Conventional vitrectomy technique for macular hole surgery has a good outcome in small and medium macular holes, but for very large macular holes (minimum linear diameter higher than 700 μm) other techniques were developed aiming to achieve greater rates of closure and visual acuity gain. The purpose of this article is to report the anatomical and functional outcomes of four very large macular hole (MH) cases which have undergone vitrectomy with the pedicle internal limiting membrane (ILM) flap technique.This is a retrospective series of four patients with large MH who were treated with vitrectomy and the pedicle ILM flap technique. Comprehensive ophthalmologic evaluation was performed before surgery and included ETDRS best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) for MH measures: height, minimum linear diameter (MLD) and external base diameter. The particular detail of this technique is related to ILM flap creation. During the peeling, the ILM was not removed completely from the retina but was left attached to the edges of the macular hole and subsequently trimmed with the vitrectomy probe using the scissors mode.Four patients with very large MH underwent PPV and the pedicle ILM flap technique was used to pursue macular closure. Median preoperative BCVA was 20/400 (range: 20/320 to 20/400) and median postoperative BCVA was 20/200 (range: 20/320 to 20/200). Of the 4 cases reported, 3 obtained anatomical closure (75%), and also presented BCVA improvement after surgery, considering the last follow-up visit of each case. No additional procedures were performed in either case. One patient demonstrated no anatomic and functional improvement.The present study describes the first Brazilian case series of very large MH treated by the inverted pedicle ILM flap technique. This technique was associated with anatomic and visual improvement in most cases, and represents an alternative therapeutic approach for large macular holes.Trial Registration Project registered in Plataforma Brasil with CAAE number 30163520.0.0000.5440 and approved in ethics committee   from  Ribeirão Preto Medical School Clinics Hospital, University of São Paulo—Ribeirão Preto, São Paulo, Brazil . A macular hole is defined as a full thickness retinal break caused in most cases by vitreoretinal traction . The preThe role of the vitreous in this disease and its classification started to be understood by Gass with the use of posterior segment biomicroscopy –15. HoweMacular holes were considered to be untreatable before the 1991 pioneering study of Kelly and Wendel  who deveFor macular holes measuring more than 500 µm, the final visual acuity usually is less than 0.2 and reoperations are often necessary , 21. TheTherapeutic options for small and medium holes are being extensively revised. Due to the lack of randomized clinical assays with an appropriate sample, there is still no consensus for large, recurrent or persistent holes , 26. ForThis is a retrospective series of four patients with large macular hole who were treated with pedicle ILM flap technique, between May 2018 and May 2019.Comprehensive ophthalmologic evaluation performed at baseline and postoperative following PPV included ETDRS best-corrected visual acuity (BCVA); MH height, minimum and maximum hole diameters measured by spectral domain optical coherence tomography (OCT) . According to the International Vitreomacular Traction Study (IVTS) , all 4 cBefore surgery, all eyes were dilated with two drops of 10% phenylephrine eyedrops administered 5 min apart and three drops of 1% tropicamide eyedrops administered 3 min apart. The initial treatment was provided by the same surgeon in a surgical environment under aseptic conditions and with topical anesthesia. A three-port PPV, core vitrectomy and trypan blue staining were performed. If an epiretinal membrane was present, it was peeled. The ILM was peeled in an area of 4–5 mm around the macular hole. During the peeling, the ILM was not removed completely from the retina but was left attached to the temporal edge of the macular hole. The ILM flap remains attached to the macular hole edge and is trimmed with the vitrectomy probe using the scissors mode. A pedicle ILM flap large enough to cover the entire MH diameter is left and inserted beneath the MH edges.A 67-year-old woman with progressive visual loss complaint in the right eye starting approximately 8 months ago. Ophthalmological examination revealed BCVA of 1.3 logMAR (20/400 snellen) in right eye (OD) and 0 logMAR (20/20 snellen) in the left eye (OS). Patient presented preserved direct and consensual pupillary reflexes and normal applanation tonometry in both eyes. Slit lamp biomicroscopy showed topical intraocular lens (IOL) in OD. Eye fundus examination revealed a grade 4 macular hole (MH) according to Gass [A 70-year-old woman presented progressive low visual acuity in OD for 1 year, with no previous eye surgeries. Initial examination revealed BCVA of 1.3 logMAR (20/400 snellen) in OD and 0.5 logMAR (20/63 snellen) in OS. Slit lamp examination shows moderate cataract in OD. Fundoscopy revealed a grade 4 MH in OD. OCT showed a full thickness MH with a minimum linear diameter of 811 μm and height of 444 μm  in OD and 0.3 logMAR (20/40 snellen) in OS. Slit lamp examination showed moderate cataract in OD. Fundoscopy revealed a grade 4 MH in OD  in OD and a maintained MH of width and thickness similar to baseline values  in OD and 0.1 logMAR 20/25 snellen) in OS. On slit lamp examination, both eyes were phakic. Fundoscopy revealed a grade 4 MH in OD. OCT showed a full thickness MH with a minimum linear diameter of 755 μm and a height of 483 μm . Michalewska et al. , in a coStudies by Michalewska et al.  and ImaiAnother important factor for final BCVA is the continuity of the outer retina photoreceptor layer. Iwasaki et al.  analyzedPark et al. , in a stIn addition to this described technique, the options reported in the literature for large macular holes are amniotic membrane tamponade , autologThe mechanism for macular hole closure using the present technique remains controversial. We agree with Michalewska et al.  hypothesOn the other hand, this technique cannot be employed for persistent holes, where the ILM has already been peeled around the fovea. For this reason, our group has worked on mathematical models to predict macular closure rates using OCT parameters  and use the ILM pedicle technique on the first approach for large macular holes with OCT parameters related to closure rates lower than 80%.The present study describes the first Brazilian case series of large MH treated by the inverted pedicle ILM flap technique. In macular holes > 700 μm, this technique showed preliminary promising results and further studies are warranted.


In this Perspective, to recast the challenge of vaccine development for hypervariable pathogens, I evaluate convergent mechanisms of adaptive variation, such as intrahost immune-mediated diversification, spatiotemporally defined antigenic space, and infection-enhancing cross-immunoreactivity. The requirements of broadly protective immune responses targeting variable pathogens are formulated in terms of cross-immunoreactivity, stoichiometric thresholds for neutralization, and the elicitation of antibodies targeting physicochemically conserved signatures within sequence variable domains.Protective vaccines for hypervariable pathogens are urgently needed. It has been proposed that amputating highly variable epitopes from vaccine antigens would induce the production of broadly protective antibodies targeting conserved epitopes. However, so far, these approaches have failed, partially because conserved epitopes are occluded  Antigenic variability is characterized by the emergence of sequence distinct variants within a species, circulating between hosts, within hosts, or temporally across populations, for which adaptive immunity elicited by one strain fails to protect against another . As a feGeneration of an intrahost quasi-species population characterized by a mutant spectrum generated by high replicative error rates that sustain a reservoir of antigenically distinct virions with varying susceptibility to host–immune response.Spatiotemporally defined antigenic space leading to persistent generation of variants resistant to the regional host population's extant immunity.Spectra of infection-enhancing cross-immunoreactivity between quasi-species or subtypes.Conserved, epitope-masking by variable immunodominant epitopes, steric hindrance, or event-modulated conformational occlusion.Neither mutually exclusive or exhaustive, these patterns typify urgent challenges in vaccine development for which traditional approaches, such as immunization by live-attenuated, subunit, or whole-particle inactivated virus, remain inadequate.Quasi-species refer to individual variants in a mutant diversified population . Althoug−4 and 10−3 per nucleotide per replication, respectively, are prototypical pathogens for studying quasi-species–mediated immune evasion  to targeted epitope(s), rather than simply the steric occupation of receptor-binding domains, mediates neutralization , which, via paratope interaction with conserved residues critical for viral entry, indiscriminately bind, and neutralize a population of antigenically diverse variants . Infectilization . Circumslization . Observalization .in situ suggest effective vaccine design for antigenically variable pathogens may need to target, rather than circumvent, the hypervariable epitopes.Conservation of physiochemical patterns, stretches of low Shannon entropy, high negative selection, and extensive convergent evolution, suggested by broad cross-reactivity, indicate that, even among antigenically variable viruses, antigenic conservation is required to preserve fitness , 22. TheCross-reactivity is necessary but not sufficient for a protective AB response targeting variable epitopes. To resolve infection in an antigenically convergent sequence space, cross-reactive AB must also bind neutralizing epitopes with low paratope-affinity-variance across isolates .Given minor physicochemical variations can alter paratope: epitope interaction, this latter requirement may explain why persistent infection has been attributed to networks of cross-reactivity and their emergent features, such as antigenic altruism, a phenomena whereby cooperation between cross-reactive variants increases population fitness at the expense of “sacrificial” variants preferentially targeted by host immune responses . This reIn silico models, consistent with clinical findings, describe this phenomenon in terms of compromised fitness among clonal lineages with high BCR affinity to physicochemically variable, rather than conserved, residues (Evidence from both clinical cohorts and preclinical models supports the feasibility of biasing affinity maturation to conserved signatures within variable epitopes. Among patients chronically infected with HCV, length of exposure to antigenically diverse quasi-species is associated with the development of bnAB targeting constrained residues, suggesting repeated exposure to variable domains partially attenuates immunodominance and shifts affinity maturation toward better conserved, more consistently presented epitopes . Polyvalresidues . Specifiresidues . These fIndiscriminate inclusion of variants in polyvalent formulations would likely recapitulate the events in natural infection leading to strain-specific neutralization, or worse, antibody-dependent enhancement via induction of cross-reactive antibody with subneutralization threshold affinity . The criin vitro assays, describing a protective immune response. For hypervariable viruses, like other pathogens, these responses are multifaceted, involving coordination across innate, cellular, and humoral immunity (Rationale vaccine design begins with a hypothesis, informed by clinical data, animal models, and immunity . Criticaimmunity . To obviimmunity . To resoThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Botrytis cinerea and antimicrobial activity toward Staphylococcus aureus, suggesting potential application in food packaging as an active biomaterial layer.The aim of this paper is to evaluate the physicochemical and microbiological properties of active thermoplastic starch-based materials. The extract obtained from grape cane waste was used as a source of stilbene bioactive components to enhance the functional properties of thermoplastic starch (TPS). The biomaterials were prepared by the compression molding technique and subjected to mechanical, thermal, antioxidant, and microbiological tests. The results showed that the addition of grape cane extract up to 15 wt% (TPS/WE15) did not significantly influence the thermal stability of obtained biomaterials, whereas mechanical resistance decreased. On the other side, among all tested pathogens, thermoplastic starch based materials showed antifungal activity toward  Environmental pollution and the management of accumulated waste has become one of the major global problems of contemporary society. World production of plastics grew up to 335 million tons in 2016, where 70% of the total amount of plastic packaging ended up in landfills [2 and O2) [In addition to biobased food packaging, there is an increased expansion of active packaging on the market . The act and O2) . Active  and O2) . Biopoly and O2) ,7,8,9,10Currently, thermoplastic starch (TPS) is one of the most investigated biopolymers for food packaging application, due to easy processing by commonly used equipment for manufacturing of the plastic materials, such as injection molding, blown film extrusion, compression molding, casting, and extrusion ,12. More−1 in the spectrum of neat starch is related to stretching vibrations of the OH groups. The band located at 998 cm−1 is attributed to the C-O stretching vibrations of the C-O-C group, whereas bands located at 1152 and 1082 cm−1 correspond to the C-O stretching vibrations of the C-O-H group. The band at 1645 cm−1 is ascribed by δ(O-H) groups from water. It has been reported in the literature that the absorbance band around 1050 cm−1 represents the amount of crystalline structure, and the bands around 1020 and 995 cm−1 are characteristic of the amorphous starch [−1 to higher frequencies, whereas the band located around 1050 cm−1 completely disappears in the case of the TPS sample. A new peak located at 1105 cm−1 has been detected in the spectrum of the S sample, confirming the presence of glycerol [−1 becomes broader, with higher intensity, and this band shifts to higher frequencies after thermal processing of starch, indicating the formation of new hydrogen bonds between water, glycerol, and starch. Regarding the spectra of TPS/WE samples, additional peaks have been detected, i.e., a 1608 cm−1 (stretching vibrations of C-C aromatic double group) and 1508 cm−1 (in-plane bending vibrations of phenyl C−H bonds) [FTIR spectroscopy is a technique that can give insight into starch granules transformation during thermal processing and detects possible interactions between components in material. Hence, in order to confirm the plasticization of starch and to evaluate interactions between grape cane extract and starch, FTIR analysis of neat powder starch, compression-molded starch material (TPS) and thermoplastic starch/grape cane extract material (TPS/WE) was performed and presented in s starch . Thermalglycerol . MoreoveH bonds) ,35. It wH bonds) . The incThe morphology of thermoplastic starch-based materials is shown in Mechanical resistance is a key parameter for food packaging because the package should maintain its integrity during packaging, transport and storage of food products. The mechanical properties of starch materials are presented in onset) of control thermoplastic starch is detected at 280 °C, whereas the maximum degradation rate temperature (Tmax) appears at 312 °C. The Tonset values decrease upon the incorporation of grape cane extract, and it is most pronounced in the case of TPS/WE15. In fact, DTG curve of TPS/WE15 displays a wide shoulder degradation peak, suggesting decomposition of bioactive components from extract, glycerol and TPS chains, all together. These data are in agreement with research work published by Agustin-Salazar et al. [onset is above 270 °C, which is significantly above the processing temperature region of TPS in the compression molding machine (140 °C), thus confirming that these formulations could be processed without risk of high thermal degradation of neat components.Thermogravimetric analysis was carried out in order to evaluate the influence of extract on the thermal decomposition of starch-based films. As it can be seen from r et al.  and Ortir et al. , where aE)-ε-vinifera and (E)-resveratrol. By another side, the solubilities of trans-resveratrol (stilbene model compound) in different alcohol solvents and water had been measured at different temperatures [The grapevine cane extract used in the present study is mainly composed of the following stilbenoids:  to 39% (TPS/WE15) using water as a solvent, from 38 to 87 in methanol/water 80/20 v/v, and from 31 to 86% in absolute methanol, for 1000 µL of DPPH solution. High antioxidant capacity of obtained grape cane extract has been already proven in our previous paper [50  values of the oligostillbenes caraphenol A and α-viniferin A were determined and compared with Trolox antioxidant standard by Li et al. [Caragana sinica was measured. Only three of these compounds showed moderate DPPH scavenging activity and lipid peroxidation inhibitory activities with IC50 values ranging from 34.7 to 89.1 μM [The radical-scavenging activity of the neat TPS and TPS/WE samples was assessed by DPPH assay, using three extractive mediums for bioactive components from the starch matrix: water, methanol/water 80/20 methanol . Neat TPus paper  and suppus paper ,46, due i et al. . All com 89.1 μM . Regardi 89.1 μM . Yun at  89.1 μM .Botrytis cinerea, Mucor indicus, Aspergillus niger, Rhizopus stolonifer, and Geotrichum candidum on the control TPS, grape cane extract and TPS/WE samples was determined. TPS control sample does not show antifungal activity toward any of tested pathogens. On the other side, grape cane extract shows complete inhibition growth only of Botrytis cinerea. TPS/WE samples show moderate antifungal activity toward Botrytis cinerea by the reduction of the growth rate of fungi. The inhibition growth rate of Botrytis cinerea at the contact surface is in the range between 29% (TPS/W5) and 43% (TPS/WE15) (see The inhibition growth (IG) of the E15) see . As the Botrytis cinerea has already been proved by several authors [Botrytis cinerea and Penicillium italicum, due to the low release of resveratrol from the biopolymer matrix into the environment [Penicillum notatum, Aspergillus niger and Aspergillus fumigatus [The antifungal activity of TPS/WE samples is mainly attributed to the presence of bioactive stilbenoids in the extract. In fact, high antifungal activity of resveratrol and moderate activity of viniferin toward  authors ,52,53. Oironment . Howeverumigatus .E. coli, S. aureus and Salmonella typhimurium were also performed. The control TPS film does not show any antimicrobial activity, as it is expected. TPS/WE samples show neglected antimicrobial activity in the contact zone toward E. coli and moderate antimicrobial activity toward S. aureus. On the other side, samples do not show any antimicrobial activity toward Salmonella typhimurium. It is interesting to note that all samples tested against S. aureus give two halo zones, first related to 100% of growth inhibition in area of 13 × 13 mm (TPS/WE15) and moderate growth inhibition in area 35 × 35 mm  than Gram negative bacteria , suggesting that the antimicrobial mechanism of resveratrol disrupts the microbial cell cycle, i.e., microbial growth, evidenced by changes in cell morphology and DNA contents [Antimicrobial activity tests of TPS/WE samples toward 5 mm see . These ralbicans . Moreovecontents .Corn starch with a molecular weight of 50,000 g/mol was obtained from Corn Products Chile Inducorn S.A. Glycerol was purchased from OCN company (China).Vitis vinifera L.) canes were briefly described in a Chilean Patent [v/v) at 80 °C for 100 min. After solvent evaporation, the extract was collected and spray-dried using a BHS Büttner-Schilde-Haas AG dryer at a rate of 15 mL/min, operated with an inlet temperature of 160 ± 5 °C, outlet temperature at 60 ± 5 °C, and injected compressed air at 40 MPa. The spray-dried grape cane extract (WE) was stored under room temperature in aluminum containers. According to HPLC analysis, the main bioactive components of the obtained extract are trans-resveratrol (14.3 mg/L) and trans-ξ-viniferin (29.0 mg/L).The detailed extraction procedure and characterization of active components from grape vine  in a high-speed blade mixer, following the same procedure as for control TPS. The concentration of glycerol and water was kept constant in all formulations. The code formulations were TPS/WE5, TPS/WE10 and TPS/WE15 for samples containing 5, 10 and 15 wt% of WE, respectively.In order to obtain control thermoplastic starch, 500 g of corn starch was homogenized with 150 g of glycerol and 25 g of water at 45 °C and a speed rate of 2800 rpm in high-speed blade mixer . Afterward, 25 g of homogenized starch was placed between two stainless steel plates that were covered with a teflon sheet. The dimension of the mold was 100 × 100 × 0.5 mm−1 at a resolution of 4 cm−1.FTIR spectra of thermoplastic starch-based materials were obtained at room temperature by Jasco FT/IR 400 spectrometer in the range of 4000–400 cmThe morphological analysis was performed by an ETEC autoscan SEM . The samples were fixed in a sample holder and covered with a gold layer for 3 min using an Edwards S150 sputter coater .−1. All measurements were carried out at room temperature and 50% of relative humidity. The reported data are the average values of six determinations. The obtained values of the tensile strength, elongation at break and Young’s modulus were within ± 10%.The tensile test was performed by Instron dynamometer model 1185, equipped with a 1 kN load cell, according to the procedure described in ASTM D638 standard. The cross speed rate was 10 mm min® thermal analyzer. The measurements were carried out at a heating rate of 10 °C/min and under nitrogen atmosphere from ambient temperature to 500 °C. For each composition, the thermogravimetric tests were performed in duplicate.The thermal stability of TPS and TPS/WE sheets was monitored by a NETZSCH TG 209 F3 Tarsus2 of each TPS/WE material was macerated with three solvents: distilled water, methanol/water (80:20), and methanol, and centrifuged at 8500 rpm for 10 min. Twenty microliters of the supernatant were recovered and mixed with 750 µL of DPPH% (133.33 µL) and incubated for 30 min at room temperature. The absorbance was measured at 517 nm, using a Genesys 10s UV-VIS spectrophotometer. The results were expressed as a percentage of DPPH radical scavenging according to the following Equation (1), where Ab and As represents absorbance of the blank and sample, respectively.For determination of the antioxidant capacity of biomaterials, the 2,2-diphenyl-1-picrylhydrazyl (DPPH) free radical was used, according to the methodology previously described by Ventura-Aguilar et al. . BrieflyE. coli ATCC 25922, Salmonella typhimurium ATCC 14028 and S. aureus ATCC 25923. The inoculum was prepared using a direct colony suspension method in nutritive broth. The bacterial growth turbidity was established by the McFarland 0.5 method (1 x 108CFU/mL). A cotton swab was used to inoculate the nutritive agar, which was moistured with the bacterial suspension and distributed over the entire surface of the Petri plates. It was left to dry for 10 min, and afterward, the corresponding starch samples were placed. The inhibition zones were determined after 24 h of incubation at 35 ± 2 °C.The antimicrobial assays were performed against 3 ATCC bacteria Botrytis cinerea, Mucor indicus, Aspergillus niger, Rhizopus stolonifera, and Geotrichum candidum were grown separately on Potato Dextrose Agar (PDA) Petri plates for a period of 3 weeks at 25 °C. Each starch sample (1cm × 1 cm) was placed on a PDA plate surface seeded with 5 mm of the fungal spore disc. The fungal plates were incubated at 25 °C for 7 days, and mycelial growth was measured daily using a Vernier caliper, in order to evaluate the diameter reached by the mycelium over time. Analyses were carried out in triplicate.For antifungal assays, the microorganisms Grape cane extract obtained from viticulture residues due to its antifungal/antimicrobial properties was included in different ratios in thermoplastic starch materials by a compression molding technique. These materials were characterized by various techniques in order to evaluate their physical-chemical properties and potential usage in the food packaging sector. Materials containing the highest ratio of grape cane extract (15 wt%) showed sufficient thermal stability, moderate mechanical resistance and highest antifungal and antimicrobial activity, confirming that viticulture waste could be good source of natural, non-toxic active components in comparison to commonly used synthetic fungicides and could be efficiently incorporated into thermoplastic biopolymers, acting as a bioactive food packaging layer.


Glaze application on monolithic zirconia (Y-TZP) can be a practical approach to improve the mechanical properties of this material.  Our study evaluated the effect of glazing side and mechanical cycling on the biaxial flexure strength (BFS) of a Y-TZP. Eighty sintered Y-TZP discs  were produced and randomly assigned into eight groups (n=10), according to the factors “glazing side”  and “mechanical aging” . Specimens were subjected to BFS test  and fractured surfaces were analyzed by stereomicroscopy and SEM. Hsueh’s rigorous solutions were used to estimate the stress at failure of glazed specimens. Two-way ANOVA, Tukey’s test (5%), and Weibull analysis were performed.o) of the GC was higher than all groups (p<0.05), except to GT, GTC-A and GTC, which were similar among them. The fractography showed initiation of failures from zirconia the tensile side regardless of the side of glaze application and fatigue. The “glazing side”, “mechanical aging” and the interaction of the factors were significant (p<0.05). Groups GC (1157.9±146.9 MPa), GT (1156.1±195.3 MPa), GTC (986.0±187.4 MPa) and GTC-A (1131.9±128.9 MPa) presented higher BFS than control groups . Hsueh’s rigorous solutions showed that the maximum tensile stress was presented in the bottom of zirconia layer, at the zirconia/glaze interface. Weibull characteristic strength (σ Glazing zirconia applied on both tensile and compression sides improves the flexural strength of Y-TZP, regardless the mechanical aging. Glazing is preferred because it prevents surface damages that may lead to phase transformation from tetragonal to monoclinic and, eventually, to low temperature degradation.15Recent studies have shown that zirconium oxide ceramics present higher mechanical properties,17 improving the mechanical properties of the material.18 Glazing has also been applied in the internal surfaces of zirconia crowns to improve bonding to resins.20 Furthermore, considering that one of the main areas subjected to tensile stress is the internal surface of the crowns,21 glaze application in this area can decrease tensile stress of the zirconia.16 A low thickness of glaze layer can also be applied under connectors areas of FDPs, especially in clinical situations where there is lack of space for veneering ceramic.The amount of glaze is negligible compared to that of glass ceramic on a bilayer zirconia restoration. Thus, the residual stresses at the interfaces is probably also very lower. So far, there is evidence that the application of a glass layer with low elastic modulus to zirconia promotes better stress distribution, because the maximum tensile stress is directed to the high-modulus zirconia,The stress at glaze/zirconia interface can vary depending on the side (tensile and/or compression) of application. Thus, the effect of glazing side on the mechanical properties of monolithic zirconia remains unclear. In the present study, it was evaluated the influence of glaze side application on the biaxial flexure strength (BFS) of 3Y-TZP ceramic, before and after cycling, under the following protocols: glaze on the tensile side, on the compression side and on the tensile and compression sides. The hypotheses were that: 1) The application of glaze on tensile and/or compression sides increase the flexural strength of Y-TZP; 2) The mechanical aging decreases the flexural strength of zirconia regardless the glazing application side.Blocks of 3Y-TZP  were rounded to a 15 mm diameter cylinder using a core drill and copious lubricant. Eighty discs  were then sectioned using a low-speed drill . The discs were subsequently polished with #600 to #1500 silicon carbide abrasives sand papers.oC/min for 90 min, 1530°C sintering temperature for 120 min; cooling until 400°C, 3.5 h dwell time and 11 h total time, resulting in a final dimensions: diameter: 12 mm; thickness: 1.20 mm - ISO 687222. The discs were randomly divided into eight groups (n=10), according to the factor “glazing side” (4 levels) and “mechanical aging” (2 levels).The specimens were sintered  at 17The zirconia discs were ultrasonically cleaned in isopropyl alcohol 9% for 5 min and dried in an oil-free air stream at room temperature. The low-fusing glaze ceramic  was applied to the zirconia discs, according to the following groups:Control: no glazing.Glaze on tensile side (GT): a low-fusing glaze ceramic layer was applied to one side of the zirconia discs.Glaze on compression side (GC): a low-fusing glaze ceramic layer was applied to one side of the specimen.Glaze on tensile and compression sides (GTC): a low-fusing glaze ceramic layer was applied on both sides of the discs.0C; time at the initial temperature: 4 min; time for temperature elevation: 5 to 15 min; temperature elevation rate: 800C/min; maximum temperature: 9200C; and time at the maximum temperature: 1 min.The low-fusing glaze ceramic  was applied by means of a brush and sintered in the Vacumat 40T furnace  as recommended by the manufacturing. The firing schedule was the following: initial temperature: 5006 mechanical cycles at 3 Hz and to a load of 84 N, under immersion in water at 37°C (A) . The specimens of the GT group had their treated side placed opposite to the load during mechanical aging. On the other hand, the specimens of the GC group had their treated side facing to the load during mechanical aging.Half of the specimens were stored in water at 37°C for 24 h and the other half were subjected to 1.2 × 1022The BFS was determined in a piston-on-three-ball configuration using a cross-head speed of 1 mm/min and 1,000 Kgf load cell at room temperature (25°C). A thin acetate film was placed between the specimen and the metallic piston (Ø=1.6 mm) for uniform distribution of the load and the disc-shaped specimens were positioned with the tensile stress on the three support balls (Ø=3.2 mm) positioned 10 mm apart in a triangular position. The thickness of the specimens was measured before and after the test. The BFS of the control groups was estimated according to ISO 6872.P is the total load causing fracture (N), b is the thickness of the fracture’s origin (mm), and X and Y are estimated according to:σ is the maximum tensile stress (MPa), v is Poisson’s ratio (0.3), r1 is the radius of the support circle (mm), r2 is the radius of the loaded area (mm) and r3 is the radius of the specimen (mm).23For the groups treated with glaze, the stress-moment relation was estimated according to Hsueh’s rigorous solutions.* is the position of the neutral plane, M is the bending moment per unit length, D* is the flexural rigidity and υ is the Poisson’s ratio of the multi-layer.i denotes the layer number, z23The stress distribution was estimated with Matlab  to plot the graphic representations of the stresses across the layers, which were based on the estimates of top, bottom and interfacial stresses obtained from Hsueh’s solutions.Fractured specimens derived from BFS test were evaluated first by optical microscopy  and then by Scanning Electron Microscopy (SEM)  to determine the fracture origins.We used the OpenEpi website (www.openepi.com) to determine the power of the study for the BFS data . The distribution of the data was evaluated using the Shapiro-Wilk’s test and homogeneity using the Levene’s test. Two-Way analysis of variance (ANOVA) and Tukey’s test (5%) were performed to compare the effect of glazing region and mechanical aging on BFS between all groups. Statistical analysis was performed using program STATISTIX . We considered a 5% significance level.o) to evaluate the reliability of the BFS of the material. The characteristic strength indicates the resistance at a failure probability of approximately 63.3%. Weibull modulus indicates the structural homogeneity of the material considering strength distribution. The calculation Weibull modulus and characteristic strength with a confidence interval of 95% were estimated by lnσc–ln [ln 1/(1-F(σc)] diagram (according to ENV 843-5):Weibull analysis considers Weibull modulus (m) and characteristic strength . The level of significance was 5%.B MPa) than the other tested groups . Moreover, mechanical aging significantly decreased the BFS of Y-TZP .The power of 100% was obtained. Statistical assumptions analysis of data indicated a normal distribution of the data (p>0.05). The results of Levene’s test indicated the homogeneity of the data as there was no statistically significant difference between the standard deviations (p=0.196). ANOVA revealed that the factors “Glazing side” (p<0.00001), “Mechanical aging” (p=0.0489) and their interaction (p<0.00001) were statistically significant. Considering the “Glazing side” factor individually, control group showed the lower BFS (737.9A±146.9 MPa) showed higher BFS than GC-A (958.7±١٢٩.١BCDMPa), GT-A (895.0±74.0CDEMPa), Control-A (780.8±88.7DE MPa) and control (722.0±145.6EMPa) groups. For non-aged groups, there was no significant difference for glazing sides and glazing increased BFS when compared with the control (no glazing). For aged groups, GTC-A (1131.9±128.9ABMPa) presented higher BFS than all groups, except to GC-A. Only GTC-A glazing increased BFS when compared with control-A. Mechanical aging significantly decreased BFS of GT and GC groups, whereas BFS of GTC and control groups were not affected , there was significant difference (p<0.0001) between the groups. Group GC (1207.6a MPa) showed significantly higher characteristic strength than control (779.5e MPa), control-A (820.1de MPa), GT-A (928.0cde MPa), and GC-A (1011.9bc MPa). Control presented lower characteristic strength than all groups, except Control-A and GT-A.24 which may be similar to those in zirconia-glazed specimens, justifying the high strength values across the glaze layers. This is particularly important because there was no chipping or delamination of the glaze, which is commonly seen in veneered specimens as a result of thermal stresses caused by coefficient of thermal expansion mismatch and zirconia’s poor thermal conductivity.25In an attempt to increase zirconia strength with a procedure that can be easily achieved in a prosthesis laboratory, the zirconia surface was glazed on the tensile and/or compression side to simulate the application of glaze on the inner and occlusal surface, respectively. The first hypothesis, which states that the glaze on tensile and/or compression increase BFS of Y-TZP was partially accepted, since only glaze applied on both side showed higher BFS than control groups for non-aged and aged conditions. Glaze on compression side and tensile side separately increased the BFS of Y-TZP only in non-aged condition. In fact, the glazing of the porcelain tends to create superficial compressive stresses,23 throughout the tough zirconia layer, as described for graded zirconia.16In this case, the reduced modulus in the near-surface regions caused the transfer of the majority of stresses to the inner core material, which is stiffer,26 with hardly any in the glaze layer, despite the pores found therein. In our study, the analysis of the stresses across the glaze and zirconia layers for the glazed groups showed that the maximum tensile stress was presented at the bottom surface of the zirconia (tensile side), considering the zirconia/glaze interface. In general, the glaze layer survived cyclic fatigue loading, and fracture occurred in the bottom surface of the zirconia layer, as demonstrated by the fracture origins, probably because it is much stiffer than the glaze layer.23Higher BFS of most glazed groups is probably due to more favorable distribution of stresses27 Hjerppe, et al.27(2010) reported that the application of glaze on tensile side decreased the BFS, whereas glaze on compression side was similar to control (no glazing), in non-aged condition. These results differ from our study, since none of the glazed groups showed BFS lower than control. The authors discussed that the residual stress caused by the cooling rate of the glaze that filled the superficial flaws of the zirconia may increase the probability of fracture. Most of the studies that investigated the effect of glazing on mechanical properties of zirconia applied that glaze in only one side.29 The authors reported increased,14 decreased30 or similar29 mechanical behavior when compared with non-glazed zirconia specimens. Further studies are necessary to evaluate the application of glaze on tensile and compression side of Y-TZP, considering the promising results of our study for mechanical properties and the advantages for bond strength to resin cement.19Few information about the effect of glazing side were found in the literature.The second hypothesis that mechanical aging decreases BFS for all groups was partially accepted, since aging decreased BFS of GT and GC groups, whereas control and GTC groups showed similar BFS to non-aged and aged conditions. The decrease in strength of specimens glazed only on the tensile or compression sides after mechanical aging in water is noteworthy. Stress distribution showed lower stress values in these groups after mechanical aging. Therefore, asymmetric stress distributions caused by glazing only in one side and the presence of water may be responsible for such decrease in strength, which did not occur in the groups glazed on both sides. However, this needs further investigation.34 The decrease of the flexural strength was reported with more aggressive protocols of mechanical cycling;35 however, all studies used a monolithic zirconia, without glaze application. The parameters used in the current study are consistent with that of Wiskott, Nicholls and Belser36 (1995), which reported that a minimum of 106 cycles should be used to simulate the masticatory function. Moreover, the mean natural chewing forces range from 70.6–146.1 N.37 Thus, the 84 N load performed in our study is within that range. In our study, mechanical aging was performed with samples immersed in water, which can negatively influence the mechanical properties of the samples.38 Considering that mechanical cycling was performed to simulate the aging caused by chewing, but without necessarily causing fracture of the samples, the parameters of 1.2×106 mechanical cycles, 3 Hz, 84 N, in water were adopted. Further studies with a higher number of mechanical cycles and loads are important to investigating the mechanical performance of zirconia, simulating more adverse clinical conditions such as the presence of parafunctional habits.Previous studies have reported that mechanical aging did not significantly decrease the mechanical properties of 3Y-TZP.16 The current study performed this analysis with a sample size smaller than the conventional recommendation of 30 specimens per group.39 Several studies have also performed this analysis with a sample size of n=10.44 Quinn and Quinn39(2010) stated that bends or wriggles in the trend line could be a consequence of small sample sizes; however, this was not seen herein.We performed the Weibull analysis to compare the reliability of the material, depending on the treatments. The Weibull moduli were not significantly different , which probably means that glazing could not change the original defects, such as by healing of surface defects. Moreover, in aged and non-aged conditions, glaze on both sides increased characteristic strength. Stress distribution possibly worked differently in glaze groups and shifted the materials’ strength to higher values.45was observed in full-contour single crowns after However, we emphasize that glaze layers can be worn off or partially removed with hydrofluoric acid etching.46 Thus, further studies should be done with full crowns varying the sides of glaze application. Considering the limitations of our study, glazing the occlusal and cementation surfaces of zirconia may improve the long term performance of monolithic zirconia.Increased load-bearing capacityBased on our research, we conclude that:The application of glaze on both tensile and compression sides improved the flexural strength of 3Y-TZP, regardless of the mechanical aging;The origin of fractures was on the tensile surface of zirconia and not on the glaze layer.Glazing of tensile and compression areas seems to be a promising approach to improve zirconia ceramic mechanical properties and long-term.


This study aims to compare the effects of storage solutions commonly used in coronary artery bypass grafting on the vascular reactivity in vein graft interposed in arterial position in syngeneic rats.Twenty-seven male Lewis rats were sacrified to sample a vein graft implanted 6 weeks ago into abdominal aorta position. The vein grafts were inferior venae cavae initially pretreated with heparinized saline solution (HS) or autologous heparinized blood (AHB) or our referent solution, GALA. The endothelial functionality, the in situ Reactive Oxygen Species (ROS) levels and the histological characteristics were conducted from segments of arterialized vein graft.At 6 weeks, graft thrombosis occurred respectively in 22% of AHB group, 62.5% in the HS group and 82.5% in the GALA group. In each group, significative intimal hyperplasia was observed. After 6 weeks, an endothelium-remodeling layer associated with an increase of wall thickness was observed in each group. Endothelium-dependent tone was reduced in the vein graft regardless of the group. No difference was observed concerning the ROS in vein graft between the different groups. In distal aortic sections, ROS levels were increased in HS and GALA groups.Storage solutions used in this experimental model of vein graft implanted in arterial position cause graft injury and a complete disappearance of vascular reactivity. GALA solution did not reduce intimal risk hyperplasia when the vein graft was exposed to arterial flow in a rat model. Ischemic heart disease remains the leading cause of death  in develTo preserve the SVG quality as well as endothelial cells (EC) viability and functionality, some intraoperative graft storage solutions have been evaluated in-vitro , 7 and sWhen venous graft is exposed to the arterial blood flow, hemodynamic strengths (shear stress (SS) and cyclic strain (CS)) are applied on the vascular wall. The impact of SS on EC depends on the type flow applied on the venous graft . IH occuThe research concerning storage solutions is in vitro human studies and it is clearly accepted that they have a fundamental role in the early preservation of the endothelium of the vein graft . HoweverFigure The inferior venae cava grafts were randomly stored in the different preservation solutions at room temperature (20 °C) before implantation. Three different storage solutions were used for the ex-vivo preservation of explanted veins. Vein grafts were stored in one of the following solutions: autologous heparinized (40 UI/ml heparin choay) blood (AHB), 0.9% sodium chloride heparinized (40 UI/ml heparin choay) serum (HS); GALA solution  prepared at the hospital pharmacy which constitutes in our institution the referent storage solution used in CABG for vein grafts. GALA solution was composed of physiologic salt solution to which was added: 0.02 ml magnesium sulfate, 1.785 mg potassium hydrogenophosphate, 0.03 ml magnesium chloride, 0.042 ml calcium chloride, 0.08 ml potassium chloride, 5000 UI/ml heparin choay, L-ascorbic acid (1 g/500 ml), 0.6 ml glucose 5%, 0.75 ml sodium bicarbonate, 1.2 ml sodium chloride, 1.5 ml L-arginine as a substrate for endothelial nitric oxide synthetase (eNOS) and 2.7 ml glutathione. The inferior vena cava segments were collected from 27 donor rats.c/Tyrc, h/h – MHC: RT1’) rats weighting 337 ± 17 g and aged 12.8 ± 0.75 weeks  were housed in a regulatory pet. No exogenous immunosuppressive drug therapy was employed. All procedures were performed according to the guidelines of the Institutional Animal Care and approved by the Ministère Français de l’enseignement Supérieur et de la Recherche (authorization number December 2014: 000375.01).Inbred male LEWIS  and pretreated with buprenorphine . A large incision through the abdominal wall allowed to expose the inferior vena cava and the abdominal aorta. The different branches of the vein were ligatured with 8–0 monofilament Prolene®. The donor rats were sacrificed in a CO2 chamber. The inferior vena cava was stored in a preservation solution  previously described. Each vein was carefully flushed with the storage solution. After storage in one of the preservation solutions and before arterial implantation, a segment of the vena cava was sampled then stored in PSS for myography and corresponding to the control vein group .Twenty-seven recipient rats were anaesthetized and pretreated as described. The abdominal aorta was exposed, isolated from the adjacent inferior vena cava and controlled with a loop between the renal arteries and the aorta bifurcation. The aorta was clamped, and an arterial segment was removed. Heparin injection (300 UI/kg) was performed during the procedure. The vein graft was interposed into the recipient’s abdominal aorta, an end-to-end anastomosis was then established between the donor and the recipient vessels, respectively, using a running 9–0 monofilament suture Prolene® at × 10 magnification Fig. . At the At 6 weeks after transplantation, under anesthesia, the abdomen was exposed, previously implanted vein grafts with a proximal and distal segments of the aorta were removed and subsequently divided into five segments of commensurate length: two segments  were stored in a 10 ml organ bath containing a physiologic salt solution (PSS) for myography and three segments  were cooled in liquid nitrogen and stored at − 80 °C for histology and immunohistochemistry.Myography: for each sacrificed recipient rat, 3 fresh segments of distal aorta, vein graft and control vein stored in PSS were analyzed. At day+ 1, the fresh segments were mounted on a wire-myograph  as previously described . BrieflyVascular segments were embedded in paraffin and cooled at − 80 °C. Sections (7 μm thickness) were obtained from the fixed arterial segments and stained with orcein to visualize elastic fibers. External diameter, lumen diameter, and media thickness were determined after images acquisition  and analyzed using the Histolab Software  for cross-sectional area (CSA) calculation as previously described .2−) [2−) into fluorescent products that are trapped by intercalation into the DNA. Sections were incubated with DHE (1 μmol/L) in phosphate-buffered solution (PBS) and DAPI  for nuclear cells at 37 °C for 30 min in a humidified chamber protected from light. Fluorescent images of ethidium bromide were obtained using a confocal microscope (Nikon) and quantified with the ImageJ (NIH) software. The different studied sections were vein graft and distal aorta samples.Dihydroethidium staining  was used to evaluate the in-situ levels of superoxide anions (O2−) . DHE penP value of ≤ .05 was considered statically significant.Data were reported as mean ± standard error the mean unless indicated otherwise. Considering the sample size, non-parametric tests (t-test or Mann-Whitney test) were conducted to assess the statistically significant of each experiment using Graphpad Prism software . Sample size: based on a previous study [us study , and to n = 1) and 3/9 in the GALA group .The mean duration of venous storage and duration of surgery, the weight gain during the follow-up were presented in the Table Among rats alive, thrombosis occurred respectively in 2/9 (22%) grafts of AHB group, 5/8 (62.5%) in the HS group and 5/6 83.3%) in the GALA group . The wall thickness of vein grafts was 105 ± 32 μm  in the HS group, 101 ± 25 μm (+ 83.9%) in the AHB group and 107 ± 31 μm (+ 83.8%) in the GALA group (0.8). The orcein staining showed an important intimal hyperplasia in the vein graft with a disappearance of endothelium layer and a structural media failure regardless the preservation solution used , about 50% in the control vein (from 10− 6 to 3.10− 6 μmol/L). No contraction was observed on the vein graft except for high doses of phenylephrine (from 10− 6 to 10− 5 μmol/L).Phenylephrine induced a significant contraction in the aorta (3.10p < 0.01) .Acetylcholine did not induce dilatation neither in the control vein nor the aorta and the vein graft. Sodium nitroprusside induced a significant dilatation in the control vein compared to the vein graft (01) Fig. . A dilatIn venous graft sections, there was no difference concerning the superoxide formation evaluated by ethidium bromide-enhanced fluorescence Fig. a. MoreovVein graft failure is the result of a complex mechanism associating endothelial injury which can occur from the surgical harvesting, intimal hyperplasia and atherosclerosis . The mai- Saphenous vein graft (SVG) represents an autologous transplantation, as it is explanted, preserved in storage solution into a cup at room temperature and then implanted in arterial system. In clinical practice, the duration of vein graft storage corresponding to the warm ischemia tissue was difficult to evaluate because no data are published. Some surgeons do not store SVG before creating the anastomoses and develop the concept of “no-touch technique” with excellent graft patency . In cont- Among the occluded veins, only an important IH could explain the vein graft occlusion. In order to obtain an arterialized vein graft, we analyzed the conduit at 6 weeks when the IH started its process. Similar results were observed in the study published by Wong et al. who performed arteriovenous fistula in a murine model and then collected for analysis at 7, 14 and 28 days postoperatively . They foMany studies showed that intimal hyperplasia is an adaptive mechanism following arterialization of the vein and is unlikely linked to vein graft thrombosis . Arteria- In the present study, regardless of the storage solution, no endothelium-dependent dilatation was observed when the vein grafts were mounted on a wire-myograph attesting to endothelial injury. The same findings were showed in the control vein and aorta groups. However, the SMC layer viability was observed in the control vein group, the preservation solutions maintained the SMC functionality from 88 to 106 min of storage.The implication of the shear stress in vascular biology and inflammation was described by Touys et al. . All vasModels of venous grafting in the arterial position have been used to improve the patency of grafts in humans , 36, whiThe high number of occluded vein grafts reduced the possibilities of analysis. Moreover, intermediate analysis of the vein grafts should have been performed in order to explain the mechanisms of vascular inflammation in relation of each group. Due to the small number of vein grafts sections we combined data from all storage solution groups in order to compare vascular reactivity to each solution.The composition of preservation solutions influences vein graft endothelial structural and functional integrity from early graft failure. However, the next crucial step will be conducted randomized clinical trial to compare storage solutions and long-term clinical outcomes because our experimental study show that some solutions do not protect the vein graft from intimal hyperplasia and thrombosis formation during the arterialization stage in this experimental study.


PurposeTo evaluate the efficacy of combining pre-operative intravitreal administration of recombinant tissue plasminogen activator (rTPA) followed by 23G pars plana vitrectomy with the subretinal administration of rTPA in the management of acute submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD).MethodsThis is a single-center case series report that included 14 patients with SMH secondary to neovascular AMD. All of them received preoperative intravitreal injection of 0.05 ml (50 µg) rTPA, followed on the next day by 23G pars plana vitrectomy with subretinal 0.1 ml (10 µg) rTPA administration and air tamponade.ResultsThere was a significant (p=0.01) overall improvement in the visual acuity post-treatment (from 1.4±0.5 log MAR to 0.9±0.4). The mean overall change in the visual acuity post-treatment was 0.5±0.3 log MAR (mean % change=31.7±15.1). There was a significant (p=0.03) overall reduction in the central macular thickness post-treatment (896±608.1 µm to 497.2±196.0 µm). The mean overall change in the central macular thickness post-treatment was 398.8±458.1 µm (mean % change=38.1±18.1).ConclusionCombined treatment of 24 hours of preoperative administration of intravitreal rTPA followed the next day by vitrectomy and the administration of subretinal rTPA with air tamponade appeared to be effective as a prompt intervention in managing acute SMH secondary to neovascular AMD. However, similar studies with larger sample size and a control comparative group are warranted to further confirm these findings. Submacular hemorrhage (SMH) is an accumulation of blood between the neurosensory retina and the retinal pigment epithelium (RPE) within the macular region . SMH is AMD patients taking anticoagulants are more prone to SMH damage, and if left untreated, the prognosis becomes very poor ,4. SeverThe most commonly practiced method of treating SMH is the injection of recombinant tissue plasminogen activator (rTPA) either subretinally or intravitreally combined with gas/air tamponade . These mTaking into consideration that the negative effects of the SMH occur as early as 24 hours and clot formation plays an important role in the pathogenesis of retinal damage, the timing of a quick and effective intervention would play an essential role for a better and optimal outcome. However, most of the patients usually present themselves to the clinic with a significant delay after the onset of symptoms and thus have a poor visual outcome; besides, mechanical clot extraction is associated with secondary complications such as proliferative vitreoretinopathy and retinal detachment. Intravitreal injection of rTPA would be one option because rTPA was shown to penetrate the retina and could not only resolve the blood clot but prevent contraction and scar formation. We would definitely agree that this option is less aggressive, however, in addition to the desired effects of intravitreal rTPA, we wanted to add the mechanical displacement and the more direct injection of rTPA into the accumulated submacular blood and to experience and evaluate the effectiveness of such prompt intervention in the treatment of acute SMH associated with neovascular AMD.https://link.springer.com/article/10.1007%2Fs00347-019-0940-0This work has earlier been presented as an abstract: Abstractband DOG 2019. Ophthalmologe. 2019, 116: 25-218. This was a single-center, prospective case series. Patients (n=14) with a submacular hemorrhage that presented to our clinic between June 2016 and February 2017 with a preoperative optical coherence tomography (OCT) evaluation and signed informed consent were included in the series. The inclusion criteria were: patients with acute SMH in the macular area with central subfoveal involvement secondary to neovascular AMD, hemorrhage not older than five days, a previously established diagnosis of AMD. The exclusion criteria were: patients with hemorrhage older than five days, hemorrhage outside the macular area, no previous established diagnosis of AMD, submacular hemorrhage due to choroidal neovascularisation (CNV) other than AMD . All of the patients were referred to our clinic from the primary health care ophthalmologists where they were initially diagnosed with neovascular AMD and were managed previously with several anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections of bevacizumab. All of the patients had a diagnosis of advanced/late AMD at the time of referral.The average time between the onset of symptoms and the diagnosis of submacular hemorrhage was 2.5 days (Range 2-4 days). The average time between the diagnosis of submacular hemorrhage and the administration of intravitreal rTPA was 1.3 days (Range 1-2 days).We do agree that pre-hospital delay is a major issue in the management of SMH in AMD patients. Most of the patients come to the hospital with a significant delay after the onset of symptoms, and they are generally scheduled for surgery the next day or even later.Preoperative examination consisted of a routine OCT volume scan of the macula region with a 30x30° pattern size (Pattern a number of 19 B-scans with a distance of about 235 - 240 µm (512-pixel x 496 pixels) using a spectral-domain OCT , best-corrected visual acuity, fundus photography, fundus autofluorescence, dilated funduscopy, and intraocular pressure (IOP) measurement. The recently described grading system based on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart of the OCT result sheet was used to define the location in relation to the fovea, the volume scan was used to determine height and location in relation to the retinal pigment epithelium (RPE). The middle of the ETDRS chart is usually automatically centered on the fovea but was manually corrected if needed. This prospective study was approved by the local ethics committee and in accordance with the principles of the declaration of Helsinki. Follow-up examinations were done at four-six weeks at our clinic in the outpatient ward, after which they all received further Anti-VEGF treatments according to the Pro Re Nata regimen by their corresponding primary health care ophthalmologists.rTPA preparation1) Preparation of the stock solution (1 mg/ml)10 mg rTPA , Boehringer Ingelheim, Germany) dissolved in 10 ml of BSS (this results in a 1 mg/ml stock solution) may be portioned and frozen at -80 ° C.2) Intravitreal injection preparation from the stock solution (1 mg/ml)Injection of 0.05 ml of the stock solution = 50 μg rTPA intravitreal3) Subretinal injection preparation from the stock solution (1 mg/ml)0.5 ml of the stock solution is added to a sterile syringe with 5 ml BSS (this results in a 100 μg/ml in the 5 ml syringe)Injection of approx. 0.1 ml = 10μg rTPA subretinalSurgeryPatients were administered intravitreal rTPA 0.05 ml (50 µg) rTPA the day before surgery. The next day, pars plana vitrectomy was performed under a standard ophthalmic operating microscope  by experienced surgeons only. A standard 23-gauge suture-less vitrectomy system was used  with the endoillumination set to 80% for all procedures. A complete core and peripheral vitrectomy was performed. Afterward, a subretinal injection of 0.1 ml (10 µg) rTPA was administered using a 41-gauge cannula . At the end of the surgery, a fluid-air exchange was made and an air tamponade was used. Finally, the infusion cannula was removed and the sclerotomies were sutured if necessary . All of the patients experienced postoperative mild inflammation, redness, and mild pain, which lasted for only two to three days. The average postoperative intraocular pressure was 14.5 mmHg (Range 10-23 mmHg). None of the patients had immediate postoperative complications of re-bleeding, choroidal effusion/swelling, vitreous hemorrhage, or hypotony. All of the patients were discharged on the third postoperative day and were followed up regularly on a weekly basis up to four to six weeks postoperatively.Statistical analysisData were presented as mean ± SD. A paired sample t-test was done to compare the outcomes of pre and post-treatment. A p-value of less than 0.05 was considered significant.2  hemorrhage. The average preoperative visual acuity was 1.4±0.5 logMAR  preoperative. The preoperative mean central macular thickness was 896±608.1 µm and the mean Fundus Fluorescein Angiogram (FFA)/OCT hemorrhage area was 21.6±17.8 mmUsing the grading system based on the ETDRS chart of the OCT, we found that five patients had a hemorrhage in the inferonasal, five patients had a hemorrhage in the supratemporal, and four patients had a hemorrhage in all four macular quadrants. All the patients had a subfoveal hemorrhage.There was a significant p=0.01) overall improvement in the visual acuity post-treatment (from 1.4±0.5 logMAR to 0.9±0.4). The mean overall change in the visual acuity post-treatment was 0.5±0.3 logMAR (mean % change=31.7±15.1)  overall reduction in the central macular thickness post-treatment (896±608.1 µm to 497.2±196.0 µm). The mean overall change in the central macular thickness post-treatment was 398.8±458.1 µm (mean % change=38.1±18.1) (Table 2 to 7.5±10.7 mm2)  overall reduction in the submacular hemorrhage area post-treatment (21.6±17.8 mm) Figure .2 (mean % change=70.4±20.6)  by around 70.4%. There was a significant improvement in visual acuity (p=0.01) by 31.7%, and a significant reduction of a central macular thickness (p=0.03) by 38.1%. SMH is a common symptom associated with neovascular age-related macular degeneration.SMH causes the degeneration of the photoreceptor cells in the retina. This SMH-induced degeneration is due to iron toxicity, retinal contraction caused by the shrinkage of the fibrin meshwork, and reduced nutrient supply to the retina, which leads to scar formation in the macula . Iron deSince the degenerative effects of the SMH start as early as 24 hours, timing is very important while treating SMH. Any delay beyond 24 hours may lead to irreversible damage to the sensory cells of the retina. Although the mechanical removal of SMH has several negative effects on the retina, such as retinal detachment (RD) and proliferative vitreoretinopathy, the use of rTPA has improved the situation drastically.An array of treatments exists to manage SMH formed secondary to neovascular AMD, which includes the administration of only rTPA or anti-VEGF drugs, or performing vitrectomy with gas tamponade, or a combination of them.TPA is a thrombolytic serine protease that activates plasminogen to plasmin that eventually dissolves the clot by cleaving fibrin in the clot . So, TPAIntravitreal TPA can cross the retina to exhibit its thrombolytic effects in dissolving the SMH . It has It has been shown that an intravitreous TPA (50 mg) injection, 12 to 36 hours prior to surgical removal of the blood, resulted in complete liquefaction of SMH . TPA hasA very short half-life (five minutes) of TPA reduces the chances of causing toxicity and interaction with other drugs . IntraviVitrectomy combined with TPA and blood removal is another common way of managing SMH. Here also TPA is used as an adjunct to liquefy the clot and facilitate the removal of the blood by vitrectomy . In thisStudies have also shown that the vision is related to the amount, location, and extension of the hemorrhage .De Silva et al. mentioned that early treatment of submacular hemorrhage using intravitreal TPA, C3F8, and anti-VEGF was effective in significantly improving visual acuity in this series of patients who presented soon after symptom onset. Treatment was well tolerated in this group of elderly and potentially frail patients . MultiplIn view of the short timescale within which photoreceptor damage occurs and the significant effect of the use of less invasive intravitreal injection of rTPA in dissolving the blood in SMH, and the complications associated with surgical removal of subretinal blood clots, we wanted, in this case series, to evaluate the efficacy of using a combined treatment of 24 hours preoperative intravitreal injection of rTPA with a 23G ppV and subretinal rTPA injection with mechanical displacement of the accumulated submacular blood, with an air tamponade as a prompt intervention of patients presenting with acute SMH. Although it is a more invasive intervention as compared to the other existing less invasive treatments of acute SMH secondary to neovascular AMD, it appeared to be effective in improving the visual acuity and reducing the SMH area significantly.In this case series, we also used a lower dose of rTPA  and observed that at such low doses, rTPA was also able to dissolve the blood clot without any side effects or complications. To the best of our knowledge, this is the first study of its kind where the preoperative intravitreal administration of rTPA has been evaluated in combination with vitrectomy and the subretinal administration of rTPA with the mechanical displacement of the SMH using an air tamponade.Combined treatment of 24 hours preoperative administration of intravitreal rTPA followed by vitrectomy and the administration of subretinal rTPA with air tamponade was found to have a significant effect on managing acute SMH secondary to neovascular AMD. This study, owing to its small sample size and limited follow-up, has certain limitations to generalize these findings. Further studies/trials with larger sample sizes and control comparative group/s are recommended to further validate these findings and may yield more useful information.


Te authors’ Chinese name list should be “岳杰，谷志涛，于振涛，张洪典，马钊，刘媛，方文涛，中国胸腺肿瘤协作组成员”.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6133982/


ClinicalTrials.gov. We conducted a cross-sectional analysis of phase III trials with primary results published between January 1, 2016, and June 30, 2017, in high-impact journals and found 74% contained at least one discrepancy between results reported in ClinicalTrials.gov and the corresponding publication. Our findings underscore the necessity for monitoring of clinical trial information and result reporting between sources; a checklist may provide a systemized procedure for investigators and editors to monitor accurate reporting.The FDA Amendments Act (FDAAA) required that information for certain clinical trials, such as details about study design features and endpoints, as well as results, be publicly reported in  Previous studies identified inconsistencies between trial information and the results reported in ClinicalTrials.gov and their corresponding publications [ClinicalTrials.gov and corresponding publications for trials published in high-impact journals.The  (FDAAA)  requiredications . A decadClinicalTrials.govClinicalTrials.gov for the following study features: cohort characteristics , intervention details, primary efficacy endpoints, and serious adverse events. These four study features were examined because they were (1) objectively comparable between the two sources and (2), in our estimation, the most important when weighing the design, significance, and interpretation of a trial.Using PubMed, we identified all phase III clinical trials with primary results published between January 1, 2016, and June 30, 2017, in journals with a 2016 Journal Impact Factor of 10 or greater  could not be compared between the two sources when they were reported in different formats. For example, if the age distribution was reported as the number of participants in certain age ranges  rather than as the mean age, or if adverse events were stratified in one source as serious vs. non-serious while in another were reported in aggregate. We conducted a cross-sectional analysis, characterizing the rate of reporting and consistency in the information and results reported for all study features between the two sources using descriptive statistics; all analyses were performed using Excel (version 16.24) and RStudio (version 1.1.447).ClinicalTrials.gov; 89 (95%) were funded by industry, 4 (4%) were funded by government institutions, and 1 (1%) was funded by other academic/nonprofit institutions. Trials were most commonly published in The New England Journal of Medicine , Annals of the Rheumatic Diseases , and Lancet Oncology .There were 94 phase III clinical trials published in high-impact journals that had results reported on Among the 94 trials, the cohort characteristics of completion rate, age, and sex were reported in both sources for 95 to 100% of trials, whereas race/ethnicity was reported in both sources for 35 (37%) trials  between ClinicalTrials.gov and corresponding publications across all study features.Primary efficacy endpoints were reported by both sources for 94 (100%) trials, of which 4 (4%) could not be compared and 20 (21%) were discordant. Among these 20 discordant studies, 1 had a different endpoint reported between the two sources and 19 had different results reported between the two sources for the same endpoint. Serious adverse events were reported by both sources for 93 (99%) trials, of which 28 (30%) could not be compared and 24 (26%) were discordant. Serious adverse event results could most often not be compared because the two sources reported their results in different formats or stratifications. For example, the publication might report serious adverse events broken down by type, while ClinicalTrials.gov and their corresponding publication, marking only a slight decrease from studies of a decade prior [ClinicalTrials.gov was not subsequently updated. Despite inconsistencies between registered and published primary outcomes of clinical trials being recently observed among a broad sample of clinical trials [A decade after the FDAAA, 74% of phase III trials published in high-impact journals contained some discrepancy in the information and results reported in de prior , 3. SuchClinicalTrials.gov and published in high-impact journals. Thus, it is likely that our study examined those trials following the best practices with respect to result reporting, making our estimates of discrepancies in reporting conservative. Investigators and sponsors that are reporting results to ClinicalTrials.gov, in addition to publishing their study in the highest impact journals, are more likely to adhere to best practices as compared to those who fail to report results to ClinicalTrials.gov. Nevertheless, these findings underscore the necessity for monitoring for concordance of clinical trial information and results reported between these sources. We propose a three-pronged approach to ensuring a harmonious reporting of result information: a checklist for investigators to use to ensure congruent reporting pre-submission to a journal, an acknowledgement of any differences that investigators recognize in the submitted manuscript, and a post-submission check by the journal editors. Sponsors and investigators face several challenges to accurate and consistent result reporting, including a high rate of research staff turnover, lack of staff dedicated to monitoring result reporting at many academic institutions and smaller companies, and poor knowledge of FDA and NIH reporting requirements. A checklist—similar to those applied in surgical settings—may provide a systemized procedure for investigators to monitor accurate reporting to ClinicalTrials.gov throughout the trial process. Additionally, investigators that recognize differences between the results in their manuscript and those in ClinicalTrials.gov should explain these in the study publication. And finally, journal editors, upon receiving a submission, should request that the trial sponsors provide a link to the corresponding ClinicalTrials.gov entry and an itemized list of consistencies between the most important trial features (such as the four we examine in this study).Our study was limited to an 18-month sample of phase III trials that were registered and reported results in both Additional file 1: Table S1. Alphabetized list of journals with a 2016 Journal Impact Factor of 10 or greater. Table S2. List of articles reporting the primary results of Phase III clinical trials published between January 1st, 2016 and June 30th, 2017 in journals with a 2016 Journal Impact Factor of 10 or greater, linked to an NCTID, and with results reported in ClinicalTrials.gov. Figure S1. Sample Cohort Flow Diagram.


AimThe aim of this in vitro study was to evaluate the new, multilayered, translucent zirconia and enhanced glass-ceramics to determine if their translucency (TP) and color stability (ΔE) are affected by thermocycling at 10,000, 30,000, and 50,000 cycles.Materials & methods® 2 Dispersive® (PRT) and Prettau® 4 Anterior® Multi® (PRTA), and two glass-ceramic: IPS e.max CAD® HT (E.max) and Vita Suprinity® HT (VS) were used. All were prepared and sectioned to get plate specimens with dimensions 12.5x14.5x1 mm (n=12) for each material. The L*a*b* values were recorded using a spectrophotometer before and after thermocycling for 10,000, 30,000, and 50000 cycles. The translucencies of the specimens were calculated using the TP formula and the color changes were giving by the color differences ΔE formula at each interval.Two pre-shaded, multilayer zirconia products: PrettauResultsOne-way analysis of variance (ANOVA) was used to analyze the data followed by Scheffe’s post-hoc test and multiple paired t-tests (P < 0.05). There was a statistically significant higher TP for E.max before (16.2) and after aging (16.9) (p<0.001**). All the tested groups showed a statistically significant increase in their TP at different intervals. PRT showed significantly higher ΔE (p<0.001**) after 50,000 cycles.ConclusionThere was a mild but significant increase in translucency in both Zirconia and glass-ceramic after thermocycling. In addition, all materials showed a significant color change with time, however, this is not clinically perceptible. Esthetic and physical durability are two of the prime factors that clinicians consider when selecting dental ceramic materials . As tran2O3) in the composition, and lowering the alumina content and the sintering temperature 1/2TP = 1/2ΔE = [(ΔL*)where L* is lightness, a* is green (-a), and red (+a) axis and b* is blue (-b) and yellow (+b) axis.Scanning electron microscopy (SEM)Random specimens from each group were coated with gold for SEM examination to inspect the grain size of the materials at baseline and after 50,000 thermocycles at 7000x.Statistical analysisStatistical analyses were done using SPSS software . The levels, kurtosis, and skew for all variables used in the calculation were within normal limits, suggestive of a normally distributed sample. Therefore, parametric tests have been used in this study. One-way ANOVA was used to compare the four groups at each cycling interval, followed by Scheffe’s post-hoc test for intergroup comparisons (p<0.05). The overall ΔE and change in TP from interval to interval have been tested using multiple paired t-tests.Translucency profile of the four materialsThe one-way ANOVA showed that there were significant differences in the TP of the four materials at each time interval. The Scheffe’s post-hoc test showed that E.max had a significantly higher TP than VS, which had a significantly higher TP than PRTA (p<0.05). PRT had significantly lower TP than the other three materials (p<0.05). This was true for baseline, 10,000 thermocycles, 30,000 thermocycles, and 50,000 thermocycles Figure . Each ofColor stability ΔEThe one-way ANOVA showed a significant difference in color stability among the different materials at each of the time periods (p<0.001). From baseline to the end of 50,000 cycles, it was observed that there was no significant difference between the E.max and VS with ΔE1 (p=0.571), ΔE2 p=0.753), ΔE3 (p=0.830) at which they had a significantly lower ΔE (p<0.05) than the PRT and PRTA. There was no significant difference in the ΔE1 between the PRT and PRTA (p=0.736). However, at ΔE2 and ΔE3, the PRTA had a significantly lower (p<0.05) delta E than the PRT , PRT (p<0.001), and PRTA (p<0.001) showed a significant change from ΔE1 to ΔE2. In addition, PRT (p=0.013) and PRTA (p=0.012) showed a significant change from ΔE2 to ΔE3  .Both zirconia groups presented the lowest values with TP at baseline of 8.2 for PRTA and 7.0 for PRT, with a statistically significant difference between them. These results concur with the manufacturer’s claim of enhancing the translucency of this new monolithic multilayer zirconia. However, they still showed less TP value than glass ceramics and this is related to the transmitted light through the zirconia, which was significantly lower than through the glass-based ceramics .Although the composition of the zirconia used is unknown, based on the composition of the monochromatic form, it’s expected that the yttria content has been increased in PRTA, reaching up to 12 mol%, which produce more cubic form zirconia grains as compared with PRT where zirconia grains exists in tetragonal form. Increasing the cubic crystals improves zirconia’s translucency owing to optical anisotropy. SEM micrographs of PRTA showed a larger grain size as compared to PRT Figure , resultiThe mild increase in TP after aging in zirconia might be related to the grain size and the transformation to monoclinic form, which could be on the superficial layer only . SimilarAfter aging the samples, they showed statistically significant differences in ΔE values between the four test materials, as well as within the same material at different time intervals. PRT showed significantly higher ΔE values, which could probably be attributed to the less yttria content compared to PRTA. However, it is worthy of note, that all the demonstrated ΔE values in all the groups were not clinically significant, at (ΔE < 3.3). This is in agreement with Alraheam et al. .The number of cycles and aging methods reported in previous literature was inconsistent, making it difficult to co-relate the findings that have been previously reported. In general, different types of lithium disilicate and zirconia will have differences in their optical properties as documented by many authors and that these properties are often brand dependent ,28. HencBased on the results of this study, the authors suggest that the new multilayer zirconia can be a viable treatment alternative to achieve acceptable esthetic results in cases of minimal occlusal reduction, comparable with E.max and VS, which require a minimal thickness of 1.5 mm to 2.0 mm to avoid fracture. However, this advantage needs to be supported by further clinical studies to assure the claim. In addition, the results indicate that there might be slight color change and an increase in the translucency of the new monolithic materials that is expected to occur after five years of intraoral use, for which the authors recommend re-evaluating the esthetic match of restoration after five years of the cementation appointment.One of the limitations of the current study was that only one brand of zirconia material was tested. Zirconia from multiple manufacturers has different formulations and chemical compositions, rendering different physical and optical properties between these materials. Thus, the results of this study cannot be generalized to other brands of Zirconia materials. The other is that although thermocycling was used to age the samples to simulate the intraoral condition, it does not replicate the intraoral environment holistically and what the restorative materials are exposed to other than the thermal factor.Within the limitations of the current study and based on the findings and behavior of materials with thermocycling, the following can be concluded: (1) E.max is significantly more translucent than all the other tested groups before and after thermocycling; (2) VS is significantly more translucent than PRTA followed by PRT, which had the least translucency; (3) The translucency of the tested materials is expected to increase intraorally with time; (4) Color changes after 50,000 cycles, though statistically significant, were within the clinically perceptible value and, therefore, clinically insignificant.