To compare the safety and efficacy of retrograde intrarenal surgery (RIRS) and modified Ultra-mini percutaneous nephrolithotomy (UMP) in semi-supine combined lithotomy position for the management of 1.5–3.5 cm lower pole renal stones (LPSs).n = 33) or modified UMP (n = 30) in diameter between January 2017 and January 2019 were analyzed retrospectively. Modified UMP was performed in semi-supine combined lithotomy position and a 9.5/11.5 F ureteral access sheath (UAS) was inserted during the procedure in order to maintain low pelvic pressure and to facilitate the removal of stone fragments. Base-line parameters, stone characteristics, illness condition, operation time, postoperative hemoglobin (Hb) drop, postoperative creatinine (Cr) elevation, length of hospital stay, length of postoperative hospital stay, stone-free rate (SFR) and complications were compared between the two groups.A total of 63 patients with 1.5–3.5 cm LPSs who underwent RIRS (p < 0.001). The mean postoperative Hb drop was less in RIRS group . The length of hospital stay and postoperative hospital stay for RIRS were shorter than UMP . The Early SFR was higher in UMP group  while SFR at 1-month and 3-months postoperatively was similar in both groups . There were no significant differences between the two groups in complications (p = 0.228).There were no significant differences between the two groups in base-line parameters, stone characteristics and illness condition. The mean operating time of RIRS group was longer than UMP group (95.61 ± 21.9 vs. 55.0 ± 16.1 min, For patients with 1.5–3.5 cm LPSs, both modified UMP and RIRS are safe and viable. The modified UMP technique was used in this study, application semi-supine combined lithotomy position and the retention of UAS can improve the surgical efficiency and maintain low pressure perfusion in the kidney, which resulted in superior treatment efficacy. Therefore, we highly recommend this technique for LPSs with heavy stone burdens. Due to the anatomic characteristics of the lower calyx, LPSs are difficult to be eliminated through the ureter, even if the stones had been fragmented , 2. RIRSRIRS is performed through natural orifice. It can reduce hospitalization time and the risk of bleeding. Previous studies indicated that although the safety is more guaranteed, the SFR of RIRS may not be so effective in the treatment of stones larger than 2.0 cm . HoweverCompared to RIRS, PCNL could reach a higher SFR though it presents greater surgical risks. In 2013, Janak Desai developed the Ultra-mini percutaneous nephrolithotomy (UMP) with a tract size of 11–14 F in order to reduce the risk of complications . As the Previous studies have shown that UMP and RIRS are both safe and effective in the treatment of medium-sized (1.0–2.0 cm) urinary calculi, the SRF immediately after surgery was high  . Zhang eIn this study, we analyzed two groups of large LPSs (1.5–3.5 cm) cases who underwent modified UMP or RIRS in our hospital to compare the efficacy and safety of the two techniques. We hope our results could provide some clinical evidence for urologists in choosing surgical options for 1.5–3.5 cm LPSs.n = 33) and UMP group (n = 30). Blood routine and serum biochemical tests were performed in all patients after surgery. Plain abdominal radiograph of the kidney, ureter and bladder (KUB) were performed on 24–48 h, 1-month and 3-months after surgery to evaluate the early SFR, 1 month SRF and 3 months SRF, respectively. Residual fragments less than 2 mm were considered “stone-free”.This is a retrospective analysis of patients treated between January 2017 and January 2019 in department of Urology, Sun Yat-sen Memorial Hospital, approved by the hospital ethics committee. Informed consents were signed by all patients. Patients aged between 18 and 80 years with single LPS of 1.5–3.5 cm were included in this study. Stone volume were calculated using the equation: length × width × height × π/6 . ExclusiFor RIRS procedure, patients were put in lithotomy position under epidural anesthesia. Ureteroscope was performed to insert a guidewire (Boston Scientific®) into the pelvis. The guide-wire was inserted and a 12/14 F or 9.5/11.5 F ureter access sheath (UAS) (COOK®) was placed through it into the proximal ureter. Then a detachable flexible ureteroscope (POLY DIANOST®) was used to examine the collection system and locate to the LPSs. The stones that were mobile were repositioned into the upper or middle calyx, and those that were immobile are treated with laser lithotripsy in situ. Holmium: YAG laser (Lumenis®) was set at low energy and high frequency  for lithotripsy. Large fragments were removed by a nitinol basket. Prior to the completion of the operation, a 6F JJ stent was placed.In the modified UMP group, patients were put in the semi-supine combined lithotomy position with operating side elevated at 45° under epidural anesthesia. A 9.5/11.5 F UAS was inserted using the same protocol as the RIRS group. 30–50 ml of saline was injected through the UAS to obtain artificial hydronephrosis. Percutaneous renal puncture was performed under the guidance of ultrasonography. Immediately after that, 10 F and 14 F fascia dilators were used sequentially to establish the tract. After the placement of the 13 F sheath, UMP was performed by holmium laser lithotripsy . Stone fragments were washed out by an irrigation pump. The UAS was used as an outflow tract for irrigation fluid along with stone fragments. After lithotripsy, ultrasonography was performed again to check for residual stones. The retention of nephrostomy tube was determined according to the removal of stone fragments and bleeding of the tract at the end of surgery. All patients received a 6F JJ stent. The nephrostomy tube was removed between 24 and 48 h after the operation. The operations in both groups were performed by Professor Kewei Xu. The JJ stent was removed around 2–4 weeks in both groups.p < 0.05 was considered statistically significant.Data analysis was performed on SPSS 23.0 software. Continuous data was presented as mean ± SD, and the Student’s t-test or rank sum test was used to analyze the differences. Dichotomous data was analyzed by the chi-square or Fisher’s exact tests. p = 0.242), gender (p = 0.824), mean body mass index , mean stone length , mean stone volume , stone side (p = 0.479), comorbidities (p = 0.894), degree of hydronephrosis (p = 0.740) and preoperative urine WBC (p = 0.246) . The mean postoperative Hb decline of the UMP group was significant higher . The mean postoperative Cr elevation was 7.88 ± 9.1 mg/dl in RIRS group and 11.40 ± 13.5 mg/dl in UMP group (p = 0. 235). The mean postoperative hospital stay of RIRS group was shorter than that of UMP group . The mean hospitalization time of RIRS group was shorter than that of UMP group .  of patients used 12/14 F ureter access sheath and the remaining patients switched to 9.5/11.5 F UAS due to difficulty in placement. In the UMP group, a single percutaneous tract (13 F) was established for lithotripsy and stone removal. Nephrostomy tube were indwelled in 53.3% (16/30) of patients in the UMP group. There were no intraoperative complications or changes of surgical methods in the two groups. UAS was successfully implanted in both groups, and no patient was excluded from the study because of unsuccessful use of UAS. The mean operation time of RIRS group was longer than UMP group . SFR in UMP group was higher than RIRS group at all points, early SFR , 1-month SFR  and 3-month SFR  although the latter two groups did not present statistical significance  in RIRS group and three cases in UMP; and all patients improved after being treated with antipyretic drugs. One case of postoperative urosepsis (ClavienII) were presented in RIRS group and showed improvement after treatment. Two patients presented postoperative gross hematuria (Clavien I) in UMP group and were spontaneously relieved after 48 h. Patients in UMP group did not have complications such as blood transfusion, interventional embolization, colon injury and pleural injury. The difference in complications between the two groups was not statistically significant p = 0.28. SFR iThe treatment of lower pole renal calculi is a difficult point in urology. As the anatomical structure of the lower calyceal is not conducive for stone excretion, ESWL is less effective in the treatment of LPSs , 16, 17.RIRS has developed rapidly in recent years and its indications for the treatment of kidney stones are becoming more extensive. It has been reported that SFR of kidney stones over 2.0 cm treated with RIRS is about 66.7–94.1% . HoweverOur research group has reported a modified UMP technique . PatientIn terms of postoperative catheterization, we adopted a conservative strategy for both groups. There was no indwelling JJ stent in both groups before the operation. Considering that the ureteral injury was relatively large during the operation, JJ stent was routinely indwelling for 2–4 weeks after the operation. The retention of nephrostomy tube was determined according to the intraoperative removal of stone fragments and bleeding in UMP group. The purpose of indwelling nephrostomy tube was to observe the characteristics of drainage fluid. Studies have shown that tubeless can be used in UMP to speed up its postoperative recovery, which warrants further study. During our modified UMP approach, the ureter was manipulated, which made it difficult to perform ‘totally-tubeless’ compared with traditional procedure. This could be a minor drawback in order to reach higher efficacy.In conclusion, both UMP and RIRS are safe and effective for the treatment of 1.5–3.5 cm lower pole renal calculi. The modified UMP technique could reach shorter operation time along with a higher Hb drop and longer hospital stay compared with RIRS. Future prospective studies with larger sample sizes were needed to verify and extend the findings of this study.


Glycogen storage disease type Ia (GSD Ia) is a rare metabolic disease due to glucose‐6‐phosphatase deficiency. Chronic kidney disease is a frequent complication that may manifest itself by glomerular lesions and tubular dysfunction from the second decade of life. We report two young GSDIa patients with malignant renal tumor. The first patient was a 25‐year‐old man. He had chronic metabolic imbalance without kidney involvement. The tumor, a type 2 papillary renal carcinoma, was accidentally discovered during follow‐up. The second patient was a 27‐year‐old woman with chronic metabolic imbalance and chronic kidney involvement. The tumor, a grade 2 papillary carcinoma, was accidentally discovered during follow‐up. These two observations are, to date, the first to be reported. We suggest that annual monitoring of kidney imaging in GSDI patients should be systematic to detect renal cancer, from the second decade of life. The annual incidence of the disease is around 1:100 000 births. It is transmitted as an autosomal recessive disease, and is due to mutations in the G6PC gene , or in the SLC37A4 gene (GSDIb) for the remaining 20%. It results from a defect in the glucose‐6‐phosphatase (G6Pase) system.When the disease is not well‐controlled, chronic acidosis due to hyperlactacidemia, hyperuricemia, and hypertriglyceridemia can be severe, and are likely to facilitate the development of other manifestations, such as liver or renal complications. Development of liver adenomas is common with increasing age, and several cases of malignant transformations have been previously described.G6pc knockout mice.Renal manifestations begin early in childhood with hyperperfusion and hyperfiltration, but remain asymptomatic for many years. Their mechanisms are multifactorial, due to glycogen deposition in kidney, and to metabolic imbalance. Worsening of renal function occurs in the second decade of life, and then can progressively evolve to renal failure. Glomerular lesions with proteinuria, proximal tubular dysfunction , and distal tubular dysfunction , can occur. Renal cysts have been recently described, in both mice and humans.Here, we report two cases of renal tumor in two young GSD Ia patients.2The first patient is a 25‐year‐old Caucasian man. Glycogen storage disease type Ia was diagnosed during infancy , and confirmed by molecular diagnosis (compound heterozygosity for both c.527A>G and c.1039 C>T mutations in the glucose 6 phosphatase gene).This patient also has both Willebrand and Gilbert diseases. He had been treated with growth hormone at 12 years of age, for 1 year, for retarded growth, with no clinical improvement. He had been an active smoker since the age of 15 years, and recently quit smoking.He used to have chronic metabolic imbalance during the second decade of life. Supplementations with uncooked cornstarch since infancy, then enteral nutrition by the age of 17 were not well tolerated because of chronic diarrhea. Blood tests performed at 22 were disturbed as follow: triglyceridemia 19 mmoL/L, uricemia 0.498 mmoL/L, bicarbonate 16 mmoL/L, lactic acid before breakfast 9 mmoL/L. The patient slowly developed hepatic polyadenomatosis. He also developed osteoporosis.When he was 22 years old, uncooked cornstarch (300‐420 g/day) was replaced by Glycosade and oral fenofibrate was started. His diet was hyperglucidic, glucides representing 63% of caloric intake. This treatment allowed an improvement of metabolic balance. His metabolic blood tests between 22 and 25 years of age were as follow: triglyceridemia between 2.28 and 4.56 mmoL/L, uricemia between 0.4 and 0.5 mmoL/L, lactic acid before breakfast between 3 and 5 mmoL/L, bicarbonate between 20 and 24 mmoL/L. Hepatic polyadenomatosis remained stable on regular MRI follow‐up since the age of 22.2 (Cockroft‐Gault), calciuria was low. It is noteworthy that renal cysts had never been observed, either on MRI or on ultrasound examination.He had no renal disease. Proteinuria and microalbuminuria were negative, creatinine clearance was 120 mL/min/1.73 mHe was referred when he was 25 year‐old in our center for his annual follow‐up. His metabolic balance was good and his blood tests were as follow: creatinine clearance 123 mL/min (Cockroft‐Gault), proteinuria <0.02 g/L, microalbuminuria 13.6 mg/L, uric acid 0.438 mmoL/L, triglyceridemia 2.52 mmoL/L, cholesterol 5.07 mmoL/L, hemoglobin 141 g/L, C reactive protein <5 mg/L, aspartate amino transferase 0.54 μKat/l (32 UI/l), alanine amino transferase 0.38 μKat/l (23 UI/l), GGT 0.69 μKat/l (41 UI/l). Glycemias were normal during 24 hours before and after meals, lactic acid were measured between 1.7 and 3.1 mmoL/L during 24 hours.Hepatic MRI showed multiple adenomas and decrease in size of the largest adenoma (41 mm vs 48 mm the year before).Renal MRI showed the appearance of a nodular lesion, at the lower pole of left kidney. The lesion diameter was 28 mm. On T1 weighted images, the lesion was isointense. On T2 weighted images, it was discretely hyperintense, with discrete contrast enhancement after injection Figure .2 (Cockroft‐Gault), no urinary albumin excretion, uricemia 0.290 mmoL/L, triglyceridemia 1.55 mmoL/L, lactatemia and glycemia normal before and after meals. Due to the rarity of this tumor and the young age of the patient, a genetic cause has been evoked but not confirmed to date (looking for a germline mutation of the fumarate hydratase gene).The patient underwent partial nephrectomy. The diagnosis of papillary renal cell carcinoma type 2 (grad ISUP2) was confirmed by histological study Figure . Nephrop3We report on a 27‐year‐old female patient with a past history of GSD Ia, admitted for the diagnosis work up of a renal mass. Her parents were consanguineous, and she had two brothers  and one healthy sister. She was diagnosed with GDS Ia at 3 weeks of life because of the family history. The identified homozygous mutation was c.79delC (p.Gln27fx). From the onset of the disease, she suffered from hepatomegaly and hypoglycemia, lactic acidosis, hypertriglyceridemia, and hyperuricemia after short fasts. Other metabolic complications included a prolonged bleeding time due to impaired platelet function, as well as an anemia due to iron deficiency, refractory to oral supplementation. She developed growth retardation with a final height of 151 cm. She was treated by a continuous enteral feeding until the age of 6 years and then, due to a poor metabolic control, nocturnal enteral feeding was resumed from the age of 13 to the age of 21. Since that age, carbohydrates account for 65% of caloric intake . Under this diet, the metabolic parameters were as follow before breakfast: glycemia between 3.85 and 5.1 mmoL/L, lactic acid between 1.2 and 4.5 mmoL/L, bicarbonates between 15 and 23 mmoL/L, triglyceridemia between 3.42 and 6.84 mmoL/L, uricemia between 0.430 and 0.770 mmoL/L. The following long term complications were observed: hepatocellular adenoma increasing in number and size since the age of 12  Figure . The hea4Kidney disease is a frequent complication of GSDI. Excessive accumulation of fat and glycogen in kidney leads to renal complications, such as hyperfiltration (70% of young adults) and proteinuria (40% of young adults), nephrocalcinosis due to hypercalciuria and hypocitraturia.A single case of renal cancer in a GSDI patient has been reported so far in the literature. A 19‐year‐old female patient, diagnosed with GSDIb and chronic neutropenia, has developed a clear cell renal carcinoma. The patient had no renal cyst before. The authors discussed the role of GCSF for triggering this cancer, whereas no kidney cancer has been described in patients on GCSF therapy.For the first patient, carcinoma developed on “healthy” kidneys. The patient had no specific risk factor for kidney cancer, but active smoking. The second patient had severe kidney involvement, but without evident cyst on regular MRI and ultrasound follow‐up. In these two patients, parameters of metabolic control do not significantly differ from the other GSDIa patients of our center cohort.Finally, it is noteworthy that both patients were very young for developing kidney cancer, whereas the median age at diagnosis for this condition is 60 years and over.5To the best of our knowledge, these two reports are the first of kidney cancer in GSDIa patients. The origin of renal cancer is not yet understood. We suggest that annual monitoring of kidney imaging should be performed in GSD I patients from the second decade of life.The authors have indicated that informed consent of patients was obtained. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation  and with the Helsinki declaration of 1975, as revised in 2000.The authors declare that they have no conflict of interest.Dr Perry drafted the initial manuscript, and reviewed and revised the manuscript. Dr Douillard drafted the initial manuscript, and reviewed and revised the manuscript. Dr Hubert, Dr Jonca, Pr Glowacki and Pr Labrune critically reviewed the manuscript for important intellectual content, and revised the manuscript. Pr Leroy provided histologic figures for patient 2, and critically reviewed the manuscript. Dr Caveriviere provided histologic figures for patient 1, and critically reviewed the manuscript. All authors approved the final manuscript as submitted.


Hyalella azteca that substantially decreases the volume requirements of standard‐volume acute test exposures  while maintaining water quality and meeting control survival criteria. Standard‐ and reduced‐volume methods were compared by conducting concurrent toxicity tests with 2 inorganic toxicants (KCl and CdCl2) and 2 organic mixtures of naphthenic acid fraction components (NAFCs) to evaluate test performance. There was no difference between methods when comparing the median lethal concentrations (LC50s) for KCl and both NAFC mixtures (p > 0.05). The LC50s for CdCl2 were statistically different (p = 0.0002); however, this was not considered biologically meaningful because the difference between LC50s was <2‐fold. In conclusion, the reduced‐volume H. azteca test method generated results comparable to standard‐volume test methods and is suitable for use in situations where limited testing material is available, such as when conducting EDA. Environ Toxicol Chem 2020;39:2221–2227. © 2020 Her Majesty the Queen in Right of Canada. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC. Reproduced with the permission of the Minister of Environment and Climate Change Canada.Effects‐directed analysis (EDA) is used to identify the principal toxic components within a complex mixture using iterative steps of chemical fractionation guided by bioassay results. Bioassay selection can be limited in EDA because of the volume requirements for many standardized test methods, and therefore, a reduced‐volume acute toxicity test that also provides whole‐organism responses is beneficial. To address this need, a static, 7‐d, water‐only, reduced‐volume method  was developed for  Effects‐directed analysis (EDA) is a tool used to determine the drivers of toxicity within complex mixtures through the use of chemical and biological techniques  requires <10 mL of solution to complete a standard 15‐min bioluminescence exposure  water‐only H. azteca test methods recommend using 275 mL and 10 organisms per test replicate and 5 or more replicates per test concentration  maintaining adequate water quality, particularly dissolved oxygen and ammonia, and 2) meeting recommended control survival criteria  and 2 organic mixtures of naphthenic acid fraction components (NAFCs) previously demonstrated to be toxic to H. azteca , reduced‐volume, water‐only test method with Hyalella azteca cultures used in the present study originated from a small lake near Burlington, Ontario, Canada . Juveniles were removed from breeding containers weekly for use in toxicity tests to guarantee that the age of the amphipods was 2 to 10 d at test initiation, which is standard procedure for our laboratory and thus directly comparable to previously published data  and industry B . These organic mixtures have been tested using a standard‐volume H. azteca acute  assay, with reported LC50s of 16.7 and 27.4 mg/L, respectively  for KCl test solutions, and 50% dilution series  for NAFC solutions.Standard‐ and reduced‐volume tests were completed simultaneously in pairs with KCl, CdCl2  were prepared in deionized water  24 h prior to test setup and mixed with culture water 2 h prior to test initiation to create the test dilutions. Industry A and industry B NAFCs were collected, extracted, and purified as described  and CdClStock solutions of the NAFC mixtures (100 mg/L) were prepared in a salt solution of 0.05 M NaOH in culture water, following procedures described in detail  were measured at test initiation (t = 0 d) and take down (t = 7 d).Water quality parameters  were used for organic NAFC tests, and test replicates contained a 2.5 × 2.5 cm square of cotton gauze, 200 mL of exposure solution, and 15 juvenile amphipods. Different volumes were used for inorganic versus organic contaminants so that our results were directly comparable to tests conducted previously in our laboratory . Two tests were completed for each organic mixture, with 3 replicates per control and test concentration per test .Static, 7‐d, water‐only 2 tests were aerated for the entire exposure, but NAFC tests were not aerated in an attempt to decrease compound volatilization. Three tests were completed for each inorganic compound, with each test consisting of 3 replicates per control and 2 replicates per test concentration . Two tests were completed for each organic mixture, with 3 replicates per control and test concentration per test .Glass beakers  were used for inorganic and organic NAFC exposures. Test replicates contained a 2.5 × 2.5 cm square of cotton gauze, 50 mL of treatment solution, and 10 juvenile amphipods. Amphipods were fed 1 mL of a ground TetraMin slurry  per replicate at test start and on day 4. A reduced food ration was used relative to the standard‐volume method to keep ammonia levels low. Survival was assessed at the end of the 7‐d exposure. Similar to the standard‐volume method, KCl and CdCldrc . The LC50s for KCl were slightly lower than the 96‐h LC50 of 460 mg/L published by McNulty et al. ; however, because this difference was <2‐fold , the difference between test methods was not considered to be biologically meaningful. The model concentration–response curves for standard‐ and reduced‐volume tests partially overlapped within the 95% CI for both reference toxicants .y et al. , which cn et al.  but compH. azteca  or industry B . In addition, the fit and overlap of the concentration–response models were comparable between methods  previously determined to be toxic to s Figure . The cons Figure  were <2‐In addition to achieving comparable toxicity results for inorganic and organic compounds, reduced‐volume tests met recommended criteria for water quality and control performance. Water quality parameters Tables  and 4 weH. azteca, with survival as the endpoint of interest, for use in EDA investigations. Reduced‐volume and standard‐volume tests were completed in parallel using representative inorganic toxicants  and complex mixtures of organic acids isolated from 2 oil sands mining operations. The reduced‐volume method was comparable to the standard‐volume test methods in terms of water quality, control survival, and acute LC50s and lowered volume requirements by 4‐ to 10‐fold. Overall, the development of a reduced‐volume acute method for the H. azteca survival bioassay is beneficial for EDA research and other situations in which limited testing materials are available, presenting a viable option for an in vivo test with a sensitive, environmentally relevant, freshwater species.The purpose of the present study was to develop a reduced‐volume, acute, in vivo bioassay method using https://doi.org/10.1002/etc.4840.The Supplemental Data are available on the Wiley Online Library at The views presented in the present study are only held by the authors and are not representative of the official policy of the authors' individual affiliations.M. Rodrigues, D. Schissler, A. Hedges, and L. Brown: experimental concept and design; M. Rodrigues, D. Schissler, and L. Brown: experimental performance; L. Deeth and M. Rodrigues: statistical analysis; M. Rodrigues and A. Bartlett: writing; R. Frank, M. Hewitt, D.G. Dixon, and A. Bartlett: technical and editorial assistance.This article includes online‐only Supplemental Data.Supporting information.Click here for additional data file.


Non‐motor fluctuations are a major concern in Parkinson's disease (PD), and they have been categorized into neuropsychiatric, autonomic and sensory fluctuations. However, this categorization does not include sleep and sleep‐related features, and the association between daytime sleepiness and other motor and/or non‐motor fluctuations in PD remains to be elucidated.To investigate the relationship between daytime sleepiness and other non‐motor and motor fluctuations in people with PD.A three‐day home diary recording daytime sleepiness, mood, anxiety, and motor symptoms was used along with the Karolinska Sleepiness Scale (KSS) and 6 days of accelerometer  registration to detect motor fluctuations among people with a DaTSCAN verified clinical PD diagnosis . Participants were categorized as motor fluctuators or non‐fluctuators according to the UPDRS part IV and/or the presence of motor and non‐motor fluctuations.Fifty‐two people with PD participated. Daytime sleepiness correlated significantly with motor symptoms, mood and anxiety among those classified as motor fluctuators (n = 28). Motor fluctuators showed stronger correlations between the individual mean level of all diary variables  when compared to the non‐fluctuators (n = 24). Stronger positive within‐individual correlations were found among fluctuators in comparison to non‐fluctuators. In general, PKG data did not correlate with diary data.Episodes of daytime sleepiness, as reported by home diaries, were associated with other self‐reported non‐motor and motor fluctuations, but were not supported by PKG data. Parkinson's disease (PD) is diagnosed based on the presence of bradykinesia, rigidity or tremor and with non‐motor symptoms (NMS) included to support the diagnosis.There are only few prospective studies on NMF in PD. Richard et al.Sleep disturbances and daytime sleepiness have not been included in any NMF category because sleep patterns can be a consequence of other parkinsonian symptoms, such as nocturnal akinesia, and can be improved by treatment with dopaminergic medication.All participants were recruited from a movement disorders outpatient unit in Stockholm, Sweden. The inclusion criterion for this study was a DaTSCAN verified clinical PD diagnosis.At an outpatient visit, participants completed questionnaires regarding daytime sleepiness  worrying, nervousness and anxiety; (2) low mood; and (3) sleepiness. The occurrence of these symptoms was rated every second hour from awakening to bed time, as “not at all”, “somewhat”, “pretty much” or “very much”. In addition, the diary included the Karolinska Sleepiness Scale (KSS) where participants rate their levels of sleepiness from 1  to 9 (extremely sleepy), which makes it possible to capture variations in sleepiness over the day.Motor symptoms were also recorded using the Parkinson's KinetiGraph , which provides dyskinesia (DKS) and bradykinesia (BKS) scores.During the inclusion visit all participants were clinically assessed according to the UPDRS, Hoehn and Yahr and MMSE during the “on” phase. All medications and co‐morbidities were recorded. Measurements of orthostatic blood pressure and weight were made. Following training on how to complete the home diary and handle the PKG device, these were provided to the participants and the PKG device was activated. All assessments and training were performed by the same experienced specialized PD nurse (A.H.). In parallel to the home diary, the participant carried a PKG device on their most affected upper limb for 6 days, including the three consecutive home diary days. Participants who were treated with oral levodopa (n = 41) had the dosage times pre‐programmed on their PKG device. After the study period the PKG and the diary were returned by mail.Data describing frequencies, means, standard deviations and comparisons between fluctuators, and non‐fluctuators were conducted using Chi‐square, Mann‐Whitney U‐ and t‐tests, as appropriate. Anti‐parkinsonian medications were expressed as total daily levodopa equivalent doses (LED),For each participant we calculated the within‐individual mean (WIM) and the within‐individual standard deviation (WISD), as well as the within‐individual correlation Spearman's r, (WIRS) between all diary variables. WIM indicates the participant's average level of self‐rated symptoms while WISD is a measure of how much these ratings fluctuate within each participant during the study period. WIRS indicates how each participant's ratings tend to covary, with a positive value showing that a high rating on one variable tends to coincide with a high rating on the other variable, and a negative value indicating that a high value on one variable tends to coincide with a low value on the other variable.P‐values for multiple comparisons.Analyses were conducted using IBM SPSS Statistics 26, and R 3.5.0 statistical software,Forty‐nine people completed the home diary for three (n = 42), 2–2.5 (n = 5) and 0.5–1.5 (n = 2) days, and 52 PKG registrations were completed and included in the analysis. Thus, three people underwent PKG registration but did not complete the diary. One people did not complete either the home diary or the PKG and was excluded.Participant characteristics are summarized in Table Table The within‐individual correlations (WIRS) tended to be positive, indicating that high ratings on one diary variable tended to coincide with high ratings on the other variables. However, for each pair of variables at least some participants exhibited negative WIRS as well Fig. . WIRS teThis study investigated the relationship between daytime sleepiness and other non‐motor and motor fluctuations using both a home diary and PKG registrations.There is no consensus on how to classify PD patients as motor fluctuators. Different classifications have been used, which makes it difficult to compare results from different studies. For example, Ossig et al.Using our definition, we found that fluctuations of daytime sleepiness, particularly as measured by KSS, correlated moderately with other fluctuations among participants classified as fluctuators, but weakly among non‐fluctuators. Overall, fluctuators showed stronger correlations between all diary variables  compared to non‐fluctuators. In agreement with previous work,Sleep disturbances and daytime sleepiness are influenced by treatment with dopaminergic medication.Interestingly, PKG data were generally weakly correlated with diary data. For example, FDS was the only PKG variable that correlated with daytime sleepiness WISD among fluctuators. It is interesting to compare our data with that of Kotschet and colleagues.This study has some limitations. In particular, participants did not complete the home diary during the full PKG registration. The reason for this was our intention to minimize the risk of diary fatigue. For example, Hauser et al.In summary, motor fluctuators showed stronger correlations between all diary variables  compared to non‐fluctuators. Stronger positive within‐individual correlations were found among fluctuators in comparison to non‐fluctuators. Fluctuations of daytime sleepiness according to home diaries showed a significant correlation with other non‐motor symptoms, but correlated relatively poorly with accelerometer measures by single usage of PKG. Our observations provide novel evidence that daytime sleepiness is associated with other motor and non‐motor fluctuations in PD.(1) Research project: A. Conception, B. Organization, C. Execution; (2) Statistical Analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the first draft, B. Review and Critique.A.H.: 1A, 1B, 1C, 2A, 2B, 2C, 3AP.H.: 1A, 1B, 2C, 3BJ.‐E.B.: 1B, 2C, 3BS.E.P.: 1B, 2C, 3BK.S.: 1B, 2A, 2B, 2C, 3BS.F.: 1A, 1B, 2C, 3BP.S.: 1B, 2C, 3AThis study was approved by the ethical review board at Karolinska Institutet, Sweden (Dnr. 2011/1866‐31/4 and 2015/761‐32). All participants provided written informed consent. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines.This work was supported by The Swedish Parkinson Foundation (865/16). P.S. is a Wallenberg Clinical Scholar. The other authors declare that there are no conflicts of interest relevant for this work.S.F. has received honoraria for lectures, educational activities and/or advisory boards during the preceding 12 months from Almiral, Biogen, Celgene, Merck, Novartis, Roche and Sanofi. The other authors declare that there are no additional disclosures to report.


Preoperative permanent atrial fibrillation (AF) is associated with impaired outcome after surgical aortic valve replacement (SAVR). The impact of preoperative paroxysmal AF, however, has remained elusive.We assessed the impact of preoperative paroxysmal AF on outcome in patients undergoing SAVR with bioprosthesis.A total of 666 patients undergoing isolated AVR with a bioprosthesis were included. Survival data was obtained from the national registry Statistics Finland. Patients were divided into three groups according to the preoperative rhythm: sinus rhythm (n = 502), paroxysmal AF (n = 90), and permanent AF (n = 74).P = .484), gender (P = .402) or CHA2DS2‐VASc score (P = .333). At 12‐month follow‐up, AF was present in 6.2% of sinus rhythm patients and in 42.4% of paroxysmal AF patients (P < .001). During follow‐up, incidence of fatal strokes in the paroxysmal AF group was higher compared to sinus rhythm group . Cardiovascular mortality was higher in the paroxysmal AF group than in the sinus rhythm group  and equal to patients in the permanent AF (5.0 per 100 patient‐years).Patients in the sinus rhythm and paroxysmal AF groups did not differ with respect to age (Patients undergoing SAVR with bioprosthesis and history of paroxysmal AF had higher risk of developing permanent AF, cardiovascular mortality and incidence of fatal strokes compared to patients with preoperative sinus rhythm. Life‐long anticoagulation should be considered in patients with a history of preoperative paroxysmal AF. The prevalence of AF is 0.5% to 1% in general population, but increases with aging and about 10% of octogenarians have AF.Several studies have demonstrated that preoperative permanent AF is a predictor of impaired outcome after adult cardiac surgery and transcatheter aortic valve implantation (TAVI).The aim of this multicenter study was to evaluate the impact of preoperative paroxysmal and permanent AF on mortality and morbidity after isolated bioprosthetic SAVR in comparison to patients in sinus rhythm.2http://clinicaltrials.gov Identifier: NCT02626871) evaluating the incidence of AF, thromboembolic complications and bleeding events in patients undergoing isolated SAVR with bioprosthesis.The CAREAVR is a Finnish multicenter, retrospective registry  over the period 2003 to 2014 (in Helsinki 2006‐2014). Hospital records were reviewed for 721 patients who underwent SAVR with a biological prosthesis. Patients with a history of cardiac surgery, permanent pacemaker as well as those undergoing any other concomitant major cardiac surgery procedure were excluded. In order to obtain complete data on cardiovascular events, only patients from the hospitals' catchment area were included in this registry.The routine postoperative anticoagulation practice was oral warfarin and subcutaneous enoxaparin started in the evening of the day of surgery. Enoxaparin was continued until therapeutic INR > 2.0 was reached. Warfarin was continued for 3 months unless there was an indication for permanent anticoagulation. Antiplatelet agents were not used routinely postoperatively. Medication was at the treating physician's discretion.2.2Patient records were individually reviewed with a standardized structured data collection protocol for preoperative, perioperative, and discharge data as well as for long‐term follow‐up events, such as AF, mortality, and causes of death.Preoperative history of AF was reviewed from the patient records and based on 12‐lead ECG, Holter‐recording or telemonitoring. In addition, the preoperative rhythm was confirmed from a 12‐lead ECG recorded during admission. Based on this information, the patients were divided into three groups: (a) sinus rhythm group had no preoperative history of atrial fibrillation; (b) paroxysmal atrial fibrillation group had preoperatively at least one documented episode of atrial fibrillation cardioverted or with spontaneous recovery of sinus rhythm within 7 days and (c) permanent atrial fibrillation group had continuous atrial fibrillation prior to surgery. The presence of AF during follow‐up was assessed from 12‐lead ECG recorded at 3 and 12 months postoperative visits and whenever patients was admitted to hospital due to suspicion of symptomatic AF.2DS2‐VASc scoreThe risk of thromboembolic complications was assessed with the CHAThe study endpoints were death from any cause, cardiovascular death , and other deaths. In Finland, data on deceased patients including the causes of death are prospectively collected into a national registry, Statistics Finland. This national registry was interrogated to retrieve the survival status and the eventual causes of death which were classified according to the World Health Organization ICD‐10 classification.The study protocol was approved by the Ethics Committee of the Hospital District of Southwest Finland and of the National Institute for Health and Welfare. Informed consent was not required because of the retrospective, registry‐based nature of the study. The study conforms to the Declaration of Helsinki. An independent, certified third‐party data monitor checked the integrity of the data of each study site.2.3P‐value of <.05 was considered statistically significant. Statistical analyses were conducted with SPSS software .Continuous variables were reported as mean ± SD if normally distributed, and as median (inter‐quartile range) if they were skewed. Continuous variables were compared with one‐way ANOVA using LSD post hoc test and categorical variables were compared using Chi‐Square test or Fisher's test. Survival time analysis was performed the Cox proportional hazard model and expressed as incidence of events per 100 patient‐years. In addition, multivariate logistic regression analysis was performed to adjust for the differences in preoperative clinical characteristics between the sinus rhythm and paroxysmal AF groups. A 3A total of 666 patients undergoing isolated SAVR with a bioprosthesis were included in the final analysis. Patients were divided into three groups according to the history of preoperative rhythm: sinus rhythm (n = 502), paroxysmal AF (n = 90), and permanent AF (n = 74). The mean follow‐up time was 4.9 ± 2.7 years.P < .001), lower estimated glomerular filtration rate (eGFR) (P = .014), higher INR (P < .001), and they were more often on warfarin therapy (P < .001) compared to the sinus rhythm group , had a higher prevalence of male gender (P < .001), diabetes (P = .034), hypertension (P = .002), pulmonary hypertension (P < .001), heart failure (P = .002), mitral valve regurgitation (P = .005), lower left ventricular ejection fraction (P = .003), larger left atrium diameter (P < .001), lower eGFR (P = .023), higher INR (P < .001), and higher CHA2DS2‐VASc score (P < .001) than the sinus rhythm patients (Table P < .001), beta blocker (P < .001), and digoxin (P < .001) medication as well as used aspirin less frequently than the sinus rhythm patients  (Table P = .055) with Kaplan Meier estimates of survival at 1, 3, and 5 years of 91.9%, 81.1%, 81.1%, respectively.All‐cause mortality in the paroxysmal AF group (7.2 per 100 patient‐years at risk) tended to be higher compared to the sinus rhythm group (4.9 per 100 patient‐years)  (Table P = .001) . This was mainly due to high rate of fatal bleeds 1.6 per 100 patient‐years compared to 0.3 per 100 patient‐years in the sinus rhythm patients  was significantly higher compared to the sinus rhythm group (3.0 per 100 patient‐years) . However, paroxysmal AF lost its significance as predictor of cardiovascular mortality .Logistic regression analysis was also performed to adjust for the differences in preoperative clinical characteristics (eGFR and left atrium size) between the sinus rhythm and paroxysmal AF groups. After adjustment of these, paroxysmal AF remained as an independent predictor of fatal stoke . There was also a trend  of higher incidence of fatal hemorrhagic strokes in the paroxysmal AF group .The majority of fatal strokes were of ischemic origin . The incidence of fatal ischemic strokes in the paroxysmal AF group was higher compared to the sinus rhythm group , and 3.5 + 2.7 years for the permanent AF group (P = .017 vs sinus rhythm group). The time to the first major bleed were 4.9 + 2.8 years in the sinus rhythm group, 4.2 + 3.0 years for the paroxysmal AF group (P = .073 vs sinus rhythm group), and 3.7 + 2.7 years for the permanent AF group (P = .004 vs sinus rhythm group).The time to first stroke/TIA were 4.4 + 2.8 years for the sinus rhythm group, 4.1 + 3.0 years for the paroxysmal AF group  . Furthermore, AF  was documented in 64% of the paroxysmal AF group patients during the 12‐month follow‐up after the discharge.At discharge, 3‐ and 12‐months after surgery, AF was present in 38.9%, 36.6%, and 42.4% of patients in the paroxysmal AF group and in 17.3%, 10.8%, and 6.2% of patients in the sinus rhythm group, respectively (P < .001) (Table P = .085). In the permanent AF group 98.3% and 97.8% of patients were on warfarin at 3 and 12 months follow‐up. There was no significant change in the use of oral anticoagulation during the study period in the paroxysmal AF patients.All patients were on warfarin therapy at 3‐month follow‐up visit. Thereafter warfarin was continued in 59.2% of the paroxysmal AF patients and in 31.9% of the sinus rhythm patients . In the sinus rhythm and permanent AF groups none of the patients had INR within the therapeutic range. In sinus rhythm and permanent AF groups there were one patient in both groups without INR value taken within 1 month preceding the event.P < .001). At 12‐month follow‐up aspirin was used in 36.4% patients in the paroxysmal AF group and 52.5% in the sinus rhythm group (P = .055). In the permanent AF group aspirin was prescribed in 6.6% and 6.7% of patients at 3‐ and 12‐month follow‐up, respectively (P < .001 for both vs sinus rhythm group) . However, to our best knowledge there are no earlier studies addressing the question of paroxysmal AF in patients undergoing SAVR with a bioprosthesis. A closest counterpart to our study is a recent paper by Shaul et al.Ngaage et alIt is also of interest that in our study the incidence of permanent AF during postoperative follow‐up was very high among the patients with preoperative paroxysmal AF. All patients with preoperative paroxysmal AF were in sinus rhythm at the time of surgery. However, a substantial proportion (39%) was discharged in AF and at 3‐ and 12‐month follow‐up visits permanent AF was present in 37% and 42%, respectively. In addition, almost 2/3 of patients in the paroxysmal AF group had documented AF  during the first 12 months after the discharge. Most probably, the incidence of AF would be even higher if an ambulatory ECG recording had been applied. The high incidence of AF is in line with Ngaage et al who reported that 50% of patients with preoperative paroxysmal AF undergoing SAVR were in permanent AF during follow‐up.4.1This study has several methodological strengths. The data were collected from electronic patient records and hospital database in which the data are stored prospectively in predefined form. A validated, structured case report form was used. A quality control monitoring of the data was performed by a clinical research organization. The patient population comes from the hospital regional catchment area where all cerebrovascular events are treated exclusively at the participating centers. All patients undergoing SAVR were scheduled for follow‐up visits at 3 and 12 months. Thus, the follow‐up data were available from almost all patients. A major strength of our study is also that in Finland each patient has a national identification code. This allows the follow‐up and identification of patients' date and cause of death through the country. Nevertheless, the retrospective set‐up carries also some limitations. It does not allow characterization of the study populations as accurately as in a prospective trial. An obvious limitation is that the presence of AF during follow‐up was based on 12‐lead ECG recorded during routine 3‐ and 12‐month follow‐up visits or in case of symptomatic AF episodes whereas no routine Holter recordings were performed. Thus, it is likely that some episodes of asymptomatic paroxysmal AF were missed.5In patients scheduled for SAVR with bioprosthesis, paroxysmal AF was associated with increased mortality—particularly increased risk of fatal strokes—and higher risk of developing permanent AF compared to those with a history of sinus rhythm. Life‐long anticoagulation should be considered in these patients after the surgery.Maunu Nissinen: research grants from Rättimäki CardioVascular Society and travel grants from Finnish Cardiac Society.Joonas Lehto: research grants from Orion Research Foundation and the Finnish Foundation for Cardiovascular Research.Markus Malmberg: research grant from Clinical Research Fund (EVO) of Turku University Hospital, Turku, Finland.Juha Hartikainen: research grants from the Finnish Foundation for Cardiovascular Research, Clinical Research Fund (VTR) of Kuopio University Hospital, Kuopio, Finland; Lectures for: Cardiome AG, MSD and AstraZeneca. Member of the advisory boards for Amgen, Pfizer, MSD, AstraZeneca, Bayer and BMS.Leo Ihlberg: full‐time employee and stockholder for Boston Scientific (since September 2016); proctor for Edwards Lifesciences.Juhani Airaksinen: research grants from the Finnish Foundation for Cardiovascular Research, Clinical Research Fund (EVO) of Turku University Hospital, Turku, Finland; lectures for Bayer, Cardiome AG and Boehringer Ingelheim, member in the advisory boards for Bayer, Astra Zeneca, Bristol‐Myers Squibb‐Pfizer and Boston Scientific.Tuomo Nieminen: lectures for AstraZeneca, Boehringer Ingelheim, FCG Koulutus, GE Healthcare, Medtronic, Orion, Sanofi; research grants from Abbvie, Medtronic, research fund of Helsinki and Uusimaa Hospital District.Tuomas Kiviniemi: lectures for Bayer, Boehringer Ingelheim, Medicines Company, AstraZeneca and St. Jude Medical, Bristol‐Myers Squibb‐Pfizer, MSD; received research grants from The Finnish Medical Foundation, Helsinki, Finland; the Finnish Foundation for Cardiovascular Research; Clinical Research Fund (EVO) of Turku University Hospital, Turku, Finland, Finnish Cardiac Society, an unrestricted grant from Bristol‐Myers Squibb‐Pfizer; Emil Aaltonen Foundation, Helsinki, Finland; and Maud Kuistila Foundation, Helsinki, Finland; member of advisory board for Boehringer Ingelheim, MSD.


Echocardiographic reference intervals for Friesian horses are poorly described.To obtain reference intervals for echocardiographic measurements in Friesians and compare these with Warmbloods.One hundred healthy adult Friesians and 100 healthy adult Warmblood horses.t test with Bonferroni correction for multiple comparisons.Cross‐sectional study. Two‐dimensional and M‐mode echocardiographic images were obtained. Echocardiographic measurements, including size, area, and volumetric measurements of left atrium, left and right ventricle, aorta, and pulmonary artery, were performed. Measurements were compared between the 2 breeds using an independent samples CI] = −245 to −63). Also the right ventricular end‐diastolic and peak‐systolic internal diameter were smaller in Friesians . Fractional shortening (99.85% CI = 0.61‐6) and ejection fraction (99.85% CI = 0.21‐4.6) were significantly larger. No structural effects of systemic hypertension, such as concentric hypertrophy, were detected.Reference ranges for standard echocardiographic measurements in Friesians were obtained. Several left ventricular measurements were significantly smaller in Friesians compared to Warmbloods, such as the left ventricular end‐diastolic volume using the 4‐chamber modified Simpsons' method (99.85% confidence interval for the difference [Our study provides reference intervals for echocardiographic measurements in Friesians useful in a clinical setting. In general, the left ventricular dimensions in Friesians were significantly smaller compared to Warmbloods, emphasizing the need for breed‐specific reference intervals. Standardized echocardiographic images and measurements are established,The Friesian breed is marked by considerable inbreeding, which presumably has contributed to their distinctive conformation and higher prevalence of several diseases.Friesians react differently with training22.1A cross‐sectional study was performed. The study sample consisted of 100 healthy adult Friesians aged (median [range]) 10 [3‐26] years and 100 healthy adult Warmbloods aged 8 [3‐25] years. The Friesians consisted of 72 mares, 23 geldings, and 5 stallions and the Warmbloods of 61 mares, 35 geldings, and 4 stallions. Whether the horse was in training, as opposed to at rest in the field, at the time of the study (yes/no) was registered, as well as information about pregnancy and lactation. Mares over 6 months of gestation or within 1 week after parturition were excluded. In all horses, auscultation, echocardiography, and ECG were performed. Inclusion criteria were: no more than a 2/6 left‐ or right‐sided systolic or diastolic murmur on auscultation, no more than mild valvular regurgitation visible with Doppler ultrasound examination, and absence of atrial and ventricular premature beats during a 15 minutes ECG recording at rest. Height at the withers, body length, and chest circumference were measured for every horse. Body length was determined from the most cranial point of the shoulder to the tuber ischiadicum, chest circumference was measured right behind the elbow. Body weight was estimated using the following formula2.2Echocardiography was performed in the standing, nonsedated horse . A 1.5 to 4.6 MHz phased array probe (M5Sc‐RS) was used at a frequency of 1.7/3.3 MHz with simultaneous ECG recording (base‐apex). Two‐dimensional images included the right‐parasternal long‐axis 4‐chamber view (4C) and the right‐parasternal long‐axis view of the left ventricular outflow tract (LVOT). M‐mode images were obtained of the right‐parasternal short‐axis view of the left ventricle (LV) at the chordal level.2.3end, LADmaxsend, LADdend, LADmaxdend), the LA area at end‐systole and end‐diastole (LAAsend and LAAdend),end, LVLsend, LVAdend, LVLdend).peak, AoDdend, PADspeak, and PADdend)peak/AoDspeak). The M‐mode variables, measured at the chordal level, included the right ventricular (RV) internal diameter at peak systole and end‐diastole (RVIDspeak and RVIDdend), the interventricular septal thickness at peak systole and end‐diastole (IVSspeak and IVSdend), the LV internal diameter at peak systole and end‐diastole (LVIDspeak and LVIDdend), and the LV free wall thickness at peak systole and end‐diastole (LVFWspeak and LVFWdend).end) were calculated using the following formulasAll images were blinded for breed and analyzed by a single observer, using dedicated software . The mean of 3 consecutive cycles was used for further analysis. Cycles following a second‐degree atrioventricular or sinoatrial block were not used for analysis, and resulted in analysis of 3 nonconsecutive cycles in some cases. Three nonconsecutive cycles were also used when image quality was inadequate to obtain 3 consecutive cycles. Heart rate (HR) was determined as the mean of 3 RR intervals of the 3 consecutive cycles on the 4C view. Images were only recorded and analyzed if HR was below 50 beats/min. The measurements on the 4C view included the left atrial (LA) diameter at the mitral valve annulus and at maximal dimension parallel to the mitral valve annulus at end‐systole and end‐diastole (LADsVolumetric measurements of the LV (LVV) were performed with built‐in algorithms using 2 different methods: (a) the 4C area‐length method and (b) the 4C modified Simpson's method, both based on the measurements performed on the 4C view.Using the 4C modified Simpson's method, the LVV is calculated as:4C‐ALsend, LVV4C‐ALdend, LVV4C‐MODsend, LVV4C‐MODdend). The stroke volume was calculated as the difference of the end‐diastolic and end‐systolic volume , and the ejection fraction as the ratio of the stroke volume over the corresponding end‐diastolic volume .The LVV was determined at end‐systole and end‐diastole using each method  were calculated for the lower and upper limits,t tests were performed for each variable and Bonferroni correction was performed to correct for multiple comparisons. The overall significance level was P < .05. For each variable, P values were considered significant if P < .002 (= 0.05/34 variables) and 99.85% CI for the mean difference were calculated.Data analysis was performed using dedicated software . Variables were tested for normality by analyzing the Q‐Q plots. Normally distributed data are presented as mean ± SD and nonparametric data as median [range]. Categorical data are presented as proportions. The homogeneity of variances was tested with the Levene's test. Age was compared between the 2 breeds using a Mann‐Whitney 3P < .001) while the chest circumference  and body length  were significantly larger in Friesians. Friesians also had a significantly higher estimated BW . Significantly more Friesians were in training (P < .001) or pregnant (P = .006). No difference could be detected between the breeds for age (P = .29), HR (P = .43), sex (P = .24), or lactation (P = .07).Summary statistics of the study sample are given in Table end. Of the LA dimensions, only the LADsend was significantly smaller in Friesians compared to Warmbloods. Apart from a smaller AoDspeak, the dimensions of the aorta and pulmonary artery were not significantly different between the 2 breeds. The IVSdend was significantly smaller in Friesians, on the other hand, the IVSspeak was significantly larger in Friesians. The functional indices FS and the EF4C‐MOD were significantly higher in the Friesians compared to the Warmbloods. No significant difference could be found for the EF4C‐AL.The echocardiographic measurements and their reference intervals are displayed in Tables 4In our study, echocardiographic dimensions between Friesians and Warmbloods of similar age and sex were compared. This analysis demonstrated that in general the LV and the right ventricular internal diameter of a Friesian were smaller compared to that of a Warmblood and that the functional indices were generally higher in Friesians. Next to breed, other factors might have influenced these differences, such as training level, body conformation, and pregnancy.4C‐MOD might be explained by the fact that a smaller LV in a body of approximately the same size needs to increase its systolic function to preserve sufficient stroke volume.end and higher IVSspeak in Friesians, despite a similar longitudinal systolic shortening of the LV (data not presented), might be explained by the shorter LV in Friesians which could affect myocardial fiber orientation, left ventricular systolic shape, or M‐mode cursor positioning. For some variables, the differences might be accounted for by the expected between day and within observer variability for echocardiographic measurements. Nevertheless, several clinically relevant differences, namely the LV size, the functional indices, and the right ventricular internal diameter, were found, emphasizing that breed influences should be taken into account when interpreting echocardiographic measurements.The higher FS and the EFend, LV mass, RWT and MWTdend, and decreased ejection fraction and FS.VO2max), is linked to LV size.The influence of breed might be difficult to distinguish from effects of sport discipline and training level.The significantly lower height at the withers of Friesians might also explain the smaller LV size and right ventricular internal diameter apart from breed‐specific influences. However, height at the withers is less correlated to echocardiographic measurements than chest circumference,In humans, changes in LV geometry are a predictor of systemic hypertension as well as a consequence of systemic hypertension.More Friesians in our study were pregnant. Pregnancy induces several hemodynamic and cardiovascular changes in humans, such as an increased HR, increased cardiac output, mild general cardiac dilatation, increased LV and RV mass, and increased LV wall thickness.A limitation of our study was the quality of the echocardiographic images. Due to the body conformation of Friesian horses, echocardiography can be challenging.Authors declare no conflict of interest.Authors declare no off‐label use of antimicrobials.The current study (EC 2018/11) was performed following the guidelines of the Ethical Committee of the Faculty of Veterinary Medicine, Ghent University, Belgium.Authors declare human ethics approval was not needed for this study.


To the EditorThe number of older adults who undergo surgical procedures has increased in recent years, especially in developed countries , 2. Earl2/FIO2 > 300 mmHg; (3) stable circulatory dynamics; (4) recovery of muscle strength: hold head for 5 s or more, hold/open hand, TOF ratio 0.9 or more; (5) no abnormalities on chest X-ray before extubation. Because many anesthesiologists regard extubation times over 15 min as indicative of poor recovery [We analyzed data from 9514 patients who underwent surgical procedures under general anesthesia in a university hospital between 2011 and 2015. Ethical approval was obtained from the Ethics Committee of Tohoku University Graduate School of Medicine (reference number: 2015-1-533). The requirement for informed consent was waived due to the retrospective nature of the study. Patients were divided into two groups according to age: one group comprised of patients aged less than 65 years (< 65 years) and the other group comprised of patients aged 65 years or more (≥ 65 years). The extubation adopted the following commonly adopted criteria : (1) conP < 0.001; ≥ 65 years: P < 0.001), brain surgery , and selection of sedative agents . In the < 65 years group, delayed extubation was also associated with emergency surgery (P = 0.048). In the ≥ 65 years group, delayed extubation was associated with age (P < 0.001), cervical surgery (P < 0.001), abdominal surgery (P = 0.032), and orthopedic surgery (P = 0.028). Other comorbidities, intraoperative fluid balance, bleeding, and operation time were not associated with delayed extubation (Fig. We performed logistic regression analysis to assess the association of various factors with delayed extubation. In both age groups, delayed extubation was associated with the male sex (< 65 years: In conclusion, our findings indicate that the influence of the anesthesiologist’s decision on delayed extubation was greater in patients ≥ 65 years of age. In addition, our findings suggest that extubation during cervical surgery was more delayed in patients who were 65 years or older.


Piriformospora indica to remediate PAH-metal co-contaminated soil by analyzing the chemical speciation of the contaminants. This study investigated the influence of the inoculation of Medicago sativa with P. indica to remediate soil co-contaminated with phenanthrene (a kind of PAH) and cadmium  by analyzing plant growth, physiological parameters and chemical speciation in rhizosphere and nonrhizosphere soils.The coexistence of polycyclic aromatic hydrocarbons (PAHs) and heavy metals has deleterious effects on environmental quality. Few reports have studied the mechanisms of plant inoculation with P. indica significantly increased plant tolerance, chlorophyll a, chlorophyll b, maximum quantum efficiency of PSII photochemistry and electron transport rate values in phenanthrene- and/or cadmium-contaminated soil. P. indica inoculation in M. sativa roots increased fluorescein diacetate activities in soils contaminated with phenanthrene, cadmium or both, especially in the nonrhizosphere. The presence of phenanthrene prevented the inoculated plant from accumulating cadmium to some extent, whereas the presence of cadmium did not prevent the degradation of phenanthrene in either the rhizosphere or the nonrhizosphere after P. indica colonization. Although the low bioavailability of cadmium in the rhizosphere restricted its transportation into the stem, P. indica colonization in plants effectively increased cadmium accumulation in roots in soil co-contaminated with cadmium and phenanthrene.The presence of P. indica combined with M. sativa for the remediation of PAH-metal co-contaminated soil.In conclusion, this work provides a theoretical basis for the use of  The coexistence of heavy metals and polycyclic aromatic hydrocarbons (PAHs) in soil has caused environmental problems worldwide . Heavy mP. indica was first discovered in the rhizospheres of woody shrubs in the sandy desert soils of the Thar region of India [P. indica belongs to the recently defined order Sebacinales [P. indica acts as a bioprotector against pathogens [P. indica is different from AMF that can be cultivated in vitro. Considering the various beneficial effects of P. indica, this fungus is regarded as having significant agronomical and ecological application value [Arbuscular mycorrhizal fungi (AMF) have been used in the phytoremediation of soil contaminated with diesel  or heavyof India . The rooacinales . Speciesacinales –15. P. iathogens , alters athogens , increasathogens , 19, conathogens , 21, andathogens , 23; P. on value . HoweverP. indica directly increases plant root biomass by producing indole-3-acetic acid (IAA) [In the remediation of both heavy metals and PAHs, bioavailability determines the remediation efficiency , 26. An id (IAA) , which iid (IAA) , 28. In id (IAA) –32. In tid (IAA) . TherefoP. indica on the chemical speciation of heavy metals and PAHs in soils co-contaminated with metal and PAH. Notably, P. indica has been widely studied for its interaction with plants. However, this study focused on different aspects of this topic: (1) investigating the tolerance of M. sativa to phenanthrene and cadmium after P. indica colonization; (2) speculating on the rhizospheric effect of P. indica inoculation by measuring microbial activity and enzyme activity in the rhizosphere and nonrhizosphere; and (3) evaluating the effect of P. indica inoculation on the phytoremediation efficiency of M. sativa in phenanthrene-cadmium co-contaminated soil.Some researchers have reported using microorganisms to promote the remediation of single-source contamination caused by heavy metals or PAHs ; howeverM. sativa was recorded to reflect the tolerance of the plant to pollutants in soil. P. indica inoculation significantly promoted both root and stem biomass compared with those of the noninoculated plants (control)  Fig. a. In addol) Fig. b. Howevents Fig. c-d. The a and Chl b contents between P. indica inoculation conditions were significant (p < 0.01) when plants were exposed to Cd and Phe contamination , Fv/Fm (maximum quantum efficiency of PSII photochemistry), and ETR (relative PSII electron transport rate), were significantly decreased under the Cd, Phe, Cd + Phe treatments compared with those of the control. However, a noticeable increase in Fm, Fv/Fm, and ETR was observed in P. indica-inoculated M. sativa in comparison to noninoculated plants.The differences in Chl t p < 0.0 when plaP. indica would be affected by phenanthrene and cadmium. Qualitative analysis by the Salkowski method showed that after adding tryptophan, the solution containing spores of P. indica under each treatment changed to pink in three repetitions, unlike in the control  is an easy and conclusive method for determining soil microorganism activity. Figure P. indica colonization significantly increased polyphenol oxidase activity in both the rhizosphere and the nonrhizosphere. The order of polyphenol oxidase activity from low to high among the different treatments was Phe + Cd < Phe < Cd < Piri+Phe < Piri+Phe + Cd < Piri+Cd < Con < Piri. These data revealed several findings: 1) polyphenol oxidase activity in soil was more easily affected by Phe than by Cd contamination; 2) the addition of P. indica significantly increased polyphenol oxidase activity in the rhizosphere; 3) in Phe and Cd co-contaminated soil, the polyphenol oxidase activity was greatly inhibited, whereas after P. indica colonization in the M. sativa roots, the polyphenol oxidase activity was remarkably enhanced compared with that in the control.Polyphenol oxidase activity in the rhizosphere and nonrhizosphere is shown in Fig. P. indica colonization effectively reduced phenanthrene content in soil.The phenanthrene degradation rates in the rhizosphere and nonrhizosphere were measured Fig. a. Genera− 1, 165 ± 4 mg kg− 1, 108 ± 10 mg kg− 1, and 156 ± 7 mg kg− 1 among the Phe, Piri+Phe, Phe + Cd and Piri+Phe + Cd treatments, respectively  than the original Cd content in the soil (10 mg kg− 1). The cadmium concentration gradient in the nonrhizosphere was similar to that in the rhizosphere. These data imply that colonization with P. indica effectively reduced the cadmium content in soil.The cadmium content in the rhizosphere and nonrhizosphere was measured and is shown in Fig. − 1, 34 ± 6 mg kg− 1, 23 ± 8 mg kg− 1, and 29 ± 5 mg kg− 1 in the Cd, Piri+Cd, Phe + Cd and Piri+Phe + Cd treatments, respectively. Likewise, the cadmium concentrations in roots were notably higher than those in stems. In stems, the Cd content showed a different trend from the phenanthrene content: the Piri+Cd treatment had a lower Cd content than the Cd treatment, and the Cd content in the Piri+Phe + Cd treatment was lower than that in the Phe + Cd treatment. This result suggested that inoculation with P. indica inhibited the transport of Cd into the stem.Additionally, the cadmium concentrations in plant roots and stems were explored Fig. b. The caP. indica successfully colonized plants grown in 120 mg kg− 1 Cd-contaminated soil, which suggests that this fungus was able to colonize roots under high Cd stress in soil. However, we found that the spore germination and hyphal growth of P. indica were seriously inhibited under 40 mg kg− 1 Cd (data not shown). Therefore, 10 mg kg− 1 Cd was selected as the test concentration.Heavy metal and organic pollutants in soil severely harm plant growth and development. Cd treatment substantially inhibits plant biomass accumulation. Shahabivand et al.  reportedP. indica in the Cd (10 mg kg− 1), Phe (40 mg kg− 1) and Phe + Cd treatments relieved the stress from heavy metals and PAHs. Though the Cd concentration in the roots of the Piri+Cd treatment was higher than that in the Cd treatment, the biomass was not significantly affected. The results implied that a high concentration of Cd could be fixed or isolated to some degree by this fungus and plant co-living system which would therefore reduce the harmful effects to the plants. Cd accumulation in stems was reduced after phenanthrene contamination in soil, which indicated that the organic pollutants accumulated in roots might hinder Cd transport from roots to aboveground parts. The Piri+Phe treatment accumulated a high concentration of phenanthrene in the roots, which decreased the biomass of the roots and stems compared to that in the Piri treatment. However, even the high concentration of phenanthrene in roots did not hinder the growth promotion effect of P. indica on host plants compared to the growth of plants in the Phe treatment. This result was different from a previous report that the accumulation of pyrene by plant-growth-promoting bacteria (PGPB) decreased stem biomass [Our data indicated that colonization with  biomass . One posM. sativa plants subjected to Cd and Phe stress showed reduced growth in terms of shoot and root length and shoot and root fresh weight. The toxic effects of Cd have widely been reported in different plant species, and Cd is known to reduce or inhibit plant growth because of the harmful impact of Cd on the processes of photosynthesis, respiration and essential element uptake [a and b contents and elevated Fv/Fm and ETR values . Polyphenol oxidase is an important oxidoreductase enzyme in soil that participates in the process of decomposition and transformation of aromatic compounds. The enhanced polyphenol oxidase activity in this study implied that P. indica has a strong ability to remediate contaminated soil.Soil microorganism activity can effectively reflect soil fertility. The soil microorganism activity was determined in order to speculate on phytoremediation efficiency. We noticed that the FDA activity in the nonrhizosphere was higher than that in the rhizosphere in the  in soil . Though  in soil . The chaCo-contamination with heavy metals and PAHs resulted in a deleterious influence on microorganism activity in soil compared to that under individual heavy metal or PAH contamination , which e+ 6 mg kg− 1, 165 + 4 mg kg− 1, 108 + 10 mg kg− 1, and 156 + 7 mg kg− 1, respectively. The high concentration of Phe in plants means that less Phe remained in the soil. In addition to plants, soil microorganisms play key roles in the removal of PAHs. In the Phe + Cd treatment, the Phe concentrations remaining in the rhizosphere and nonrhizosphere were higher than those in the Phe treatment, which was reasonable due to the higher microorganism activity in the Phe treatment. Though no significant difference in FDA activity was detected between the Phe and Phe + Piri treatments, P. indica colonization obviously reduced the Phe concentration in the rhizosphere and the nonrhizosphere. Similar data were collected from the Phe + Cd and Phe + Cd + Piri treatments. In total, the Phe concentration in the rhizosphere was lower than that in the nonrhizosphere, suggesting that the rhizosphere effect was responsible for the lower accumulation of PAHs in the rhizosphere soil than in the nonrhizosphere soil [In the Phe, Piri+Phe, Cd + Phe and Piri+Phe + Cd treatments, Phe accumulation in plants was 135 ere soil .P. indica colonization increased Cd accumulation in roots. However, in comparing the Piri+Cd and Piri+Phe + Cd treatments, it was notable that the addition of Phe reduced Cd accumulation into a certain degree. The bioavailability of heavy metals determines phytoremediation efficiency [P. indica colonization significantly reduced the Cd concentration in the rhizosphere compared with that in the nonrhizosphere. On the other hand, plant root exudates also contribute to the acidification of heavy metals, which increases the efficiency of phytoremediation. P. indica colonization significantly promoted root growth and development, and the roots in turn secreted exudates to increase the bioavailability of heavy metals and enhance phytoremediation efficiency in the rhizosphere, forming a virtuous cycle.The order of Cd concentrations in roots from high to low was as follows: Piri+Cd, Cd, Piri+Phe + Cd, and Phe + Cd. The data indicated that ficiency . Microorficiency . TherefoP. indica colonization had positive effects on photosynthetic processes and increased the tolerance of M. sativa in soil contaminated with phenanthrene, cadmium, and combined cadmium and phenanthrene, especially in soil only contaminated with cadmium. The phenanthrene and cadmium co-contaminated soil affected soil microorganisms more severely than individual phenanthrene or cadmium contamination. P. indica inoculation in M. sativa roots increased the FDA activity in soils contaminated with phenanthrene, cadmium and both pollutants, especially in the nonrhizosphere. The addition of P. indica stimulated the roots of M. sativa to accumulate higher concentrations of phenanthrene and cadmium, thereby enhancing phytoremediation efficiency. A clear diagram of our conclusions about the phytoremediation effect of M. sativa colonized by P. indica on soil co-contaminated with phenanthrene and cadmium is provided in Fig. P. indica combined with M. sativa could contribute to the remediation of PAH-metal co-contaminated soil for sustainable agriculture.In conclusion, Medicago sativa seeds were provided by Professor Diter Von Wettstein, Department of Crop and Soil Sciences, Washington State University.Phenanthrene with a purity of 98% was purchased from Sigma (USA). The rest of the chemicals were purchased from Dingguo .The experimental soil had never been contaminated by PAHs or heavy metals and was collected from the topsoil (0–20 cm) at Hebei University of Technology, China. The soil is a phaeozem  from Hebei Province . The tes− 1.Phenanthrene was dissolved in acetone and added to a small part of the soil. One day later, after the acetone had volatilized, a small part of the soil was added to the whole sample soil and incorporated thoroughly. The final concentration of phenanthrene in the soil was measured as 40 ± 3 mg kg− 1.An aqueous solution of cadmium nitrate was added to the prepared soil, and the final concentration of cadmium in the soil was measured as 10 ± 2 mg kg− 1 and 40 ± 3 mg kg− 1, respectively. The prepared soil and a control soil without any pollution were moved into boxes and aged in the dark for 15 days.The acetone stock solution containing phenanthrene was first added to the test soil. After the acetone evaporated, the cadmium nitrate aqueous solution was added to the soil previously polluted by phenanthrene. The final concentrations of cadmium and phenanthrene in the soil were measured as 10 ± 2 mg kgP. indica isolate DSM11827  was applied. The P. indica was supplied by Karl-Heinz-Kogel . The P. indica was maintained at 23 °C on CM medium [− 1 agar was added; for liquid cultures, 100 mL medium was inoculated in a 300-mL Erlenmeyer flask. To test whether Cd and Phe would affect IAA production, 5 mg kg− 1 and 20 mg kg− 1 cadmium and phenanthrene, respectively, were added to the liquid cultures. The CM medium was inoculated with 20 mycelium plugs from the margin of a growing colony of P. indica on CM solid medium. The liquid cultures were incubated at 23 °C at 150 rpm on a rotary shaker.In this work, the M medium . For solP. indica under the Phe, Cd and Phe + Cd treatments was measured using the Salkowski method according to the literature [− 1 was applied. The injection volume was 10 μl. The column temperature was kept at 40 °C.The IAA content was quantified by Agilent HPLC equipped with an HCR C18  reverse-phase chromatographic column. The IAA concentrations were always determined in parallel in medium in which no fungus had been cultured but which had been incubated under the same conditions.The IAA production ability of terature . The quaterature . The parP. indica grown on CM medium plates for 3–4 weeks was used for the preparation of the spore suspensions. To collect spores from the CM agar plates, sterilized water containing 0.05% Tween-20 was added. The spores were released by gently scratching the surface of plates with a spatula, and the suspension solution was filtered through Miracloth  to remove the mycelium. After that, spores were collected by centrifuging the suspension solution at 3500 rpm for 7 min. Then, the spores were washed at least 3 times with sterilized Tween-H2O. By using a hemacytometer in combination with a microscope, the spore densities were determined. The spore concentration was adjusted to 500,000 spores/mL with sterilized Tween-H2O. For inoculation, 3 mL spore suspension was pipetted on top of plant roots in a square Petri dish. The seeds of M. sativa were surface-sterilized in 70% alcohol for 1 min and then in 3% NaClO for 15 min. After sterilization, seeds were repeatedly washed with sterile deionized water and planted in the MS medium [P. indica spores were added to the root surface. Then, the seedlings containing P. indica spores were transferred into the different types of soil in pots (5 kg). Three replicates were applied for each treatment.S medium  for germM. sativa was collected.The plants were rejuvenated in the shade for 1 week. Then, the pots were transferred to a greenhouse with natural light and watered daily to maintain soil moisture (approximately 300 mL water/pot). Three months later, the plants were harvested, and soil from the rhizosphere and nonrhizosphere of a and Chl b, respectively [M. sativa using a portable fluorometer : F0 , Fm , Fv/Fm (maximum quantum efficiency of PSII photochemistry) and ETR (the relative PSII electron transport rate). M. sativa plants were dark-adapted for 30 min to measure the influence of the experimental factors on photosystem II (PSII) efficiency.Chlorophyll content in the youngest fully expanded leaves (0.1 g) was extracted by 80% acetone and centrifuged at 4000 rpm for 20 min; the optical density of the supernatant was read at 663 and 645 nm wavelengths for Chl ectively . The fol2HPO4–2.2 g, NaH2PO4–0.1 g, pH 7.6) at room temperature. The turbid liquid was shaken at 180 rpm for 30 min, and then 0.5 mL of fluorescein diacetate (FDA)  solution was added into the mixture. The absorbance value was recorded at OD490nm.Soil microorganism activity was measured according to methods in the literature . First, 2SO4. The extracted liquid was concentrated to 5 mL by a rotary evaporation instrument in a 60 °C water bath. Then, 5 mL concentrated extracted liquid was transferred to a silica gel-alumina column for chromatography and eluted with a methylene chloride-hexane  mixture. The condensed elution was nearly dried, diluted to a final volume of 1 mL and used for HPLC determination. The parameters used for HPLC were as follows: methanol and water  were used as the mobile phase. A flow rate of 1 mL min – 1 and detection wavelength of 254 nm were applied. The content of phenanthrene was quantified by Agilent HPLC equipped with an HCR C18  reverse-phase chromatographic column. The phenanthrene recovery from soil was 97 ± 3%.A three-step sequential extraction method was used to detect the concentrations of phenanthrene in different chemical speciations in the soil . The ultR C18  reverse-phase chromatographic column. The oven temperature was first maintained at 100 °C for 2 min, then increased to 300 °C at a rate 10 °C min− 1, and finally kept at 300 °C for 10 min. A phenanthrene standard was added to the uncontaminated plants and soil to measure phenanthrene recovery. A procedural blank as well as a spiked blank and duplicate samples were included every batch of 10 samples in the analysis. The phenanthrene recovery from plants was 99 ± 5%.The phenanthrene in plants was extracted by acetone and dichloromethane . After centrifugation and rotary evaporation, the concentrated phenanthrene was exchanged with 1 mL hexane for analysis. The content of phenanthrene was quantified by HPLC equipped with an HCM. sativa was extracted by mixing 0.5 g soil with 10 mL HCl solution and then heating for 3 h (45 °C). After cooling, cadmium was extracted by mixing the soil with HNO3 and HClO4  for digestion  and then adding HF and HClO4  for further digestion . The same method was used to extract cadmium from the plants. At the end of the extraction step, the supernatant was harvested by centrifuging at 6000 rpm for 20 min. Then, the supernatant was filtered through a 0.45 μm microfiltration membrane and quantified by inductively coupled plasma optical emission spectrometry (ICPOES).Cadmium was determined according to methods in the references , 49. Soi− 1 for 1 min. Then, the sample was kept in the dark at 30 °C for 2 h. Four milliliters of citric acid-phosphate buffer  was added to the sample. Finally, 35 mL ether was added and shaken for 2 min. The absorbance value at 430 nm was recorded after 30 min of extraction.The enzyme activity of polyphenol oxidase was determined according to the soil enzyme analytical methods manual . Ten graIn this study, all data are expressed as the means ± SE and represent at least three independent biological experiments. The significance of differences was analyzed by using one-way analysis of variance (ANOVA) with Duncan’s multiple range test.