching and C-H deformation [The absorbances at 1149.4 cmc bridge . The absormation .−1. Similar results were obtained by Demiate et al. [Sour starch was expected to show higher carbonyl and carboxyl content than native starch, as a result of oxidation during the fermentation/sun drying production process . Such die et al.  and may w/w) was obtained for both.The amylose content of native and sour cassava starches was determined by potentiometric titration, and a value of 18%  after production was also evaluated. The results of the density of the final dry particleboards are shown in 3. Initially the densities of the particleboards increase with the increase of the total mass of mixture used, independent of being subjected or not to the heat post-treatment. The mixture expands until reaching the top press platen, which defines the maximum height of the particleboard. The measured values coincide with the expected ones: Greater mixture mass placed between the press platen implies higher density. However, for expected densities above about 350 kg/m3, the measured densities show a negative deviation. This is a consequence of the high amount of water vapor that is retained within the panel while it stays inside the press. After removal, this internal pressure results in a springback effect, causing the particleboard to expand, thus decreasing its density. For expected densities above around 550 kg/m3, this actually tends to cause internal bursting, since the cohesive strength of the binder, still warm and with high moisture content, is not sufficient to balance the internal stress caused by trapped vapor. The minimum value of the density obtained was 215 kg/mNo significant difference was found in the equilibrium moisture content of the particleboards. This was in the range of 10.4% to 12.3% for non-heat-treated boards, and of 8.4% to 11.6% for heat-treated boards.2 was attained, corresponding to a density of 318 kg/m3. Note that according to European Technical Specification CEN/TS 16368, for lightweight particleboards type LP2 (the most demanding) with thicknesses between 20 and 25 mm, the minimum requirement for the IB is 0.30 N/mm2 [The internal bond strength (IB) provides an overall evaluation of the board’s mechanical integrity, indicating how well the core material is bonded together. The IB values of the particleboards produced are given in 30 N/mm2 .3, the IB decreases, due to the higher board density causing vapor entrapment and, as a consequence of the resulting internal stress, rupture of inter-particle bonds. For the highest expected densities, this ends up leading to full delamination, as discussed before, and a virtually null IB. Heat post-treatment has two distinct effects on the IB of the particleboards. For expected densities up to 313 kg/m3, it leads to a lower IB. Heat treatments are used for the physical modification of starch granules, inducing crystalline rearrangement and promoting intramolecular bonds [For expected densities above 313 kg/mar bonds .The actual outcomes of the treatment are highly dependent on the starch’s botanical origin . In the 3, where the IB shows a maximum value. Since the IB decreases for higher densities, thickness swelling increases again. It must be noted that the values obtained for the TS can be considered quite low. According to European Standard EN 312, for non-load-bearing boards for use in humid conditions with thicknesses between 20 and 25 mm, the maximum acceptable value for TS is 13% [3, which displayed the best IB result, the measured TS is 8.7%. It is important to note that these boards are intended for furniture use in dry conditions .The thickness swelling (TS) results are shown in S is 13% . For theThe heat post-treatment consistently causes a significant decrease in TS. Once again, this may be related to the physical modifications that are known to occur in starches subject to heating , which translate into reduced swelling power .3 and 407 kg/m3. These low density values were obtained thanks to the good self-foaming property of the starch, which allows for the separation of wood particles and the creation of low density domains while maintaining good cohesion. Very good internal bond strength and thickness swelling values were obtained. The best overall performance corresponded to a panel with a density of 318 kg/m3, an IB of 0.67 N/mm2, and a TS of 8.7%. Heat post-treatment revealed to not be beneficial in terms of internal bond strength, but led to a decrease in the thickness swelling.Lightweight particleboards, bonded with an adhesive system, based on sour cassava starch with added chitosan and wood fibers, were produced with densities between 207 kg/mThe use of this 100% natural adhesive system allows for producing low density particleboards with excellent performance. Optimization of the adhesive formulation and production conditions will be the subject of future studies.


Dear Editor,1 PFR (PFWRIRIRR-NH2) is one kind of AMP identified among the derivatives of lactoferrin.2 Our previous results showed that PFR inhibited the proliferation of human acute myeloid leukemia (AML) HL60 cells potentially without toxicity against normal cells. In addition, PFR induced necrosis by membrane disruption detected using scanning electron microscopy.3 However, the underlying mechanisms of these effects are not clearly understood.Antimicrobial peptides (AMPs) are an ancient class of short polypeptides present in a large number of species in nature with a variety of functions.4 induced by PFR in HL60 cells  followed by a delayed and moderate increase in mitochondrial calcium concentration (observed by Rhod-2 staining) in a dose-dependent manner  is a common drug used in the treatment of AML with the drawbacks of drug resistance and drug-related toxicity.a-C Fig.  increasea-C Fig. . Similara-C Fig.  and LDH a-C Fig.  were inca-C Fig. –c and 1ma-C Fig.  were obsa-C Fig.  and kidna-C Fig. .In summary, we found a novel mechanism by which PFR induces necroptosis through ER stress, elevated cytoplasmic calcium, and mitochondrial ROS Fig. . FurtherSupplementary Information


Pedicularis depends on floral characters. However, some important characters may be lost during the process of pressing the specimen. Pedicularis delavayi was described from northwestern Yunnan, and widely adopted as a variety of P. siphonantha. Unfortunately, the name “P. siphonantha var. delavayi’ incorrectly referred to P. milliana (a new species described in this study) or P. tenuituba in some herbarium specimens and publications. Moreover, phylogenetic relationships among P. delavayi, P. siphonantha and its allies (P. milliana and P. tenuituba) were not fully resolved. In this study, we sampled 76 individuals representing 56 taxa. Of them, 10 taxa were from P. siphonantha lineage, and 11 individuals of P. delavayi represented 9 populations. These species were named as P. siphonantha group on the basis of morphological similarity. Nuclear ribosomal internal transcribed spacer (nrITS) and four chloroplast genes/regions were used for phylogenetic analyses. Phylogenetic analyses showed that the P. siphonantha group was polyphyletic: P. delavayi was sister to P. obliquigaleata in clade A; and the remaining species of P. siphonantha group were monophyletic in clade B, named as P. siphonantha lineage. In the P. siphonantha lineage, P. milliana, P. siphonantha, and P. tenuituba were well supported as monophyletic, and P. dolichosiphon was sister to P. leptosiphon. Morphologically, P. delavayi differs from species of the P. siphonantha lineage in having a long petiole (~ 50 mm) and pedicel (~ 40 mm), a ridged corolla tube, and a folded lower-lip of the corolla. Therefore, both morphological characters and phylogenetic evidence strongly supported to reinstate P. delavayi as an independent species and describe P. milliana as new species. In addition, P. neolatituba was proposed to reduce as a new synonymy of P. delavayi.Morphological identification of  Pedicularis L. (Orobanchaceae) show striking interspecific variations , Bull. Acad. Imp. Sci. Saint-Pétersbourg 32: 531, pl. 1, fig. 7. 1888 ≡ Pedicularis siphonantha var. delavayi (Franch. ex Maxim.) P. C. Tsoong, Fl. Reipubl. Popularis Sin. 68: 374. 1963. Type: China. Yunnan: Lijiang (Li-kiang), Yulong Snow Mountain (Suee Shan), alt. 4,000m, 14 Aug. 1886, J. M. Delavay s.n. .Synonymy: Pedicularis neolatituba P. C. Tsoong , in Fl. Reipubl. Popularis Sin. 68: 418–419, pl. 72, f. 1–3. 1963. Syn. nov. Type: China. Sichuan: Songpan (Dongrergo), alt. 4,700m, 9 Aug 1922, H. Smith 3162 .Perennial herb, barely 10 cm tall, drying black or not. Roots fleshy, fusiform. Stems 1 to several, unbranched and erect or ± ascending, 2–10 cm, with lines of hairs. Basal leaves numerous, mostly membraneous and no leaf blade when beginning to flowering, blades development delayed; petiole up to 5 cm, winged, glabrescent; leaf blades lanceolate-oblong, 10–30 mm, sparely pubescent on both surfaces, abaxially furfuraceous, pinnatipartite; leaf segments 5–10 pairs, triangular-ovate to oblong-ovate, margin dentate; leafe veins sparely pubescent. Cauline leaves alternate or pseudo-opposite; petiole 0.5–5 cm, sparely pubescent; leaf blades and segments similar to basal ones. Flowers alternate and axillary, dense, flowering ± synchronous; pedicel 0.5–4 cm, sparely pubescent. Calyx tube 0.8–1 cm, 1/3–2/5 cleft anteriorly, mid-upper part inflated in flowering, sparsely long-pubescent; calyx lobes 3 or 5, rarely 2, lateral lobes leaflike, and posterior lobe ± entire or absent. Corolla purple-red, base whitish, and white spots on the base of galea and the center of lower lip; corolla tube 3–6.5 cm, slender, glabrescent, ridged; galea strongly twisted apically; beak slender, semicircular or slightly S-shaped, bent upward, to 1.2 cm; lower lip ciliate, 1.5–2.0 × 1.5–1.8 cm, lobes emarginate, middle lobe smaller and involute; filaments attached near tube throats, pubescent. Capsule obliquely oblong, apiculate, 1.4–1.7 × 0.4–0.6 cm; seed black, linear-ovate.Pedicularis delavayi is endemic to the Hengduan Mountains region. After re-examination of the herbarium specimens and extensive field expeditions, we confirmed that this species occurs in northwest Yunnan , and west and north Sichuan . This species mainly grows in alpine meadows or at the margin of alpine shrub, at the altitude over 3600 m a.s.l.According to field collection and herbarium records, flowering individuals were collected from early June to early August. Fruiting specimens conserved at the herbaria were difficult to identify. In August 2007 and 2008, we collected fruiting individuals with mature seeds at Daxueshan Mountain of Shangri-La, northwest Yunnan.Pedicularis delavayi is not common, and it is restricted to alpine meadows. Its habitats may be threatened by human activities in pasture and tourism. This species can be considered Least Concern (LC) according to IUCN Red List criteria.L.-M. Gao et al., 25794 (KUN); Lijiang, Yulong Mt. H.-D. Li & H. Tang LHD2014-01 (KUN), LHD201-20 (KUN), LHD201340 (KUN); Shangi-La, W.-B.Yu 015 (KUN), W.-B.Yu et al. HW10130 (KUN), HW10172 (KUN), HW10200 (KUN), LIDZ1258 (KUN). Sichuan: Daocheng, Bowa Mt., Sichuan Vegetation Exped. 1923 (CDBI); Jiulong, Qing-Quan Wang 20508 (CDBI), W.-B.Yu et al., LIDZ1116 (KUN), YWB201507224 (KUN), YWB201507260 (KUN); Kangding, Zheduo Mt., Ru Jiang & Cun-Li Jin 02086 , W.B.Yu et al., HW10316 (KUN); Xiangcheng, Wuming Mt., Fu-Sheng Yang Y0071 (PE).China. Yunnan: Deqin, Pedicularis milliana W. B. Yu, D. Z. Li & H. Wang, sp. nov. [urn:lsid:ipni.org:names: 77185944–1] Type: China. Yunnan: Shangri-la, Xiaozhongdian, Tianbao Mountain, 27°36′22.8″N, 99°53′14.4″E, Alt. 3687m, 22 July 2010, Wen-Bin Yu, Wei Jiang, Yang Luo & Min-Lu Liu HW10095 . Perennial herbs, low to tall, drying black or not. Roots usually cylindric. Stems solitary and ± erect, or sometimes numerous and outer stems procumbent, striate, pubescent or sparsely pubescent. Leaves basal and cauline; petiole of basal leaves 15–30 mm, petiole of cauline leaves 10–25 mm, winged, sparsely long pubescent; leaf blade lanceolate-oblong to linear-oblong, 10–60 × 7–16 mm, abaxially sparsely long pubescent along midvein, furfuraceous, adaxially glabrescent or sparsely pubescent, pinnatisect; segments 6–15 pairs, somewhat lanceolate to broadly ovate or triangular, pinnatifid, or double dentate. Flowers axillary, dense, sometimes interrupted at basal position; bracts leaflike, glabrescent or long ciliate. Calyx pubescent; tube to 1.2 cm, 1/4–1/3 cleft anteriorly; lobes 3, lateral lobes large and leaflike, posterior one smallest. Corolla rose-red; tube 40–80 mm, finely pubescent; galea strongly twisted apically, without a conspicuously auriculate protrusion; beak semicircular or slightly S-shaped, to 1.1 cm, slender; lower lip lobse 3, ciliate, 1.1–1.5 × 1.5–2.0 cm, 2 lateral lobes larger, slightly incurved at the upper margin, middle lobe slightly smaller, emarginate, 2-lobed. Anterior filament pair pubescent. Capsule ovoid-oblong, to 20 mm long; seed dark brown, linear-ovate.ca. 1.2 × 3.0 mm.Pedicularis milliana is endemic to northwestern Yunnan. This new species mainly occurs in humid meadows, along the grassland of mountain streams, or at the margin of low shrubs, at the altitude between 3000 m and 4000 m. Generally, this species grows close to wetland species, P. longiflora, P. rhinanthoides, and/or P. cephalantha.According to field collection and herbarium records, flowering plants were collected from early June to early August. Fruiting specimens were collected from July to September.Pedicularis milliana is a common species in alpine meadows in northwestern Yunnan. Its habitats are likely to be threatened by human activities. This species can be considered Least Concern (LC) according to IUCN Red List criteria.Pedicularis and several other groups of seed plants, and authored dozens of papers or book chapter on the taxonomy and revision of Pedicularis.The species epithet honors Dr. Robert R. Mill, who works at the Royal Botanic Garden Edinburgh, UK. Dr. Mill is a taxonomic expert for S.-D. Zhang & H.-J. He, 08836 (KUN), W.-B. Yu et al. 2014123 (KUN); Lijiang, W.-B. Yu et al. LIDZ1580 (KUN), YWB-003 (KUN); Shangri-La, W.-B. Yu et al., HW10095 (KUN), HW10122 (KUN), HW10141 (KUN), HW10156 (KUN), HW10163 (KUN); Weixi, Hengduanshan Exped. 01644, 3104 (PE), W.-B. Yu et al. 2014099 (KUN).China. Yunnan: Deqin, S1 Table(DOCX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S1 FigThis photo was prepared by A. E. Grabovskaya-Borodina.(JPG)Click here for additional data file.S2 FigW.-B. Yu 015 (KUN) from Daxue Mountain, Shangri-La, NW Yunnan. A, Habit. B, leave. C, calyx tube. D, calyx tube open. E, corolla lower lip. F, stamens and style. This line drawing was prepared by X-L. Wu.This drawing is based on the gathering (JPG)Click here for additional data file.S3 FigThis gathering was collected at Tianbao Mountain, Shangri-La, NW Yunnan. This photo was taken by W.-B. Yu.(JPG)Click here for additional data file.S4 FigA. Habit; B. calyx; C. flower; D. stamens and style. This line drawing was prepared by M.-L. Liu.(JPG)Click here for additional data file.S1 FileThe matrix is partitioned by regions.(NEX)Click here for additional data file.