Purpose. To evaluate the efficacy of autologous tenon grafting combined with conjunctival flap as a treatment for scleromalacia or scleral thinning after pterygium excision without any additional donor graft tissue. Methods. Twenty-six cases underwent autologous advanced tenon grafting combined with sliding or rotating conjunctival flap for scleromalacia after pterygium surgery ranging from 2 years to 30 years. The extent of scleral defect measured from 2.0 mm to 6.8 mm in diameter. The cosmetic outcome was defined as complete resolution of scleromalacia or completely conjunctival reepithelialization and firm adhesion between subtenon and scleral tissue over scleral thinning without significant complications. Results. All cases achieved the covering of conjunctival and tenon or subtenon tissue over scleromalacia or scleral thinning with this procedure. Preoperative pain, inflammation, and choroidal exposure disappeared after surgery. Immediate postoperative complications, such as large wound dehiscence or reopening of the scleral wound, did not occur in any of the patients. There were no significant clinical complications during the mean postoperative follow-up period of 14.17 months in all cases. Conclusions. We obtained excellent outcome with fewer complications after autologous advanced tenon graft and conjunctival flap, without an additional donor graft, in scleromalacia or scleral thinning caused by previous pterygium excision. Scleromalacia commonly occurs after pterygium excision  and resuThe sclera , temporaThere is a clinical need for new graft materials that compensate for the disadvantages and limitations of conventional donor materials. Thus, we utilized an autologous advanced tenon graft as a strategy for maintaining the integrity of the globe in patients with scleral thinning or scleromalacia after pterygium excision without any donor graft materials. Herein, we report our experiences of autologous tenon graft with conjunctival flap, with more than 12 months of follow-up.We retrospectively reviewed the medical records at Pusan National University Hospital, Busan, Republic of Korea, between April 2009 and November 2012. Twenty-six eyes of 26 consecutive patients with scleromalacia or scleral thinning after pterygium excision were included. All patients presented with clinical signs of noninfectious scleromalacia or scleral thinning with impending globe rupture. The major indication for surgical intervention was severe scleral thinning, uveal exposure, and impending globe perforation. Patients with previous strabismus surgery, filtering operation, or any other procedure that could result in poor tenon tissue harvesting were excluded from the study. The limitation of indication of this procedure was any scleromalacia with acute or chronic inflammatory reaction, or marked deficiency of adjacent conjunctival tissues. Microbiologic analysis for isolation of the original organism of scleritis was performed with scleral debridement materials.The clinical outcome was assessed using anterior segment examination and best-corrected visual acuity (BCVA), and surgical complications were recorded. Each patient or their legal representative received a comprehensive explanation about the surgery and its implications, and written informed consent was obtained prior to the surgery. This study was approved by Institutional Review Board Ethics Committee (E-2013048) in the Pusan National University Hospital. This investigation adhered to the tenets of the Declaration of Helsinki.Each patient received a comprehensive ophthalmic examination including measurement of distant BCVA using Snellen charts at 4 m and anterior segment slit-lamp examination. Characteristics of preoperative ocular symptoms were recorded in the chart.All operations were performed by one surgeon (Jong Soo Lee) under subconjunctival and topical anesthesia. The main surgical technique consists of sliding or rotating conjunctival flap and making advanced tenon flap from healthy conjunctival and tenon tissue nearby scleromalacia lesion.First, we surgically removed all melting scleral tissues, calcific deposits, and the involved conjunctival tissues in and around the affected sclera. After complete removal of necrotic tissue, the size of the scleral thinning or scleromalacia was measured with calipers. The healthy adjacent tenon tissue was undermined and trimmed to fit the scleral defect. The advanced graft of tenon tissue was usually obtained from the superonasal or inferonasal site, rather than the medial site, because the medial tenon tissue is less movable than the mentioned two sites of tenon tissues. The surgeons were also aware that tightening of the advanced tenon flap may limit ocular movement. If we use the medial tenon tissue to cover the scleral thinning, this advanced medial tenon flap may often induce the limitations of eye movement, especially in lateral gaze. So, we have to reduce the tensile strength by medial advanced tenon tissue, for example, making long and thin thickness of advanced tenon graft.The devitalized or thinning scleral defect was covered by the advanced flap of tenon graft and fixed to the margin of bare scleral lesion with Vicryl 8-0 interrupted sutures . Thus, it was important to make a fixed suture of advanced tenon graft on the healthy margin of the scleromalacia against the original tension of tenon to prevent slipping of the advanced tenon flap. Afterwards, the scleromalacia was covered completely by the adjacent healthy upper or lower nasal advanced tenon flap, and then rotating or sliding bulbar conjunctival flap was made from healthy adjacent conjunctiva and fixed with Prolene 9-0 interrupted sutures  to prevent wound dehiscence between the conjunctival and scleral tissue by ocular movement .After all the procedures were completed, dexamethasone 0.1% eye drop  and ofloxacin 0.3% eye drop  were applied on the eye with bandage. The bandage was opened the next day and topical fluorometholone 0.1% , moxifloxacin 0.5% , and carboxymethylcellulose 0.5%  were prescribed 4 times daily starting 1 day after the surgery in all eyes and gradually tapered over a 1-month period according to graft site status. Conjunctival stitches were usually removed 2~5 weeks  after surgery.After the operation, subjective symptoms of patient and surgical wound status were recorded at postoperative days 1 and 7 and at 1, 3, and 6 months or final visit when clinically indicated.In all, 26 eyes of 26 patients  underwent autologous tenon graft and conjunctival flap surgery. All patients had a common etiology of scleromalacia in that patients had previous history of pterygium surgery over a wide interval of 2 years to 30 years . The extent of scleral defect measured from 2.0 mm to 6.8 mm in diameter. The mean postoperative follow-up period was 14.7 months (±7.83), ranging from 6 to 38 months. The mean preoperative visual acuity was 0.26 ± 0.23 by log MAR; and the visual acuity was slightly improved to 0.25 ± 0.38 after surgery. The change of visual acuity between pre- and postoperative ocular surface is not significant.There was no evidence of bacterial or fungal infection in scleromalacia or scleral thinning by culture. Unacceptable cosmetic appearance due to severe choroidal exposure and scleral thinning was present in eight patients. Other main preoperative symptoms included foreign body sensation, ocular pain with calcified deposit, and impending scleral perforation. The size of the diameter of scleral lesion varied . The cosThere were no significant ocular complications, such as penetrating injury or globe rupture and secondary infection during or after this operation. Complete reepithelialization of ocular conjunctival surface was obtained within 4 weeks after surgery.Immediately after the surgery, the most common subjective symptoms were pain and redness. Ocular discomfort including pain usually resolved within 1~2 months in all cases, and sometimes redness lasted as long as 4 months. Transient diplopia appeared in three cases but spontaneously disappeared after 1 week. Significant complications such as wound dehiscence, detachment of tenon graft tissue, immune reaction, or cosmetic problems did not occur. Tectonic success of the graft was achieved in all patients during the follow-up period . PreoperOver the last decade, numerous donor tissues and synthetic materials have been used to reconstruct the ocular surface –13. HoweScleral thinning, caused by previous pterygium surgery, showed favorable results after tectonic corneal lamellar grafting . The tecAmniotic membrane consists of a thick basement membrane and is endowed with anti-inflammatory , antifibFascia lata can be prepared in any size or any shape and is suitable for scleral patching. It provides good tectonic support and cosmetic success and may be used as either an autograft or homograft. However, fascia lata has an increased risk of necrosis because of its poor vascularization and requires an additional surgery to obtain the graft tissue.Split thickness of dermal graft has the ability to survive on an avascular surface. Although dermal grafts are also flexible and nonbulky with good tensile strength, they have the disadvantage of being cosmetically unacceptable and are unsuitable for use in infective cases . Also, dTherefore, we planned and attempted to use autologous advanced tenon tissue near the scleromalacia or scleral thinning without any secondary additional donor graft tissue. Tenon tissue as graft materials can be easily obtained from the patient without the need of additional donor site preparation. We made an advanced tenon flap, which has abundant blood supply and causes very little immune reaction. As the advanced tenon flap has a better survival rate of graft material due to abundant vasculature of flap, the firm adhesion of tissues between sclera and conjunctival surface was made simulated with lack of tensile strength of advanced tenon flap tissue. Thus, we think that the morphological outcome of this procedure is better and safer than that of conjunctival flap alone. Another distinguishing advantage of tenon tissue over the scleral graft is that relatively large defects can also be indicated. In our study, the largest diameter of scleral defect was measured to be more than 6 mm in 8 patients (30.8%). Despite these large defects, no patients suffered from graft necrosis or wound dehiscence. No wound dehiscence occurs due to plentiful blood supply from autologous tenon and subtenon tissue, resulting in restoration of the ocular surface and maintenance of the ocular tectonic support. According to our result, none of the patients showed wound dehiscence or granuloma formation. We would like to recommend to the beginner surgeon that this technique might be useful to patients with small to moderate sized scleral thinning rather than those with large sized over 10 mm impending perforations or full thickness perforations.Additionally, we used a sliding or rotating conjunctival flap over the advanced tenon graft in attempt to provide epithelial coverage and to minimize the risk of postoperative graft failure. The reformation of the ocular conjunctival surface prevents conjunctival epithelial breakdown and subsequent melt and infection. Full reconstruction of ocular integrity and the conjunctival surface also results in excellent cosmetic outcome.On the basis of our clinical experiences, autologous advanced tenon graft combined with conjunctival flap would be beneficial for the treatment of scleromalacia or scleral thinning without inflammation.


International Journal of Circumpolar Health reached another milestone in June 2015 with a change of the chief editorship from Kue Young  to Rhonda Johnson .The Establishment in 1973 as an organ of the Nordiska Samarbetskommitten för Arktisk Medicinsk Forskning (NoSAMF), reporting to and financed by the Nordic Council of Ministers (NCM).The dissolution of NoSAMF in 1996 and the transfer of the journal to joint ownership by the Nordic Society for Arctic Medicine (NSAM) and the International Union of Circumpolar Health (IUCH). Editorial and administrative functions were assumed by the Centre for Arctic Medicine at the University of Oulu.Arctic Medical Research to International Journal of Circumpolar Health in 1997.Changing of the name from Creation of the International Association of Circumpolar Health Publishers (IACHP), a consortium of several universities, research institutes and professional/academic organizations as the publisher of the journal in 2004.Merging of IACHP with the International Network for Circumpolar Health Research (INCHR) to form the Circumpolar Health Research Network (CHRN) in 2013, which became the publisher of the journal.The closing of the editorial office at the University of Oulu, the publication agreement between CHRN and Co-Action Publisher and the change to a completely on-line journal in 2012.The institution of publication fees in 2013.Over the years, the journal has undergone several major changes. It might be helpful to our readers to highlight them:IJCH serves an essential function in the dissemination and translation of scientific knowledge on all aspects of circumpolar health to our community of health researchers, providers, managers, policy makers and community leaders. The quality and impact of the journal continues to improve, thanks not only to the increasing range of scientific endeavour in the arctic but also to the countless hours of volunteer effort by our growing ranks of peer reviewers willing to share their expert critique of manuscripts upon request. If you are not yet on our reviewer list and would like to be, please contact Rhonda Johnson. And if you are engaged in meaningful and interesting work related to circumpolar health, please consider sharing your experiences and lessons learned with our readers through submission of manuscripts. Check out the “For Authors” tab, and consider joining the on-line discussions via Facebook, Twitter and LinkedIn. We welcome your contributions to the continuing success of our journal.As outgoing and incoming editors-in-chief, we firmly believe that  School of Public Health University of Alberta Edmonton, CanadaKue Young University of Alaska Anchorage Anchorage, AK, USARhonda Johnson


Dear Editor-in-ChiefIranian Journal of Psychiatry and Behavioral Sciences (IJPBS) recently has faced to some cases of unethical duplicate submissions. These papers were published in another journal before IJPBS decelerate the reviewer’s decisions. This can be classified as self-plagiarism or even redundant publication . Almost all journals and publishing guidelines prohibited this act (-). However, some authors continue to do it. I think the most important reason for it may be the urge of authors for publishing their study. In the absence of proper low and enforcement, some authors do this without any fear or shame.Duplicate submission is an unethical act because:When authors submit a paper for a specific journal, they transfer the right of publishing to that journal. Hence, two journals may be claimant it. It seems like a shopkeeper sell something into two people at the same time!In instruction for authors of almost all journals, including IJPBS, duplicate submission is prohibited. If authors accept this instruction and do something in opposite way, a kind of lying is happened.When authors submit a paper in two different journals simultaneously, some reviewers spend their times in reviewing a paper that would never be published in their journal. Hence, wrongdoer authors waste the reviewers times .It is possible that two or more journals unknowingly and unnecessarily publish the same article .What editors can do against this phenomenon? Editors should never allow the wrongdoers to submit their paper in their journal again.Editors of both involved journals should declare the name and affiliation of wrongdoers to make them “known” to the other journals and editors. Declaration of scientific fraud has been done before .Editors should inform the supervisor or the chief of the department of wrongdoer and ask them to do the appropriate action against this phenomenon. Journals should emphasis on that the repetition of this act will have negative effect on the reputation of the affiliated department.Editor of the affected journal should consult with the editor of the other journal that involved determining the proper course of action. It can be the rejection the paper by both journals .At last, I want to ask you and all other editors-in-chief of scientific journals to face duplicate submitters decisively.


It is a formidable task to start a journal about a discipline that doesn’t even exist as a separate specialty in most parts of the world till date. Further, the journal was the vision of few like-minded intellectuals who neither represented any professional body or society, nor had any means to raise funds for this endeavor. But they had energy and optimism to follow their dream. When we pondered over the high morbidity and mortality of surgical neonates, we realized that the possible solutions lie in evidence based practice, training of pediatric and neonatal surgery health care staff, and reduction of preventable morbidity and mortality. Launching the Journal of Neonatal Surgery is also a humble step towards this endeavor. We believe that this has given Neonatal Surgery a special status within the gamut of Pediatric Surgery and would give impetus to the establishment of a separate Neonatal Surgery Health Services. Appreciation and recognition of one’s work is the fuel for further hike. We started this project with a vision that if not success, the intention and struggle are in our control. It is a splendid moment for us to announce its achievements as indicated by its wide readership. Its wide penetration is also reflected in the global contribution of the manuscripts. Indexing of the Journal of Neonatal Surgery with PubMed and PubMed Central is an additional feather in its cap. All the manuscripts published since inception of Journal of Neonatal Surgery have been archived in PubMed Central and they can be retrieved free of cost. This will definitely further increase our visibility and readership. Indexing with Medline and getting Impact Factor are our next goals, albeit we have been calculating our unofficial impact factor. All these attainments would have not been possible without contributions from our authors, peer reviewers, and editorial team members and we gratefully acknowledge them for their continuous support for sustaining this open access venture.Source of Support: NilConflict of Interest: Both the authors are editors of the journal. This article is not externally peer reviewed.


The resistant strains were found to be resistant against all tested pesticides except etoxazole. The bioactivity of etoxazole was many times that of the other tested insecticides and acaricides widely used in vegetable crops in China. On the basis of our research, etoxazole can be expected to be extensively used on vegetable crops in China.Etoxazole, 2--2-ethoxy-phenyl]-4,5-dihydrooxazole, an organofluorine chitin synthesis inhibitor, was assayed for its bioactivities against several major insect and acarus pests and compared to several other pesticides: two chitin synthesis inhibitors, hexaflumuron and chlorfluazuron; a pyrethroid, permethrin; an organophosphate, acephate; a carboximide, hexythiazox; and a tetrazine, clofentezine. The LC Vegetables are a leading economic crop, and insects and acari have important impacts on yield and quality. In recent years, many new physical and biological control methods have been developed that favor the environment and beneficial organisms, such as biological control organisms, organic insecticides, and physical and horticultural activities. At present, due to restrictions imposed on agricultural and economic development, developing and applying new chemical insecticides and acaricides are still major measures for coping with insect and acari damage in vegetable production systems in China. However, the toxicity of chemical insecticides and acaricides is a primary drawback, as they are a hazard to the environment, human health, and beneficial organisms. Insects and acari have developed resistance to many pesticides because pesticides with a similar mechanism on targets were used repeatedly. Insect growth regulators are designed and synthesized to take advantage of unique aspects of development compared to other organisms , which Etoxazole  was proThe mechanism of action of etoxazole (inhibition of the moulting process during insect and mite development) is similar to that of benzoylphenylureas , a clasThe rotational application of compounds with different modes of action in order to prevent or delay the rapid development of resistance is one of the major techniques used in resistance management strategies. The nervous system is the most commonly targeted site of the current main pesticides against insects and acari, and so far, little cross-resistance between them and etoxazole has been reported. Although it has been almost ten years since etoxazole was publicly introduced in 1994 and launched in 1998 as an acaricide/insecticide, its insecticidal and acaricidal activities have not yet been evaluated in detail . MoreovSpodoptera exigua(Hübner) (Lepidoptera: Noctuidae); diamondback moth,Plutella xylostellaL. (Plutellidae); bean aphid,Aphis craccivoraKoch (Hemiptera: Aphididae); and the carmine spider mite,Tetranychus cinnabarinus Boudreaux (Trombidiformes: Tetranychidae) were used in this research because they are several of the most important pests of vegetables and are widely distributed in China. Laboratory colonies of these organisms were raised without pesticide use. Field-collected insecticide-resistant colonies were also established. In this paper, we report on the bioactivity of etoxazole against these insects and spider mites and compare the results with those of several pesticides. The purpose of our research is to ascertain the bioactivity of etoxazole as an alternative pesticide against pests in vegetable crops and to evaluate its application prospects.The beet armyworm,Etoxazole (purity 99%) was synthesized by our group using the method ofS. exiguawas obtained from the College of Life Science, Nankai University, and reared in isolation under standard laboratory conditions of 27 ± 1ºC, 50∽75% RH, 14:10 L:D, and no exposure to any insecticides for several years. A susceptible strain ofP. xylostellawas reared on cabbage plants under standard laboratory conditions without exposure to chemicals for the past ten years. A susceptible strain ofA. craccivorahas been kept under laboratory conditions of 20 ± 1ºC, 40%∽60% RH, natural illumination, without any exposure to insecticides, since the model of screening for new compound’s bioactivity to bean aphids was established in 1990s , for 24 hours. The adult mites were removed after 80 eggs had been laid. To obtain young mites, the mite eggs were allowed to develop on the leaves for 6 days. Then, the leaves with young mites were placed on leaves of the test plants. The cultured conditions of adult mites, mite eggs, and young mites were the same  from fresh cabbage leaves were dipped into the test solution for 10 sec. After air-drying on a filter paper, the leaf disks were treated with the test compound and then placed individually into Petri dishes (7 cm diameter). Second-instar larvae were transferred individually into the Petri dishes. Infested leaves treated with water and DMSO were provided as controls. Six replicates (10 larvae per replicate) were performed. Percentage mortalities were evaluated four days after treatment in the culture conditions and corrected with Abbott’s formula  againstformula .A. craccivorawere assayed by a slightly modified FAO dip test. A stock solution in DMSO of a concentration of 200 mg·L-1was prepared and then diluted to the required series concentrations with water containing Tween-20. Tender bean shoots with 60 healthy uniform apterous adults were dipped in the concentration series of the compounds for 5 sec and then air-dried. Infested leaves treated with water and DMSO were provided as controls. Each test was carried out in triplicate. The processes of all tests were performed under standard laboratory conditions. Percentage mortalities were evaluated four days after treatment and corrected with Abbott’s formula  againstformula .-1was prepared and then diluted to the required series concentrations with water containing Tween-20. Spider mite eggs and young spider mites on leaves were prepared as described in acarus strains. There were about 80 spider mite eggs or young spider mites per leaf. The mite-infested plants were soaked in the series of compounds for 3 sec; then, the superfluous liquid was removed by shaking the plants. Infested leaves soaked in water and DMSO were provided as controls. Each test was carried out in triplicate. The processes of all tests were performed under standard laboratory conditions. After 10 days, the unhatched egg rates (%) were calculated and percentage mortality of young spider mites was evaluated and corrected using Abbott’s formula  against mite eggs and young mites was evaluated by the same procedure with a slightly modified FAO dip test. A stock solution in DMSO of a concentration of 200 mg·Lformula .50value  was calculated using probit analysis of the concentration-dependent mortality dates performed with the statistical software DPS v. 7.05 . That is to say, if the percentage mortality of the control was less than 5%, the result was directly used; but if the percentage mortality was less than 20%, the result was corrected by V=((X-Y)/X)*100 , or the test was invalid. The LCv. 7.05 .50values and the slope ± SEM of these pesticides were calculated according to the bioassay concentration-response curve and are shown inS. exigua, having a greater toxicity than hexaflumuron and chlorfluazuron. Furthermore, the toxicity of etoxazole EC was greater than that of etoxazole. The commercial 5% chlorfluazuron EC was tested for its insecticidal activity and compared with 5% etoxazole EC. It was found that the toxicity of 5% etoxazole EC againstS. exiguagreater than that of chlorfluazuron EC.The concentration-mortality curves as the bioassay results of these pesticides are presented in50values of etoxazole, hexaflumuron, chlorfluazuron, 5% etoxazole EC, and 5% chlorfluazuronEC against the resistant strain ofS. exiguaare shown inThe LC50values and the slope ± SEM of these pesticides were calculated according to the bioassay concentration-response curve and are presented in50value of etoxazole was less than the LC50values of hexaflumuron and chlorfluazuron againstP. xylostella(P. xylostellawas greater than that of 5% chlorfluazuron EC.The concentration-mortality curves as the bioassay results of these pesticides are presented inostella. Hence,50values of etoxazole, hexaflumuron, chlorfluazuron, 5% etoxazole EC, and 5% chlorfluazuron EC against the resistant strain ofP. xylostellaare shown inThe LCA. craccivorawere assayed. The concentration-mortality curves as the bioassay results of these pesticides are presented in50values and the slope ± SEM of these pesticides were calculated according to the bioassay concentration-response curve and are presented inA. craccivora. The toxicity of 5% etoxazole EC againstA. craccivorawas greater than that of etoxazole. The commercial 30% acephate EC was bioassayed for its insecticidal activity compared to 5% etoxazole EC. It was found that the toxicity 30% acephate EC was less than that of of 5% etoxazole EC.The mortality rates of etoxazole, permethrin, and acephate against the susceptible strain of50values of etoxazole, permethrin, acephate, 5% etoxazole EC, and 30% acephate EC against the resistant strain ofA. craccivoraare shown inA. craccivorawas greater than the toxicities of permethrin and acephate. Accordingly, the toxicity of 5% etoxazole EC was great than that of 30% acephate EC.The LCT. cinnabarinuswere assayed. The concentration-mortality curves as the bioassay results of these pesticides are shown in50values and the slope ± SEM of these pesticides were calculated according to the bioassay concentration-response curve and are given in50value of etoxazole was less than the LC50values of hexythiazox and clofentezine againstT. cinnabarinusnymphs (The mortality rates of etoxazole, hexythiazox, and clofentezine against nymphs of thenymphs . The to50values of etoxazole, hexythiazox, clofentezine, 5% etoxazole EC, and 5% hexythiazox EC against the resistant strain ofT. cinnabarinusare shown inT. cinnabarinuswas greater than the toxicities of hexythiazox and clofentezine. Accordingly, the toxicity of 5% etoxazole EC was great than that of 5% hexythiazox EC.The LCT. cinnabarinuswere assayed. The concentration-mortality curves as the bioassay results of these acaricides are shown in50values and the slope ± SEM of these pesticides were calculated according to the bioassay concentration-response curve and are presented in50value of etoxazole was les than the LC50values of hexythiazox and clofentezine against spider mite eggs (The effects of etoxazole, hexythiazox, and clofentezine against eggs of the susceptible strain of the mitete eggs . The to50effects of etoxazole, hexythiazox, clofentezine, 5% etoxazole EC, and 5% hexythiazox EC against the resistant strain ofT. cinnabarinusare shown inThe LCIn conclusion, it was seen that etoxazole is an effective insecticide/acaricide. On the basis of bioactive results, 5% etoxazole EC was an excellent formulation alternative to etoxazole applied in vegetable fields. Furthermore, etoxazole combined with other insecticides/acaricides in vegetables can be used to achieve integrated pest management. Consequently, etoxazole is a suitable biorational alternative to traditional, highly toxic pesticides, with important significance to vegetable crop protection from insects and acariin China.


Prevalence of graft occlusion is high after coronary artery bypass grafting (CABG). Routine use of aspirin after CABG reduces graft failure and ischemic complications. The benefit of concomitant clopidogrel administration remains a controversial issue.We sought to evaluate the impact of use aspirin plus clopidogrel versus aspirin alone on graft patency and adverse cardiovascular events 18 months after CABG.In this single-centre prospective randomized study, 200 consecutive patients undergoing elective CABG were randomly assigned to two groups: 97 patients received aspirin 300 mg (A) and 103 patients received aspirin 100 mg plus clopidogrel 75 mg (AC). Antiplatelet protocol was initiated immediately after surgery and continued daily for one year. Graft patency was evaluated by multislice computed tomography angiography (MSCT) 18 months after surgery. The occurrence of major cardiac or cerebrovascular adverse events (MACCE) and bleeding complications during follow-up were assessed.Preoperative patient characteristics were similar in both groups. MSCT graft patency was assessed in 194 patients (97%). A total of 542 grafts and 680 distal anastomoses were analyzed. Overall graft patency was 83.1% in group A and 89.4% in the AC group (p = 0.04). Patency rates in the A group versus AC group were similar: Left internal mammary artery , right internal mammary artery , radial artery , saphenous vein graft . Clinical follow-up was complete in 200 patients. The incidence of MACCEs was similar in both groups . The need for percutaneous coronary re-intervention showed no statistically significant differences .Compared with aspirin monotherapy, the combination of aspirin plus clopidogrel following CABG did not significantly increase graft patency or reduce the incidence of adverse cardiac events.


TSPYL2 locus has been reported in people with ADHD. However, the role of Tspyl2 remains unclear. Therefore here we used a Tspyl2 loss-of-function mouse model to directly examine how this gene impacts upon behavior and brain anatomy. We hypothesized that Tspyl2 knockout (KO) would precipitate a phenotype relevant to neurodevelopmental conditions. In line with this prediction, we found that Tspyl2 KO mice were marginally more active, had significantly impaired prepulse inhibition, and were significantly more ‘sensitive’ to the dopamine agonist amphetamine. In addition, the lateral ventricles were significantly smaller in KO mice. These findings suggest that disrupting Tspyl2 gene expression leads to behavioral and brain morphological alterations that mirror a number of neurodevelopmental psychiatric traits.Testis specific protein, Y-encoded-like 2 (TSPYL2) regulates the expression of genes encoding glutamate receptors. Glutamate pathology is implicated in neurodevelopmental conditions such as autism spectrum disorder, attention deficit hyperactivity disorder (ADHD) and schizophrenia. In line with this, a microduplication incorporating the The online version of this article (doi:10.1007/s10519-015-9777-8) contains supplementary material, which is available to authorized users. Testis Specific Protein, Y-encoded Like 2 (TSPYL2) is X-linked and expressed in both the developing and adult brain  receptor subunit 2b (NR2B) and reelin   for 4 weeks before testing. All experiments described in the present study occurred during the dark phase.Tspyl2 gene (Tspyl2m/Y), designated knockout (KO) and their wildtype (WT) littermates were used throughout the study. The generation of KO mice on a pure 129 Sv/Ev genetic background has been fully described previously, with the loss of Tspyl2 transcripts  filled with bedding to a depth of 5 cm and topped with 20 marbles evenly spaced apart in four rows of 5 marbles for 30 min  allowing access into each chamber. The chambers of the social apparatus were cleaned and fresh bedding was added between consecutive subjects  with the stranger was recorded by a researcher who was blind to group assignment  was demarcated by a red line  was dissolved in 0.9 % NaCl solution on the day of testing to obtain 2.5 mg/kg, in a volume of 5 ml/kg. This low dose was selected based on evidence that it typically elicits a measureable locomotor response in mice, with minimal stereotypic or ataxic behaviors . Animals were anesthetized during scanning with isoflurane/air mixture at 3 % for induction and 1.5 % for maintenance via a nose cone. A quadrature RF coil with 23 mm inner diameter was used. A set of scout images . T-tests confirmed that both WT and KO mice had a significant preference for the chamber containing stranger 1 rather than the empty chamber . When stranger 2 was introduced, there was no main effect of chamber, or genotype, nor any interaction between genotype × chamber sides. Both Tspyl2 KO and WT mice spent a similar time in the chamber containing stranger 1 and the chamber with stranger 2. .There was no main effect of genotype on the time spent exploring the whole chamber; and there was no main effect of chamber side during the habituation period. When stranger 1 was introduced, there was however a main effect of chamber  . Therefore, the PPI attenuating effects of Tspyl2 KO mice were marginally more active than WT controls, though this difference did not quite reach significance . Total distance travelled in 30 min in the open field was shown in Supplementary Fig. 4. There was no group difference in the number of entries in the central arena .The distance moved in 10 min bins during the habituation period in the open field was taken as a measure of spontaneous locomotor activity. The There was no significant group difference in distance moved in 10 min bins following saline injection Fig. a. Thus tF = 12.464, p < 0.001]. The total distance moved was significantly greater in the Tspyl2 KO group relative to WT mice  = 7.034, p < 0.01]  ANOVA. There was a significant main effect of genotype [Tspyl2 KO mice . Therefore all animals with MRI data were considered together in the analyses of group differences. ROI tracing of the lateral ventricles, cerebral cortex, hippocampi and cerebellum are shown in Fig. Tspyl2 gene on a 129 Sv/Ev background led to sensorimotor gating impairment, mild hyperactivity and hyper-sensitivity to the dopamine agonist AMPH. However, Tspyl2 loss-of-function did not alter social interaction as tested here, nor did it cause gross abnormalities in volume of the whole brain, hippocampus or cerebellum, although smaller ventricular volumes were observed in KO mice.In this study, we found that loss-of-function of the Tspyl2 loss-of-function mice have reduced expression of NR2B  can induce behavioral sensitivity to AMPH Below is the link to the electronic supplementary material.


Rosin, an abundant raw material from pine trees, was used as a starting material directly for the synthesis of rosin acid starch. The esterification reaction was catalyzed by lipase (Novozym 435) under mild conditions. Based on single factor experimentation, the optimal esterification conditions were obtained as follows: rosin acid/anhydrous glucose unit in the molar ratio 2 : 1, reaction time 4 h at 45°C, and 15% of lipase dosage. The degree of substitution (DS) reaches 0.098. Product from esterification of cassava starch with rosin acid was confirmed by FTIR spectroscopy and iodine coloration analysis. Scanning electron microscopy and X-ray diffraction analysis showed that the morphology and crystallinity of the cassava starch were largely destroyed. Thermogravimetric analysis indicated that thermal stability of rosin acid starch decreased compared with native starch. With the challenges of fossil resource depletion and the environmental problems, development of polymers from renewable resources either entirely or partially has attracted more and more attention . As a ubRosin acid is the major component (about 90%) of crude rosin which is a kind of natural product obtained from the exudation of conifers. Rosin acid is a mixture consisting primarily of abietic acid, levopimaric acid, and pimaric acid. More than 1 million tons of gum rosin is produced worldwide per year and generally used as ingredients for inks, vanishes, adhesives, cosmetics, medicines, chewing gums, and so forth . Rosin aLipases are an important group of biotechnological catalysts which catalyze the hydrolysis of triglycerides into free fatty acids and glycerol. Besides, they can also catalyze esterification, acidolysis, interesterification, alcoholysis, and aminolysis and have been widely applied in food, dairy, detergent, and pharmaceutical industries . Lipases Candida antarctica lipase (Novozym 435) as catalyst. The reaction conditions were investigated, and the structure of rosin acid starch was studied.In this work, rosin acid starch was synthesized successfully using immobilizedGum rosin was supplied by Guangxi Wuming Chaoyan Rosin Plant, China and was used directly for esterification reaction. Cassava starch (approximately 17% amylose and 83% amylopectin) was purchased from Guangxi Cenxishi Sanjiao Food Scuffled. Novozym 435 with activity of 10 unit/mg was purchased from Novo Industries, Denmark. DMSO, methanol, and acetone were of analytical grade purchased from Chengdu Kelong Chemical Reagent Co., China.In order to improve its solubility for the subsequent reaction, the cassava starch was pretreated according to the literature . CassavaPretreated cassava starch (0.25 g) was dissolved in DMSO (50 mL), followed by the addition of rosin acid at various molar ratios from 1.5 to 7.5 (relative to AUG). To the mixtures, different amount of immobilized lipase ranging from 5% to 25%  was added. Reaction was carried out at set temperatures for different times. The rosin acid starch was collected after precipitation by adding 150 mL of methanol, then washed with 50 mL methanol twice, and dried at 70°C for 24 h. All reactions were performed in triplicate unless otherwise stated.V0 and V are the titration volume of HCl consumed in native starch and rosin acid starch, respectively, C is the molar concentration of HCl, and m is the sample mass in dry weight basis.The DS, defined as the average molar ratio of attached rosin acyl groups per AUG, was determined by a titration method . 1 g samm1 is the starch mass in dry weight basis (g) and m2 is the rosin acid mass in dry weight basis (g).The reaction efficiency of rosin acid was calculated as follows:−1 with a resolution of 4 cm−1.FTIR spectra were recorded on a MAGNA-IR 550 spectrometer . The samples were mixed with dry KBr at a ratio of 1 : 300. The spectra were recorded in a transmittance mode scanning from 4000 to 500 cmThe morphologies of native starch, pretreated starch, and Rosin acid starch were observed using a Supra 55  scanning electron microscopy (SEM). Before testing, the samples were mounted onto the specimen stubs with double-sided tape and then coated with a thin layer of gold to make the sample conductive. SEM was performed under high vacuum at an accelerating voltage of 5 kV. The photographs were taken using automatic image capture software.α radiation, Ni filter disk, 30 mA, and 40 kV. The scattering angle (2θ) was varied from 4° to 60° with a step width of 0.02°.The X-ray diffraction patterns of the native starch and rosin acid starch samples were measured using a D/MAX 2500 V diffractometer  under the following conditions: Cu KThe thermogravimetry analysis was carried out in a STA449F3  simultaneous thermogravimetry and differential scanning calorimetry (TG/DSC) apparatus. The experiments were performed under argon flow at 30 mL/min and temperature from 28°C to 600°C at a heating rate of 10°C/min.According to literature , 0.1%  0.098 was achieved in mild reaction conditions after optimizing the molar ratio of rosin acid/AUG, reaction time, reaction temperature, and catalyst dosage. Esterified starch was characterized by FTIR spectroscopy and iodine color reaction analysis. SEM and XRD data indicated that the starch granule was completely destroyed, and some of the crystalline particles became of amorphous state with new crystalline regions formed in the rosin starch ester. Due to the character of rosin acid, the thermal stability of rosin acid starch decreased compared with native starch. In the next step, in order to expand applications of the rosin acid starch, more experiments should be carried out to investigate its properties, such as mechanical properties, biodegradable properties, and the possible antioxidant properties and antibacterial properties.


Odors of biological relevance  are known to effectively influence basic survival needs of rodents such as anti-predatory defensiveness and mating behaviors. Research focused on the effects of these odors on rats’ behavior mostly includes multi-trial paradigms where animals experience single odor exposures in subsequent, separated experimental sessions. In the present study, we introduce a modification of the olfactory hole-board test that allows studying the effects of different odors on rats’ behavior within single trials. First, we demonstrated that the corner holes of the hole-board were preferentially visited by rats. The placement of different odors under the corner holes changed this hole preference. We showed that holes with carnivore urine samples were avoided, while corner holes with female rat urine samples were preferred. Furthermore, corner holes with urine samples from a carnivore, herbivore, and omnivore were differentially visited indicating that rats can discriminate these odors. To test whether anxiolytic treatment specifically modulates the avoidance of carnivore urine holes, we treated rats with buspirone. Buspirone treatment completely abolished the avoidance of carnivore urine holes. Taken together, our findings indicate that the olfactory hole-board test is a valuable tool for measuring avoidance and preference responses to biologically relevant odors. Challenged by the large diversity of natural odor blends in their environment, most mammalian species have developed highly sensitive olfactory systems to identify and discriminate biologically relevant odors. In rodents, the detection of some odors is of critical importance because they trigger different basic behaviors essential for their survival. In particular, odors transmitted between individuals of the same species (pheromones) are used to communicate information on the gender, reproductive state, social status, and subject identity. Thus, pheromones have been highly associated with the mediation of, e.g., mate choice, parental care and territorial behaviors . PredatoResearch focused on the effects of odors on rats’ behaviors often include multi-trial paradigms where animals experience a sequence of single odor exposures e.g., . In the Experiment 1, rats were tested for hole preference in the classical 16-hole configuration. Experiments 2 and 3 were conducted to assess whether rats display a shift in hole preference when both aversive and attractive odors were presented in the preferred corner holes. Experiment 4 tested if avoidance behavior to holes with carnivore urine samples can be reduced by treating the rats with the anxiolytic compound buspirone.In the present study, a series of four experiments has been conducted to investigate if the hole-board test can be used to investigate behavioral responses of rats to different odors within single trials. In ad libitum. Cages were kept in temperature and humidity-controlled rooms  under a 12 h light/dark cycle with lights on at 6:00 am. Behavioral testing was conducted during the light phase between 8:00 am and 3:00 pm.Testing was carried out using 64 experimentally naive male Sprague-Dawley rats (2–3 months-old) weighing 200–350 g at the time of testing. Rats were bred and reared at the local animal facility . They were housed in groups of 5–6 animals in standard Macrolon Type IV cages with water and food available All experiments were carried out in accordance with international ethical guidelines for the care and use of laboratory animals for experiments (2010/63/EU), and were approved by the local authorities .Figure 1B Inlay), four back wall holes , four front wall holes  and four center holes . Supplier-specific lids were used to close particular holes, meaning that the number and/or the location of the holes could be modified as required for each experiment. The apparatus was located in a small testing room with dimmed illumination (illumination: ∼30 lx).All experiments were conducted in a computer-controlled hole-board apparatus  consisting of three testing boxes constructed from transparent Plexiglas (51.5 cm× 51.5 cm× 41 cm) and a height-adjustable frame with infrared detectors (sample rate: 100 Hz). A removable hole-board with 16 holes (3 cm diameter) in a grid-pattern was placed on the floor of the testing box. Holes were categorized into four corner holes  for each single hole. More specifically, a head dip was counted when the animal placed its head into a hole for at least 300 ms with the ears even with the floor of the hole-board. A minimal time interval of 300 ms had to elapse after a head dip before a new hole visit was counted. For the experiments with odor presentations (Experiments 2–4), the holes of the center region were covered (12-hole configuration). Then, animals were individually placed into the testing box and exposed to four odors simultaneously. For this, 1 ml odor samples (described in detail below) were pipetted into small glass bowls  and placed underneath the hole of each corner prior to testing. The animals were not able to touch the odor samples. For each test session, one corner hole contained only water which served as a control odor. The location of the different types of odor samples was pseudo-randomly changed across individuals (Experiments 2–4) and tests (Experiment 4). The wall holes were always left empty. Head dips into the wall holes were used to assess baseline levels of exploration behavior and to control for individual differences in the total number of head dips. After each test, the testing boxes were thoroughly cleaned with soapy water and ventilated with clean air, before the next rats were tested.For n = 12, 3–6 months-old) individually in a metabolic cage  for ∼30 min on consecutive days. Female urine samples of individual animals were mixed up to ensure that urine from all estrus cycle phases were present. All urine samples were aliquoted into 1 ml portions and stored at – 18°C until usage.Urine samples from foxes, bobcats, pumas and coyotes were purchased from Maine Outdoor Solutions Inc., . We previously demonstrated that urine samples of these carnivores induce avoidance behavior in an open-field experiment . Urine sHole visits were expressed as percentages of total hole visits. In all figures, behavioral data are shown as box-and-whisker plots. The horizontal line represents the median and the box the lower and upper quartiles. The whiskers were calculated with the Tukey method .post hoc comparisons by Holm-Sidak’s test were used. Non-normally distributed data were analyzed using the Friedman test followed by Dunn’s multiple comparisons test. Either hole location (Experiment 1) or odor (Experiments 2–4) was used as within-subject factor. A p < 0.05 was considered statistically significant. All analyses were carried out using GraphPad Prism.For statistical analysis, data were first tested on normal distribution (D’Agostino and Pearson omnibus test). For normally distributed data, analyses of variance (ANOVA) and Experiment 1). In Experiments 2–4, we therefore excluded animals with more than 65 or less than 15 total hole visits from further analysis.Pilot tests revealed that the hole visit behavior of animals that are extremely active or extremely inactive is only marginally modulated by odors  it is known that rodents prefer to remain in the periphery of the apparatus (thigmotaxis), whereas the bright and unprotected areas are usually avoided . TherefoFourteen male Sprague-Dawley rats were tested. They were put into the middle of the hole-board  and their hole visits were recorded for 20 min.Figure 1 illustrates the local distribution of hole visits . The total number of hole visits ranged between 15 and 74 head dips , with a mean of 39 head dips. The subsequent analysis revealed that there were clear differences in the percentage number of total hole visits according to the position of the holes . Corner holes were visited significantly more often than holes with other locations (Holm-Sidak’s tests: ps < 0.0001). Furthermore, the back wall holes were visited more often than the center holes (p = 0.001). There were no significant differences in the hole visits within the different hole categories .Experiment 1, rats were tested in the 16-hole configuration of the hole-board without any odors. Our results indicate that rats showed the highest rate of head dips for corner holes, and the lowest rate of head dips for center holes . This finding is in line with the results of previous hole-board and related exploration-based rodent models and can be explained by thigmotaxis  or too active . Based on these thoughts, the testing protocols of the following studies were designed and the exclusion criteria were defined.It is well-established that aversive odors, such as predator odors, innately induce a variety of defensive responses including avoidance and escape behavior . On the Fourteen male Sprague-Dawley rats were used in this experiment. The following odor samples were presented: fox urine, bobcat urine, female rat urine, and water. The locations of the odor samples were pseudo-randomized.Figure 2. The different odor samples significantly affected the corner hole visits . Post hoc pairwise comparisons with the water control indicated a strong increase of visits to the holes with female rat urine (Holm-Sidak’s test: p < 0.0001), while holes with fox urine (p = 0.03) or bobcat urine (p = 0.02) were visited less often. The mean number of total hole visits was 39 (data not shown).The percentage of total hole visits for each corner hole of the present experiment is shown in Experiment 2 investigated whether simultaneous presentation of both aversive and attractive odors led to changes in hole visit behavior. We showed that holes with carnivore urine samples were clearly visited less often than the hole with water, i.e., carnivore urine was avoided. These results support findings from previous studies showing avoidance behavior to carnivore urine. For instance, Our second observation is that rats were attracted to the hole containing urine from female rats. Sexually naive male mice similarly preferred to investigate female urine over water in a Y-maze test . In the Taken together, the present experiment is in agreement with the rats’ natural motivation to approach odors of potential mating partners  and to aThe previous experiment showed that rats avoid holes with carnivore urine and preferred holes with female rat urine. However, this phenomenon could also be explained by a simple avoidance of odors from other species, whereas odors from conspecifics are preferred. To exclude this possibility, we exposed rats to urine samples from an herbivorous species (elk), an omnivorous species (mona monkey) and a carnivorous species (puma). Based on previous studies , we woulPuma concolor), herbivore urine , omnivore urine  and water as a control odor.Twenty two male Sprague-Dawley rats were included in this experiment. Rats were exposed to carnivore urine , as indicated by a significant odor effect . Post hoc pairwise comparisons of the percentages of corner hole visits with the percentage of water control hole visits showed that the holes with the urine from mona monkeys and pumas were avoided , whereas the holes with elk urine were not differently visited (p = 0.14) than the water control hole. The mean number of total hole visits was 31 (data not shown).Again, the holes with the different odor samples were differently visited by the rats . These findings as well as similar findings from literature  or the 5-HT1A receptor agonist buspirone . Injections were given intraperitoneal (i.p.) and were administered at a volume of 1 ml/kg. Each rat received each of the three treatment conditions in a pseudo-randomized order with 24 h between each test. Rats were exposed to fox urine, coyote urine, female rat urine, and water as control odor.F = 2.28; p = 0.129, Figure 4A].The analysis of the total numbers of hole visits confirmed that buspirone has only minor sedative properties and did not significantly affect the total number of hole visits  with holes with fox urine (Holm-Sidak’s test: p = 0.005) or coyote urine (p = 0.042) being avoided. The holes with female rat urine were not visited more often by rats than the water hole (p = 0.105). Notably, different effects were observed after treatment with 1 mg/kg buspirone. Although there was again a main effect of odor , the percentages of total hole visits for the different corner holes were not different from water .The percentages of corner hole visits after treatment with saline or buspirone  are illustrated in 1A receptor agonist buspirone dose-dependently blocked the avoidance of holes with carnivore urine in the olfactory hole-board test. Importantly, buspirone did not affect the total hole visits and the visits of holes with attractive female rat urine  indicating a specific anxiolytic effect on behavioral changes induced by carnivore urine. We further showed that the olfactory hole-board test is inappropriate for testing compounds with strong sedative effects such as midazolam  tetralin], another 5-HT1A receptor agonist, decreases freezing and increases approach behavior to TMT , a synthetic predator odor (Our finding that buspirone reduced predator odor-induced defensive behavior supports previous findings showing that treatment with 8-OHDPAT [(±)-8-hydroxy-2- with sequential presentations of different odors . MoreoveExperiment 1, As mentioned in Experiments 2 and 3. Rats avoided visiting corner holes with urine of potential predators . Simultaneously, rats visited holes with urine from female rats more often indicating attraction behavior. Importantly, the odor-induced avoidance response was specific to the urine of omnivore and carnivore species. In contrast, the number of visits to holes with urine of an herbivore species was indistinguishable to that of the control holes. This supports the idea that rats are able to discriminate between urine of different species, both predator and non-threatening species (Experiments 2 and 4), a variable efficiency to induce hole preference was recognizable. It has been shown that male rats are more attracted to odors of estrous females than that of non-estrus females . Treatment with buspirone specifically abolished the avoidance response to holes with carnivore urine. Notably, such effects are difficult to detect when the anxiolytic compound has strong sedative effects, as was the case with midazolam since too few hole visits were observed after midazolam treatment. The finding that the olfactory hole-board test provides direct measures of olfactory responses in rats that can be specifically pharmacologically manipulated further makes it possible to use this test to examine, for instance, the specificity of anxiolytic treatment effects.The present study further tested whether the avoidance of carnivore urine holes can be reduced by treating the rats with the anxiolytic compounds midazolam or buspirone (The present study demonstrates that the olfactory hole-board test may provide an appropriate tool for the assessment of olfactory aversion and preferences in rats. In contrast to many other testing paradigms, this paradigm allows testing of up to four odors simultaneously in single trials. Furthermore, the olfactory hole-board test is applicable to test anxiolytic treatments without sedating properties indicating predictive validity.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


After publication of this article, it has come to our attention that a few corrections had not been updated. We are publishing this erratum to highlight what has been updated from the original article. The updates are as follows:-52.5 % to 52.8 %.Abstract – the abstract has been updated to reflect the figures in Table 2, patient survival percentage has been updated from Freedom from acute rejection, graft failure or death has been updated from 0.05 to 0.04.Table 2 – The P value for Figure 3 captions were incorrect on the original article. This has now been updated. The caption for 3b was updated from Patient survival to Death-censored graft survival. The caption for 3c was updated from Death censored graft survival to Patient Survival.The corresponding text relating to Fig. 3 has also been updated in line with the figure changes. In the original article it was:-Patient survival was numerically and statistically similar in both treatment groups at 5 years and equivalent at 10 years  . Death-censored graft survival was also equivalent in the two groups by 10 years  . Combining trends in mortality and graft failure, all-cause graft survival was generally similar over time among participants randomized to both trial arms, and by 10 years was 34.3 % in those treated with rATG versus 30.9 % in those treated with basiliximab at (two-sided P = 0.56) .This has now been updated to the following:-Death-censored graft survival was also equivalent in the two groups by 10 years  . Patient survival was numerically and statistically similar in both treatment groups at 5 years and equivalent at 10 years  . Combining trends in mortality and graft failure, all-cause graft survival was generally similar over time among participants randomized to both trial arms, and by 10 years was 34.3 % in those treated with rATG versus 30.9 % in those treated with basiliximab (two-sided P = 0.56) .


The prediction of conformational b-cell epitopes plays an important role in immunoinformatics. Several computational methods are proposed on the basis of discrimination determined by the solvent-accessible surface between epitopes and non-epitopes, but the performance of existing methods is far from satisfying. In this paper, depth functions and the k-th surface convex hull are used to analyze epitopes and exposed non-epitopes. On each layer of the protein, we compute relative solvent accessibility and four different types of depth functions, i.e., Chakravarty depth, DPX, half-sphere exposure and half space depth, to analyze the location of epitopes on different layers of the proteins. We found that conformational b-cell epitopes are rich in charged residues Asp, Glu, Lys, Arg, His; aliphatic residues Gly, Pro; non-charged residues Asn, Gln; and aromatic residue Tyr. Conformational b-cell epitopes are rich in coils. Conservation of epitopes is not significantly lower than that of exposed non-epitopes. The average depths (obtained by four methods) for epitopes are significantly lower than that of non-epitopes on the surface using the Wilcoxon rank sum test. Epitopes are more likely to be located in the outer layer of the convex hull of a protein. On the benchmark dataset, the cumulate 10th convex hull covers 84.6% of exposed residues on the protein surface area, and nearly 95% of epitope sites. These findings may be helpful in building a predictor for epitopes. Epitopes are binding areas on antigens. The prediction of b-cell epitopes is critical for the development of vaccines and immunotherapeutic drugs . B-cell It is time-consuming and expensive to use experimental techniques to identify b-cell epitopes , especiaSome other methods use protein structure to predict epitopes, building the model using simple scoring-based approaches. CEP  utilizesAlthough many methods are proposed, the performance of b-cell epitope predictors is moderate. With the increase of antigen-antibody crystal structures, it is possible to analyze these complex structures. A more detailed description of the b-cell epitope area becomes important. In this paper, we applied four types of depth functions; half-sphere exposure (HSE) , ChakravThe dataset for this paper was first used as benchmark dataset in Ansari and Raghava . It contSolvent accessible surface area (ASA) is calculated by NACCESS . Relativpk is the value from the Weighted Observation Percentage (WOP) matrix generated by PSI-BLAST [p1, p2,…,p20 is represented by 20 zeroes, then conservation is one.Conservation measure, our use of which was motivated by Valdar’s 2002 work, is defiSI-BLAST , dividedα atoms in two half-spheres around a residue’s Cα atom. One of the half-spheres corresponds to the side chain’s neighborhood, the other half-sphere is in the opposite direction. There are two ways to compute HSE, depending on whether information is available about both the Cαand Cβpositions (HSEB) or only about the Cαpositions (HSEA). HSE can be divided into HSEAU, HSEAD, HSEBU and HSEBD, depending on whether the half-sphere selected is an up half-sphere (U) or a down half-sphere (D). In this paper, we calculated HSEAU, HSEAD, HSEBU and HSEBD, with radius 13Å.Half-Sphere Exposure (HSE) is a 2D measure, introduced by Hamelryck . HSE condepth-1.0 [Chakravarty  defined epth-1.0 .Atom depth (DPX), first introduced by Pintar –40, is dx is a point in d-dimensional space with probability measure P. HSD is defined as the minimum probability mass carried by any closed half space containing x. For a protein, the probability P(H) is estimated by the empirical distribution. The i-th residue HSD is then defined by:Resi) is the number of residues in the half space which is divided by the plane through that i-th residue, and N is the total number of residues in the protein. The use of residue HSD is motivated by Shen [Tukey  introduc by Shen , 48.http://miconvexhull.codeplex.com/) is used to calculate the convex hull of a point set. [In mathematics, the convex hull of a set X of points in Euclidean space is the smallest convex set that contains X. For instance, when X is a bounded subset of the plane, the convex hull may be visualized as the shape formed by a rubber band stretched around X. For a protein, we consider all residues in a protein to be a point set X. In this paper, MIConvexHull (int set. .1(X). The remaining atoms of the protein comprise the set X-CH1(X). We then compute the convex hull of X-CH1(X), such that the atoms on the convex hull surface of X-CH1(X) are defined as the secondary level of the convex hull of the protein, denoted as CH2(X). Generally speaking, the k-th level of the convex hull of the protein is the convex hull of the set X-∪i = 1..k-1{CHi(X)}, denoted as CHk(X). Finally, one protein can represent a union of n convex hulls, i.e. X = ∪i = 1..n{CHi(X)}. The level of the k-th convex hull of a residue is defined as the minimal level of convex hulls of atoms that are in the residue. For instance, Glycine contains Cα,Cβ, N,O atoms, where Cα∈CH2(X), Cβ∈CH3(X), N∈CH3(X), and O∈CH5(X). The level of the convex hull for Gly is 2, as that is the minimal of {2, 3, 3, 5}. The k-th convex hull is a useful tool for classifying the residues. Take the exposed residues of a protein for example; all exposed residues can be divided into k convex hulls.Let X be all the atoms of the exposed residues (RSA>0) in a protein. Atoms which are on the convex hull surface are defined as the first level of the convex hull, denoted as CHk(X)) for each residue. The cumulate k-th convex hull of X (denoted as CHk(X)) is defined as the union of k convex hulls, i.e. CHk(X) = ∪i = 1..k{CHi(X)}. Obviously, CHm(X) is a strict subset of CHn(X), if m<n. If a residue is in CHi(X), then this residue is also in the cumulate i-th convex hull CHi(X). Clearly, we can choose a finite value K0 for which CHk(X) will cover (contain) all the exposed epitopes on the protein surface. K0 is defined as follows:For given exposed atoms of a protein X, we can calculate the k-th convex hull , which is available at <www.sourceforge.net/projects/chops>.KThe cumulate k-th convex hull of protein 1NCA:N is shown in epitopes in the k-th convex hull (CREPIk) of a protein is the number of epitopes in the k-th convex hull divided by the total number of epitopes in this protein. The coverage ratio of epitopes in the cumulate k-th convex hull (CREPIk) is the number of epitopes in the cumulate k-th convex hull divided by the total number of epitopes in the protein. The coverage ratio of exposed residues in the k-th convex hull (CREXPk) is the number of exposed residues in the k-th convex hull divided by the number of total exposed residues in the protein. The coverage ratio of exposed residues in the cumulate k-th convex hull (CREXPk) is the number of exposed residues in the cumulate k-th convex hull divided by the number of total exposed residues in the protein. The proportion of epitopes in the k-th convex hull (PROPk) is defined as the number of epitopes in the k-th convex hull divided by the number of all residues in the k-th convex hull. The proportion of epitopes in the cumulate k-th convex hull (PROPk) is defined as the number of epitopes in the cumulate k-th convex hull divided by the number of all residues in the cumulate k-th convex hull.The coverage ratio of 1 is 2/10 = 20%, CREXP1 is 20/200 = 10%, and PROP1 is 2/20 = 10%.For example, there are 10 epitopes and 200 exposed residues on an antigen protein. Two epitopes and 20 residues are in the first convex hull. Then, CREPIAll exposed residues (RSA>0) are considered. In the following sections, the term non-epitopes will refer to non-epitopes with RSA values larger than zero. Amino acid composition is defined as the count of a type of amino acid divided by the length of the antigen protein. Secondary structure was computed by the DSSP program, and then eight types of secondary structure are combined into three types: (1) Helices, which groups α-helices, 3-helices and π-helices. (2) Strands, that is, isolated β−bridges and extended strands participate inβ−ladders. (3) Coils, consisting of hydrogen-bonded turns, bends and others. The secondary structures of epitopes and non-epitopes are shown in Correlations between RSA and depth functions are also considered. 5). It shows that Chakravarty depth for all epitopes is below 8Å. Further examination of non-epitopes with residue depth above 8Å shows that the median RSA and the conservation of these residues are 1.4 and 0.84, respectively, In contrast, the median of the RSA and the conservation for epitopes are 49.5 and 0.36. With information about the depth function, the epitopes are easily distinguished from non-epitopes.The conservation of epitopes is widely used in the prediction of epitopes. The average conservation scores for epitopes are not significantly lower than for non-epitopes. We further analyze the relationship between RSA, Chakravarty depth and conservation  than for non-epitopes, using the Wilcoxon rank-sum test. This indicates that epitopes are closer to the convex hull. It is also consistent with the results in Rubinstein et al.  which fo1(X)) of the protein. k, CREXPk and PROPk in the k-th surface convex hull, where k = 1,…15. There are 42.2% of the epitopes in 1st convex hull of the protein (CREPI1 = 42.2%). These 42.2% of epitopes cover 26.0% of the surface area of the protein (CREXP1 = 26.0%). There is approximately one epitope per six residues of CH1 . We also noted that CREPIk, CREXPk and PROPk are decreased while k is increasing. This indicates that the percentage of epitopes would be decreased when the residue in the protein interior. Take the k = 2 for example; there are 12.6% of the epitopes in the secondary convex hull (CH2). These residues in CH2 cover 7.76% of the protein surface. Each epitope is around 4 non-epitopes.Epitopes prefer the outer layer of the protein surface, but not all epitopes are in the first convex hull , all values of HSEBU for epitopes are smaller than the values of HSEBU for non-epitopes . We analyzed the cumulate k-th convex hull of different antigen protein chains. 0≤5) of the antigen chains, all epitopes are covered in the top five layers of the convex hull of the antigen. There are a total of 86.0% ((3+8+7+6+5+7+4+2+3+4)/57 = 86.0%) proteins for which all epitopes are located in top 4~13 layers of the convex hull. This also indicated that there is only one protein for which all epitopes are located in the first layer of the convex hull (CH1). From these results, we can see that the convex hull functions can further describe the distribution of epitopes.K0 of the cumulate k-th convex hull can contain all the epitope sites. If the K0 value is too small, many epitopes will not be considered. On the other hand, if the K0 value is too big, too many non-epitopes will be considered. To estimate a proper K0 value, 7 chains  were randomly selected as a test set, and the remaining 50 chains were used as training set. We calculated CREPIk, CREXPk and PROPk of CHk  for each protein in the training set. Then, averages for three kinds of ratios in CHk were computed. For a given protein, we do not know which Kk will contain many more residues, including both epitopes and non-epitopes. The more epitopes included in CHk, the larger CREPIk will be. The more non-epitope sites included in CHk, the larger CREXPk will be, and the smaller PROPk will be  and 1QFU:A(84.2%). The average of the CREXP10s is 77.3%. This indicates that just 77.3% of the exposed residues are covered in CH10. The average value of PROP10 is 8.2%. We further analyze CH6 for the test dataset, and CH6 for 1FSKA, 1IAIM, 1KB5A, 1OTSA covers 100% of the epitopes. The remaining 7th, 8th, 9th, 10th layers of the convex hull contain zero epitopes. This indicates that the cutoff of K0 = 10 is probably robust for the test data.We test our results on the test dataset. CREPIRelative Solvent Accessibility or solvent surface is widely used in the analysis of proteins and protein functions. The accessible surfaces are always the residues for which RSA >5%. If the cutoff 5% is used, about 2.4% of the epitopes are buried, in the dataset used in this paper. We use the k-th convex hull and the cumulate k-th convex hull to categorize the protein residues, and analyze the location of epitopes on different layers of the proteins. On each layer of the protein, we compute the four different types of depth functions to analyze the location of epitopes on different layers of the proteins.Based on RSA of the epitopes and non-epitopes on the protein surface, the average RSA for epitopes is significantly greater than the average RSA for non-epitopes. Nevertheless, there is no significantly difference between RSA values of epitopes and non-epitopes which are in top eight convex hull layers see . It may Correlation between RSA and different depth functions are also analyzed. Chakravarty depth, DPX, Half-sphere exposure using up half-sphere achieve higher absolute Person correlation coefficients. HSD, half-sphere exposure using down half-sphere  and half space depth(HSD) achieve lower absolute Person correlation coefficients. Depth functions provide more detailed description of the b-cell epitopes It may provide useful clues for b-cell epitope prediction.The conservation for epitopes is not significantly lower than that for non-epitopes. This is due to the fact that some non-epitopes may play important biological functions, such as glycosylation sites and pockets, giving higher conservation. For example, for the residue LEU259 of hiv-1 JR-RF gp120 core protein (2B4C:G), its Chakravarty depth is 13Å, RSA is just 0.2, while its conservation is 0.98; this residue is a glycosylation site.10 just covers 84.6% of the residues on protein surface area, but nearly 95% of the epitope sites.Epitopes prefer to be located in the outer layer of the protein surface, but not all epitopes are in the convex hull of the protein. For Chakravarty depth, HSEAU, and HSEBU, the average depth function values for epitopes are smaller than the average values for non-epitopes on the surface. On the benchmark dataset, CHwww.sourceforge.net/projects/chops>. As demonstrated in a series of recent publications [Our software for calculating the Convex Hull of Protein Surface (CHOPS) can be downloaded from <ications –63 in deications . We shalS1 FigB: residue in isolated β-bridge; E: extended strand, participates in β-ladder; G: 3-helix; H: α-helix; S: bend; T: hydrogen bonded turn; I: 5-helix.(DOC)Click here for additional data file.S2 Figα position.HSEA:Half-Sphere Exposure using information only about the C(DOC)Click here for additional data file.S3 Figα and Cβ positions.HSEB: Half-Sphere Exposure using information about both the C(DOC)Click here for additional data file.S4 FigThere is no significantly difference between epitopes and non-epitopes in the top 8 convex hull layers .(DOC)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.


The ala of the nose, with its particular texture and characteristics, poses both aesthetically and functionally intriguing challenges and is rather problematic regarding choices for reconstructive methods. Both flaps and grafts have been used to restore natural structure of nasal ala. The present study summarizes a ten-year experience of reconstructive surgery using small composite grafts from non-cartilage bearing tissues, and large composite grafts, containing cartilaginous tissue, with a mean follow-up of 4 years and 8 months.Cumulatively 56 patients were reported. Some of them required surgery due to previous cosmetic rhinoplasty. In 47 of the cases, a small graft from the non-cartilage bearing junction of ear lobule to helical rim sufficed. Nine patients had rather large defects for which grafts were harvested from the helical root. Donor sites were primarily closed and grafts were implanted in place in a single, rapid session.All small grafts had excellent take. Of 9 large grafts, 5 had excellent take, three had acceptable, and one, in a male smoker, failed to take. During follow-up, no gross deformity or poor scar was detected in either donor or recipient site.We have demonstrated that using both large and small auricular composite grafts has favorable long term results for reconstruction of alar rim deformities. However, use of small grafts seems more beneficial and applicability of large grafts requires further studies. Cosmetic nose surgery or nasal beautification is still the most common surgical operation of the authors. Secondary rhinoplasty comprises about 40% of these operations. Many of these secondary cases were shown to have radical alar base resection which may compromise external nasal valve function.1-3 The most common causes of alar rim distortion include trauma, congenital malformations, anatomical variations such as alar cartilage malposition,4 surgical interventions and cosmetic rhinoplasty. All these factors might alter the symmetry and contour of alar rims and prevent their ability to perform their role as external valve stabilizers.4 Skin replacement5 and cartilage or bone grafts6-9 have been used successfully for reconstructive operations in many instances. However, as the alar rims provide both skin cover and external valvular support, preservation of both functions is required. Therefore, autologous grafts that simultaneously replace both the cutaneous and cartilage deficiencies are often required for replacing the alar rim. Composite skin/cartilage grafts and skin/dense subcutaneous tissue/skin grafts harvested from the ear provide an ideal material for such reconstructive surgeries. Patients with abnormality of alar rims or excessive alar base resection are challenging cases to reconstruct.The alar rims are fragile and complex structures. Their unique size, height, thickness and symmetry form the natural nasal appearance and function. The specialized skin which supports and supplies these complex structures provides competence of the external nasal valves and patency of the inlets to the nasal airways.We present a decade-long experience with composite grafts, consisting of skin/ dense subcutaneous tissue/ skin from non-cartilage bearing pinea between the helical rim and lobule of the auricle, to restore the normal appearance and function of the alar rim.This prospective case-series study was pertinent to 56 patients with alar rim malformation, who presented between 2001 and 2011. The major causes of alar rim malformation in the study population were iatrogenic causes and trauma, that is, small and stenotic nostrils due to extensive alar base resection during previous rhinoplasty. Mean length of follow-up was 4 years and 8 months, with a maximum of ten years in some cases. All reconstructive procedures were performed using open approach. In 47 patients who had undergone previous rhinoplasty and needed small grafts, a wedge shape composite graft was harvested from the junction of the ear lobule to helix, as shown in As demonstrated, the site of previous incision in alar base was incised with a Number 15 blade to the required extent . The donFifty six patients with a mean age of 22 years (range between 17 and 62 years) made up our study population. All small grafts had excellent take and satisfying appearance for patients without obvious deformity of donor site. Five of the large grafts had excellent take, 3 of them had acceptable take and one failed to take. The pre-operative and post-operation pictures of four patients were shown in 10-12 Composite graft from either the helical rim or the root has been recommended for reconstruction of alar rim defects.13 Sangavi presented a case report of a 16 year-old girl with isolated congenital alar defect who underwent reconstruction with auricular composite graft. Composite auricular graft resulted in an excellent nasal contour correction without healing abnormality or any obvious deformity in the donor site.12 Coban and his colleague used the root of helix as the composite graft donor site for reconstruction of post-burn alar rim defect.14 Constantian used auricular composite graft reconstruction in 100 secondary and tertiary rhinoplasty patients.15 In his series, 99% of the grafts survived in their entirety and only two patients had partial unilateral graft loss. Moreover, Klinger and colleagues reported reconstruction of a full-thickness alar wound in a 20 year-old man using an auricular conchal composite graft16 which resulted in a complete repair of the defect with excellent wound healing as well as good functional and aesthetic results. However, the basis of treatment in these cases is resection of scar tissue or deformed ala, then grafting a piece of tissue with a 3-dimensional shape similar to normal anatomy to the alar area defect. These procedures are complicated and time-consuming, require a great deal of expertise, and it is not always feasible to harvest tissue with such characteristics. Moreover, there are challenges such as failure to take and healing abnormalities at the donor as well as recipient site. In the present series of 56 patients, we evaluated long term results of composite graft take in patients undergoing alar rim reconstruction. Our results demonstrated that composite graft has favorable results in alar rim reconstruction. In the present study, we utilized two different sets of grafts. For small defects or for individuals with congenital or acquired nostril stricture, a small wedge-shaped part of (non-cartilage bearing) helico-lobular junction, consisting of dense subcutaneous tissue in the middle and skin on both sides was used. This composite graft had excellent take in all 47 patients who needed small grafts. Due to limited manipulation, injury of donor site was very limited and no gross deformity or scar was observed in any of these patients. The other type of graft was harvested from the helix root. It was similar to the more traditional composite graftsin that it contained cartilaginous tissue.6 These grafts were needed to reconstruct alar rims in 9 patients who had relatively larger defects. We observed that in 5 cases the grafts had excellent take. In 3 individuals the grafts had acceptable take but in one patient, who was a male smoker, the graft failed to take. It has been suggested by other authors that auricular composite graft used for reconstruction of the alar rim should not be larger than 1.5 to 2 centimeters in diameter17 to ensure reliable revascularization. This supports our results which showed that in 9 patients who needed large composite grafts, only 5 patients had excellent graft take Where as all 47 patients with small grafts had excellent graft take. The main advantage of composite graft is that it can be performed in a single, fast surgical procedure with excellent contour correction.12 The main disadvantage of composite graft is that its use for large defects (larger than 2 centimeters) has not been recommended, and other therapeutic modalities such as nasolabial or forehead flap can be performed for these defects.18,19 Moreover, the final color of composite graft may not be very satisfying.12 In conclusion our results demonstrated that using auricular non-cartilage bearing composite grafts has favorable long term results in reconstruction of alar rim deformities. Although this holds true for both large and small grafts, it seems that there is the possibility of further improving the results of large grafts.The ala is an important component of nasal anatomy, both aesthetically and functionally. Prior to attempting to re-establish the anatomy and functions of lost skin and skeletal structures, these defects should be carefully assessed. This approach may be beneficial for not only attaining desired results in surgery, but also for preventing fibrosis and contracture. Composite grafts are complexes of full thickness skin and surrounding periosteum and cartilage or skin/dense subcutaneous tissue/skin.The authors declare no conflict of interest.


In Surgical revascularization by CABG surgery Left internal mammary artery (LIMA) to Lt.ant.descending (LAD) is considered gold standard conduit of choice for myocardial revascularization. Although conventional angiography is gold standard for assessing graft patency but rarely available in operating room in Bangladesh. So intraoperative florescence imaging (Novadaq Technologies SPY TM System IFI) is an angiography like imaging using fluorescence indocyanine green excited laser light, (ICG) this device permits validation of graft patency intraoperatively.To ensure patency after completion of graft and do revisions if necessary peroperatively when chest is open is mandatory for implementation of one of the techniques for intraoperative graft validation in Bangladesh. IFI is the safe, cost-effective, less time consuming and has no radiation risk. So the aim was to evaluate the intraoperative fluorescence imaging (IFI) system in the real-time assessment of graft patency during CABG to ensure the highest quality of the surgery and evaluate feasibility of the IFI to visualize flow in the native and grafted vessels in CABG specifically LIMA to LAD.It was a descriptive cross sectional study at NICVD between July 2013 to June 2014 NICVD on Spy TM System (IFI) in CABG surgery focused on 36 patients' LIMA to LAD grafts.Of the total 36 patient's mean age 54 ± 8.38 years, body mass index 25.87 ± 2.39. The quality of LIMA to LAD graft were assessed by using. Quality of anastomosis were assessed intraoperatively to validate graft. peroperative assessment of LIMA to LAD by IFI system revealed 32 (88.8%) patent anastomosis, Narrowing of anastomosis 2 (5.55%) stenosis of the anastomosis in 2(5.55%).Using IFI system is a best way to validate patency of LIMA graft intraoperatively. Since it does not have any adverse effect may become the gold standard for surgical management in the near future.


Kidney transplantation is the preferred treatment for patients with end-stage renal disease. While open surgery remains the gold standard, minimally invasive surgery has recently been introduced for the recipient undergoing kidney transplantation. Our team has employed the robotic surgical system to perform renal transplantation in obese recipients to minimize the risk of surgical site infections, with good results in terms of complications and graft and patient survival. However, others groups have performed kidney transplantation robotically in nonobese patients using different techniques. The da Vinci surgical system allows the performance of kidney transplantation under optimal operative conditions. Larger studies and long-term follow-up of recipients are required to determine the effectiveness of this approach. In this article, we describe our experience and review the development of the robotic-assisted kidney transplantation (RAKT). The first successful kidney allograft transplantation in human from a living donor was performed by Joseph Murray in 1954 for which he received the Nobel Prize in 1990 . The sucIn this article, we describe our experience and review the development of the robotic-assisted kidney transplantation (RAKT).2, an open surgical approach is chosen. Otherwise, if the patient is obese, with a BMI ≥30 kg/m2, the patient is approached by a minimally invasive robotic-assisted technique. Patients without LD are placed on the waiting list and if BMI ≥30 kg/m2 weight loss program is started.The initiation of the robotic kidney transplant program at The University of Illinois at Chicago was in 2009, when we performed our first robotic-assisted transabdominal renal transplantation from a diseased donor . After tOnce a deceased donor becomes available, obese patients will undergo robotic-assisted surgery, and nonobese patients will undergo open surgery. Previous surgeries are not considered a contraindication to perform a robotic-assisted procedure. The only exclusion criteria are severe atherosclerosis of the iliac vessels of the recipient or the graft vessels (for a deceased donor). We did not consider age or immunologic risk status as a contraindication for RAKT.The patient is positioned supine with the legs on leg rests. Operating surgeon is at the console of the robot and the co-surgeon positioned at the bedside. A 7-cm upper midline incision is made, and a hand-access device is inserted. Subsequently, four additional trocars are inserted. One 12-mm port, for the 30° robotic scope, is placed at the umbilicus, and two 8-mm robotic ports for robotic arms are placed in the right upper and left lower quadrants (for right site implantation). Another 12-mm port, for the assistant, is inserted on the left on the umbilicus. At this point, the da Vinci surgical system is docked into position (from the patient’s right side) and integrated to the ports. After appropriate vascular dissection, the graft is brought into the operative field through the midline incision and appropriately oriented for implantation to the external iliac vessels.The renal vein and artery are sutured end-to-side in a continuous fashion to the external iliac vein and artery, respectively, with 5–0 or 6–0 expanded polytetrafluoroethylene suture. The bladder is distended with saline and methylene blue in order to facilitate its dissection. The muscular layers are incised, and the bladder mucosa is prepared. The ureter is anastomosed to the bladder with running 5–0 polydioxanone suture. Upon completion of the anastomosis, the seromuscular layer is closed over the ureterocystostomy with a 4–0 polyglycolic-acid suture to create an antireflux mechanism. Placement of a double J ureteral stent depends on the surgeon’s preference. The intraoperative fluorescence vascular imaging using indocyanine green or intraoperative Doppler is used to assess the kidney perfusion.Considering the intraperitoneal location of the graft, we prefer to perform kidney biopsies under laparoscopic guidance. Ultrasound-guided biopsy potentially can cause significant bleeding. The procedure is completed under general anesthesia, and antibiotic prophylaxis is routinely given. Our preference for port positioning is one infra umbilical and one in the upper quadrant on the site of the graft. A Tru-Cut biopsy needle, usually 18 G, is introduced through the abdominal wall and directed towards the upper pole of the graft. Bleeding from biopsy sites is controlled effectively with cauterization. Patient is observed for 6 h and discharged home unless immediate initiation of treatment is needed. Using this technique, we did not observe any complications.The first RAKT was performed in France and reported in 2001 . The rec2 who had been on hemodialysis for 5 years. The operative time was 223 min, and the blood loss was less than 50 cm3. The kidney had immediate graft function. No perioperative complications were observed, and the patient was discharged on postoperative day 5 with normal kidney function. The RAKT was performed by the technique we described above. The indication for a robotic approach was morbid obesity since higher BMI in kidney transplant recipients is associated with increased risk of surgical site infections which negatively impact graft survival [Despite the early success of this operative procedure, the enthusiasm for RAKT was missing, and further development did not occur until 2009, when our group reported the first full RAKT . The recsurvival .2 compared to 38.1 ± 5.4 kg/m2 in the control group (p = 0.02). There were no surgical site infections (SSIs) in the robotic group, while 28.6 % (8/28) in the control group developed an SSI (p = 0.0004). The patient and graft survival were comparable between the two groups. Within the last 5 years, we have applied this standardized technique, over 135 robotic-assisted kidney transplants in obese recipients. The highest BMI of a transplanted patient was 58 kg/m2, and the mean BMI of the group was 43 kg/m2. We did not observe any SSIs in RAKT patients (unpublished data).In 2013, still our group • publishThe first transabdominal RAKT in Europe was performed by Boggi et al.  in 2011.2. The robot was docked between the split-legs of the patient in a lithotomy position. A GelPOINT port was used to seal the midline incision in the periumbilical region. The pelvic bed was cooled to 18–20 °C with the introduction of 180–240-ml ice slush via modified Toomey syringes. A temperature probe was used to continuously monitor renal cooling. The graft was inserted into the abdomen through the GelPOINT port incision. The vascular anastomosis and the ureteroneocystostomy were performed robotically. The vascular anastomosis time was 25.4 min, and the ureterovesical anastomosis time was 17.4 min. Mean intraoperative renal surface temperature was 20.3 °C. The average incision length was 6.1 cm. The kidney graft was retroperitonealized for the final position. The 6-month graft function was excellent.Later, Menon et al. , 12•, 132 (range 18.9–28.2 kg/m2). All of the patients with robotic surgery resumed oral intake and ambulation within 24 h after operations. Overall, the average post-transplant hospital stay was 13.6 ± 3.5 days.During the same year, Tsai et al.  reportedA comparison of all four techniques is given in Table Rosales et al.  in 2010 Minimally invasive surgery including small-incision open kidney transplantation, laparoscopic, and RAKT are feasible. The da Vinci robotic surgical system has clearly the advantages of three-dimensional vision and control of the camera by a surgeon. Articulated instruments with a wide range of movements allow ease of suturing. Tracks of the surgeon’s movements 1300 times/s eliminates the tremor and increases the precision, essential for performing a good vascular anastomosis. However, vascular anastomosis through robotic arms can be technically demanding due to a lack of tactile feedback . This isOur experience demonstrate benefit of RAKT in obese recipients •, also iIn the literature, different techniques have been proposed. Both transperitoneal and extra-peritoneal approach to kidney transplantation are feasible. Also, the incisions made for the graft placement are different. Every technique has its advantages, described by the authors.Hand assistance, easier through an upper midline incision, could facilitate some operative steps, such as handling the graft during performance of the vascular anastomoses, could improve exposure especially in obese recipient, and could be useful in case of sudden hemorrhage. Incision in the upper abdomen also avoids a highly colonized pubic and groin areas. This type of incision, though puts the patient in a slightly higher risk to develop incisional hernia and in cases of conversion, should be extended to gain full access to iliac vessels.Moreover, in our view, working transperitoneally avoids the traditional disadvantages of retroperitoneoscopy, such as limited working space, easy collapse during suctioning and blurred vision, while still maintaining the option of the graft placement in a retroperitoneal pocket. In our series, the graft remained in the intraperitoneal location, and we did not observe any disadvantages to this approach, although some complications such as a paratransplant hernia  and renaIntraoperative regional hypothermia is a reasonable technique. We believe that this approach can be useful for surgeons with limited experience in robotic suturing as a protection if longer time to perform the anastomosis is needed. If the anastomosis time is kept in a 30–40-min range, intraoperative cooling of the graft may not be necessary.For achievement of immediate function of the graft, we consider important to decrease the level of the pneumoperitoneum to below 10 mmHg. This maneuver seems to decrease the potential negative effect to the microcirculation of the graft from the higher intraperitoneal pressure.Robotic-assisted kidney transplantation is an emerging modality of minimally invasive surgery, and several surgeons are trying to perform it in different ways. Despite the enthusiasm for RAKT, the current high cost is the most prohibitive factor for its widespread use.By achieving adequate kidney graft function and minimizing surgical complications, robotic-assisted renal transplantation gives the opportunity to the disadvantaged group of obese patients with ESRD to have more a realistic access to transplantation with good results in terms of outcome. We believe that this, in a long term, will compensate the initial coast and will prove profitable even from a financial viewpoint. However, robotic surgery in organ transplantation is a very advance application of the technique, and a level of expertise is needed in any surgeon who considers this approach. Larger studies and long-term follow-up of recipients are required to determine the effectiveness of RAKT.