Thus, it is important to understand how variable NH4+:NO2− ratios impact the microbial ecology of anammox reactors. We observed the response of the microbial community in a lab scale anammox membrane bioreactor (MBR) to changes in the influent NH4+:NO2− ratio using both 16S rRNA gene and shotgun metagenomic sequencing. Ammonium removal efficiency decreased from 99.77 ± 0.04% when the ratio was 1:1.32 (prior to day 89) to 90.85 ± 0.29% when the ratio was decreased to 1:1.1 (day 89–202) and 90.14 ± 0.09% when the ratio was changed to 1:1.13 (day 169–200). Over this same timespan, the overall nitrogen removal efficiency (NRE) remained relatively unchanged . When the ratio was slightly increased to 1:1.17–1:1.2 (day 202–253), the ammonium removal efficiency increased to 97.28 ± 0.45% and the NRE increased to 88.21 ± 0.01%. Analysis of 16 S rRNA gene sequences demonstrated increased relative abundance of taxa belonging to Bacteroidetes, Chloroflexi, and Ignavibacteriae over the course of the experiment. The relative abundance of Planctomycetes, the phylum to which anammox bacteria belong, decreased from 77.19% at the beginning of the experiment to 12.24% by the end of the experiment. Analysis of metagenome assembled genomes (MAGs) indicated increased abundance of bacteria with nrfAH genes used for DNRA after the introduction of lower influent NH4+:NO2− ratios. The high relative abundance of DNRA bacteria coinciding with sustained bioreactor performance indicates a mutualistic relationship between the anammox and DNRA bacteria. Understanding these interactions could support more robust bioreactor operation at variable nitrogen loading ratios.Anaerobic ammonium oxidizing (anammox) bacteria are utilized for high efficiency nitrogen removal from nitrogen-laden sidestreams in wastewater treatment plants. The anammox bacteria form a variety of competitive and mutualistic interactions with heterotrophic bacteria that often employ denitrification or dissimilatory nitrate reduction to ammonium (DNRA) for energy generation. These interactions can be heavily influenced by the influent ratio of ammonium to nitrite, NH However, other nitrogen metabolisms can disrupt this loop. Bacteria performing dissimilatory nitrate reduction to ammonium (DNRA) with nrfA or nrfH cytochrome nitrite reductases convert nitrite back to ammonium, forming antagonistic relationships with anammox bacteria that can disrupt reactor performance  and 50% nitrite (NO2−), or a NH4+:NO2− molar ratio of 1:1  was continuously supplied to purge the system of oxygen and maintain circumneutral pH (6.9–7.2) (A 1 L anaerobic membrane bioreactor (MBR) was operated for 1 year prior to the experiment. The reactor was enriched for anammox bacteria from anaerobic digester solids. The specific details of initial inoculation and operation can be found in . A polyv6.9–7.2) . Tempera6.9–7.2) .4+and NO2−were loaded at the conventional 1:1.32 ratio at concentrations of 500 mg-N/L and 660 mg-N/L, respectively. On day 89, the influent ammonium concentration was raised to 600 mg-N/L, decreasing the NH4+:NO2− ratio to 1:1.1. On day 169, the influent nitrite concentration was raised to 680 mg-N/L, increasing the NH4+:NO2− ratio to 1:1.13. From day 200 to 252, the total nitrogen loading was slowly increased while also increasing the NH4+:NO2 ratio from 1:1.13 to 1:1.2 as shown in 4+:NO2− ratios was selected for the experiment in order to maintain stable operation of the reactor, as lower ratios (<1:1) have been demonstrated to lead to the accumulation of free ammonia (FA) (Brocadia sinica) has also been shown to have higher sensitivity to nitrite inhibition than other strains such as Kuenenia (The experiment took place over 252 days during which the hydraulic retention time (HRT) of the reactor was maintained at 12 h (via an effluent pump) and the solids retention time (SRT) was maintained at 50 days (via biomass wasting). For the first 88 days of the experiment, NHnia (FA)  and highnia (FA) . The domKuenenia . Thus th2.2.Biomass samples were collected every 2–10 days via syringe through an extraction port, flash frozen in liquid nitrogen, and stored at −80°C until further use. Genomic DNA was extracted from the samples using the DNeasy PowerSoil Kit  as described in the manufacturer’s protocol. DNA quality was assessed using a NanoDrop Spectrophotometer  and Bioanalyzer 2100 . DNA was quantified using a Qubit fluorometer , diluted to 10 ng/μl with nuclease free water , and stored at −20°C until further use. Shotgun metagenomic sequencing samples were sent to the Joint Genome Institute (JGI) in Walnut Creek, CA. There, DNA was sequenced (150 bp paired-end) on an Illumina HiSeq 2500 1 T sequencer . 16S rRNA sequencing for samples collected from day 1 to 45 were sequenced at the Institute for Environmental Genomics at the University of Oklahoma and the remaining samples were sequenced at JGI on an Illumina MiSeq sequencer .2.3.The microbial community composition was evaluated by 16S ribosomal RNA sequencing of 28 DNA samples collected throughout the experiment. The V4 region was amplified using primers 515F (5′-GTGCCAGCMGCCGCGG-3′) and 806R (3′-TAATCTWTGGVHCATCAG-5′), with barcodes attached to the reverse primer. Amplicons were pooled at equal molarity and purified with the QIAquick Gel Extraction Kit . Paired-end sequencing (250 bp paired-end) was then performed on the Illumina MiSeq sequencer . The full protocol is provided by 2.4.Three DNA samples were used for metagenomic sequencing, two from single timepoints on day 37 and 140 and one bulked from samples taken on days 232, 235, and 237. Resulting sequences from each time point were processed separately according to the procedure previously reported in 2.5.Principal component analysis (PCA) was applied to evaluate the correlation between taxa abundance for different pathways  and reactor performance parameters. In order to assign pathways to specific taxa, 16S rRNA sequences obtained from metagenomes with genes encoding for each pathway were aligned to representative sequences from amplicon sequencing following the procedure described in 3.3.1.4+:NO2− ratio of 1:1.32, the average ammonium and nitrite removal efficiencies were 99.77 ± 0.04% and 96.85 ± 2.31%, respectively  was steadily increased from 2.60 g-N/L·d on day 200 to 2.99 g-N/L·d on day 250 , the only anammox MAG recovered, accounted for 44.97% of all reads on average across all three metagenome samples. AMX1 had an average GC content of 42.29%, a genome size of 3.1 Mbp, and 2,859 open reading frames (ORFs) which was consistent with other previously reported anammox genomes for this strain , resulting in 27,836 contigs with a median N50 of 2,138 bp. Contigs were binned to draft genomes resulting in 129 draft genomes accounting for 74.62% of quality filtered reads on average across all three samples . These Ms strain .3.4.hdh), hydrazine synthase (hzsA/B/C), hydroxylamine oxidoreductase (hao), respiratory nitrate reductase (narGH), nitrous oxide reductase (nosZ), and cytochrome c membrane associated nitrite reductases (nrfAH) with relative abundances ranging from 4.3 to 32.3%. For the purposes of this study, we are utilizing nrfAH, the gene encoding the one-step reduction of nitrite to ammonium as a proxy for DNRA. Likewise, we are employing nirK and nirS, both used for nitrite reduction to nitric oxide, as proxies for denitrification. The abundance of functional analogs nirK and nirS, were only 0.9 and 0.1%, respectively; however, the relative abundance of respiratory nitrate reductases narGH was 30.99% on average, indicating the wide prevalence of nitrate reduction capacity. The nitrogen gene relative abundances for samples from day 37 and 140 were nearly identical; by day 232, the relative abundance of nrfAH nitrite reductases and narGH nitrate reductases increased slightly and the relative abundance of anammox associated hydrazine synthase and hydrazine dehydrogenase decreased slightly , IGN01 (Ignavibacterium), CFLX01 (Chloroflexi), PROT01 , and BAC01 all contained narGH. AMX01, CFLX01, and IGN01 also contained nrfAH. The abundance of AMX01 decreased from 9.67 RPKM on day 37 to 7.81 RPKM on day 232, while the abundances of CFLX01 and IGN01 increased from 14.11 and 9.18 RPKM on day 37 to 23.02 and 15.98 RPKM on day 232. Many of the MAGs that encoded for narGH also lacked the remaining genes necessary for the full denitrification pathway, which could result in the accumulation of nitrite. This is consistent with previously reported results  superfamily, including formate channel focA and formate permease fdhC. Previous research has shown that some denitrifying bacteria have a higher affinity for nitrite than nitrate  changes between day 232 and day 37 were calculated using each MAG’s coverage normalized to three reference genomes . Of the taxonomy .Brocadia had the lowest replication rates at all three time points with an average of 1.14. CFLX13 (Chloroflexi) had the highest replication rates with an average of 2.15. PROT03  experienced the most substantial decrease in replication rates during the course of the experiment, falling from 1.85 at day 37 to 1.43 at day 232 (a 23% decrease); CPR01 experienced the most significant increase, from 1.39 on day 37 to 2.15 on day 232 (a 55% increase). With the exception of CPR01, all of the MAGs that demonstrated increased replication rates between time points had negative log-ratio changes between day 37 and 232. This observation could be an indication of higher mortality rates suggestive of r-type strategists, or organisms well adapted to optimize growth during unstable environmental conditions. These types of organisms have shorter life cycles but very high reproduction rates associated with low efficiency substrate utilization , and nrfAH (DNRA) associated taxa , but will also undergo variable changes in composition due to weak selection pressures (drift) . In anam4.2.4+:NO2− ratio change, we observed increased abundance of bacteria capable of performing DNRA. Amplicon sequencing and shotgun metagenomic sequencing revealed increased abundance of bacteria belonging to Ignavibacteriae, Chloroflexi, and Bacteroidetes, phyla previously associated with DNRA in anammox reactors . Thus, further research is needed to identify and parameterize the equilibrium of this dynamic.The balance between DNRA and anammox is predicated on an exchange of nitrate, ammonium, and organic carbon substrates as shown in osystems . Despiteosystems . This ti4.3.4+ requires 1.32 moles of NO2− to be fully oxidized) but also to the reduction of nitrite to ammonium by DNRA bacteria and, to a lesser extent, nitrite reduction to dinitrogen gas by denitrifying bacteria. The abundance of DNRA bacteria was also positively correlated with the nitrite removal efficiency, nitrogen removal efficiency, and nitrogen removal rates , the relative abundance of anammox bacteria in the system decreased from 77.19 to 12.24% by 16S rRNA amplicon sequencing. This coincided with the growth of bacteria capable of performing DNRA; the phyla Ignavibacteriae and Chloroflexi increased from 7.73 and 4.57%, respectively, to 23.36 and 38.22%. These results demonstrate the positive effects of a stable dynamic between anammox and DNRA, which can result in robust reactor performance and enhanced nitrogen removal.In a single-stage anammox MBR, adjusting influent NHThe datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/EA and JL supervised the study. EA, JL, and LA-C designed the study. EA and JL maintained the bioreactor. CW analyzed the bioreactor performance, 16S rRNA gene data, metagenomics data, and wrote the manuscript. SS contributed to data analysis and visualization. RK contributed to metagenomic data analysis. LJ, KY, and WZ assisted with study design and manuscript revision. All authors read the manuscript and contributed with their input.This research was supported by the National Natural Science Foundation of China (Nos. 51709005 and 51708362), and the National Science Foundation through the Engineering Research Center for ReInventing the Nation’s Water Infrastructure (ReNUWIt) ECC-1028962. This material is also based upon work supported by the National Science Foundation Graduate Research Fellowship under grant no. DGE 1106400.Author JL was employed by CDM Smith.The remaining 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.Any opinion, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the National Science Foundation.


Wastewater treatment plants (WWTPs) are one of the largest biotechnology applications in the world and are of critical importance to modern urban societies. An accurate evaluation of the microbial dark matter  proportions in WWTPs is of great value, while there is no such research yet. This study conducted a global meta-analysis of MDM in WWTPs with 317,542 prokaryotic genomes from the Genome Taxonomy Database and proposed a “wanted list” for priority targets in further investigations of activated sludge.Compared with the Earth Microbiome Project data, WWTPs had relatively lower genome-sequenced proportions of prokaryotes than other ecosystems, such as the animal related environments. Analysis showed that the median proportions of the genome-sequenced cells and taxa (100% identity and 100% coverage in 16S rRNA gene region) in WWTPs reached 56.3% and 34.5% for activated sludge, 48.6% and 28.5% for aerobic biofilm, and 48.3% and 28.5% for anaerobic digestion sludge, respectively. This result meant MDM had high proportions in WWTPs. Besides, all of the samples were occupied by a few predominant taxa, and the majority of the sequenced genomes were from pure cultures. The global-scale “wanted list” for activated sludge contained four phyla that have few representatives and 71 operational taxonomic units with the majority of them having no genome or isolate yet. Finally, several genome mining methods were verified to successfully recover genomes from activated sludge such as hybrid assembly of the second- and third-generation sequencing.This work elucidated the proportion of MDM in WWTPs, defined the “wanted list” of activated sludge for future investigations, and certified potential genome recovery methods. The proposed methodology of this study can be applied to other ecosystems and improve understanding of ecosystem structure across diverse habitats.Video AbstractThe online version contains supplementary material available at 10.1186/s40168-023-01503-3. This project has greatly promoted the taxonomy and distribution of microorganism research in various ecosystems including WWTPs. For instance, Ju and Zhang [23 bacteria and 2.0 ± 0.2 × 109 species as an important pool in the whole Earth microbiome (~ 1012) [Wastewater treatment plants (WWTPs) are one of the largest applications of biotechnology in the world , which und Zhang  detectednd Zhang  tried tond Zhang  estimate(~ 1012) .In recent years, high-quality and complete genome sequence-based analyses begin to take dominant positions in research due to the rapid development of sequencing technology and the diversity of research objectives. Compared to the low phylogenetic resolution and primer mismatches of 16S rRNA gene amplicon sequencing , high-quAlthough prokaryotes comprise the majority of the WWTPs’ biomass, we are still short of knowledge on their roles in ecosystems because most prokaryotes and their genomes remain uncharacterized . These uHere, we made a worldwide survey to elucidate the proportions of MDM in WWTPs by linking 16S rRNA gene amplicons and genomes, then defined the priority of these unknown prokaryotes, and finally proposed diverse methods to recover more genomes. Three types of important samples in WWTPs were chosen, i.e., AS for the major aerobic treatment process, aerobic biofilm as other types of wastewater treatment reactors like moving bed biofilm reactor (MBBR), and anaerobic digestion sludge (DS) for sludge treatment in WWTPs. The data was collected from the public database, including 1984 AS samples from 28 countries, 195 aerobic biofilm samples from 6 countries, and 854 anaerobic DS samples from 10 countries. To our knowledge, this is the first research to evaluate the present situation of MDM in WWTPs with the following three questions be answered: (1) what are the genome-sequenced proportions of prokaryotes in different processes of WWTPs; (2) what is the “wanted list” in AS of WWTPs; and (3) are there any other methods that can recover more genomes in WWTPs to help us clarify the system? It is worth noting that the methodology developed in this study is feasible and transferable to enable a more comprehensive understanding of other ecosystems.ftp://ftp.microbio.me/emp/release1/otu_tables/deblur/emp_deblur_90bp.subset_10k.rare_5000.biom), which collected a total of 262,011 sequences in 10,000 samples taken from 17 microbial environments (EMPO level 3). The raw Illumina amplicons sequencing data for any regions of 16S rRNA gene in worldwide WWTPs were collected from the NCBI public database with the keywords of “activated sludge”, “biofilm”, and “digestion sludge”. Finally, we got 1984 AS samples in 28 countries, 195 aerobic biofilm samples in 6 countries, and 854 anaerobic DS samples in 10 countries . According to GTDB metadata, the genomes were divided into five subgroups, i.e. “isolation”, “complete genome”, “high-quality genome”, “medium-quality genome”, and “low-quality genome”, respectively. We firstly consulted the “ncbi_genome_category” field in the GTDB metadata to establish if NCBI (as parsed by the GTDB) indicated a genome was derived from an environmental source or not and the value of “none” means the genome comes from isolates. Then the complete genomes were extracted from the column of “ncbi_assembly_level” with the keyword “Complete genome”. Finally, we collected the high-quality (HQ), medium-quality (MQ), and low-quality (LQ) genomes based on the value of the columns “mimag_high_quality”, “mimag_medium_quality”, and “mimag_low_quality”, respectively. Besides, 3533 genomes in three recent wastewater studies were also downloaded for analysis [We downloaded 317,542 genomes  in GTDB (Release 207 version)  in July analysis , 41, 42.analysis  with theanalysis .E value < 1e–5) [Pnumber and Pabundance were used to represent the genome-sequenced proportions of taxa  number and corresponding cell number  sum in a specific environment. The whole flowchart was shown in Fig. Alignment between the amplicons and genomes was performed using BLASTn   with theFor the global-scale “wanted list” analysis of AS, ASVs in V4 region (1208 out of 1984 AS samples) were extracted and clustered at a 97% level with vsearch (version 2.18.0)  to finalThe network of priority criterion was constructed by the spiec.easi function from the package SpiecEasi (version 1.1.1)  with thevia BLASTn  [The 71 OTUs were aligned as query  < 1e–5)  with EMPThe GTDB R207 contained 317,542 genomes of prokaryotes, including 311,480 bacteria and 6062 archaea, respectively. Figure Pabundance in the 10,000 samples was 57.6% with the upper and lower quartiles of 31.7% and 91.3%, respectively . These values increase obviously compared to another research with 38.1% for Pabundance and 18.8% for Pnumber [Pabundance and 68.2% of Pnumber) was significantly higher than that of other groups , animal corpus (98.3%), animal secretions (98.3%), and animal surface (92.6%) exceeded 90.0%, and their corresponding median Pnumber exceeded 50.0%. Of course, some environments might be really simple and only have a few taxa with the high abundance, such as plant corpus and animal corpus , hypersaline (20.8%), sediment_non-saline (21.9%), and sediment_saline (27.5%) samples were all less than 30.0%, and the median Pnumber values for sediment  samples were less than 10.0% . The results showed that the median of  Pnumber  due to tPabundance and Pnumber of AS were 56.3% (47.9–65.1%) and 34.5% (29.4–39.2%). Similarly, the median Pabundance and Pnumber of biofilm were 48.6% (43.8%–60.9%) and 28.5% (20.7%–39.5%), respectively. For DS, medians of Pabundance and Pnumber were 48.3% (35.1–56.7%) and 28.5% (25.1–31.6%). From the WWTPs level, the Pabundance and Pnumber of all samples were 54.0% and 32.4%, which was much lower than animal samples and a little lower than Saline samples in EMP  or tight (present in > 50% samples with a relative abundance > 0.1%) levels, and got 92 and 34 OTUs respectively Table S. FinallyIt is of paramount value to know the dark part in the “wanted list”. The results showed only 20 OTUs had isolates, 36 OTUs had sequenced genomes, and 15 OTUs were poorly investigated without genome information Fig. c, especiConnecting the 16S rRNA gene to the genome is limited due to the challenges of reconstructing HQ and complete genomes that included 16S rRNA genes by only short-read sequencing, especially for ecosystems with high complexity like AS . HoweverPnumber for Denmark AS decreased from 35.9 to 16.9% and the median of Pabundance declined obviously from 65.1% to 26.1% after removing the genomes recovered by the hybrid assembly method. For AS in Hong Kong, the Pnumber improved from 20.1 to 33.2% if the database included the hybrid genomes, and the Pabundance obviously increased from 25.3 to 57.5% due to the recovery of 20 high abundance genomes  because genomes contain much more genetic information and have more variants than the 16S rRNA gene . Besidesvia effluent discharge [The ecosystems of WWTPs have high diversity and complexity with a few predominant species that contribute to high relative abundances. Predominant taxa always have higher priority for genome sequencing and isolation than taxa with low abundance and the above analysis shows that at least one-third of the predominant genomes have not been sequenced in WWTPs. This situation may be caused by several reasons. Firstly, the characterization of genomes mainly comes from pure cultures before the wide application of high-throughput sequencing, and the cultivation and genome research happens more often in the vicinity of humans  than envischarge . Additioischarge , 66. Conischarge , 70.Candidatus Accumulibacter (OTU_15) for phosphorus removal. Compared with the other two studies mentioned above, the “wanted list” in this research enriched the catalog through a network approach to explore the potential notable taxa such as the OTU_14 (g_Elev-16S-1166), which had the highest abundance of 0.6% in AS. OTU_14 still lacks genome/isolate information with no described species in this genus, and the in situ physiology of this genus in AS has not been determined.The global-scale “wanted list” microbial community could be determined based on different criteria according to research aims. The most widely accepted and used criteria is to filter the taxa according to abundance (> 1% or 0.1%), such as 28 cores defined by a global bacterial study in WWTPs   bacteria and (b) archaea. Figure S2. The length and quantity distribution of 16S rRNA gene for GTDB R207. Figure S3. Genome sequenced results of environments in EMP and worldwide WWTPs. Yellow represents the genome-sequenced proportion of taxa (Pnumber) and green represents the sum of corresponding relative abundance (Pabundance). Amplicons share 100% identity and 100% coverage with the sequenced genomes. For the box plots, the middle line indicates the median, the box represents the 25th–75th percentiles, and the error bar indicates the 10th–90th percentiles of observations. The results are based on the analysis of 10,000 EMP samples with EMPO level 2 and the worldwide WWTPs samples. Figure S4. Genome sequenced results of environments in EMP and worldwide WWTPs with (a) 98.7% and (b) 97% identity. Yellow represents the genome-sequenced proportion of taxa (Pnumber) and green represents the sum of corresponding relative abundance (Pabundance). The results are based on the analysis of 10,000 EMP samples with EMPO level 3 and the worldwide WWTPs samples. Figure S5. The correlation between Pabundance/Pnumber and α-diversity indices of EMP and WWTPs samples, including (a) Observed OTUs, (b) Chao 1, and (c) Shannon. Figure S6. The proportions of total abundance and cell number of sequences whose relative abundance <0.1% in WWTPs . Figure S7. The abundance (cell number) of top 10 phyla in AS with Silva 138 database. Figure S8. The overlap of sequenced genomes among three types of samples in WWTPs .Additional file 2: Table S1. List of projects. Table S2. The “wanted list” of activated sludge at global level. Table S3. The “wanted list” of activated sludge at global level (Strength). Table S4. The “wanted list” of activated sludge at global level (loose). Table S5. The quantity of ASVs and corresponding aligned genomes in different samples. Table S6. The list of sequenced genomes in activated sludge. Table S7. The list of sequenced genomes in Biofilm. Table S8. The list of sequenced genomes in anaerobic digestion sludge.


Intestinal strangulation is constriction of the intestine by a band of tissue, ligament or blood vessel causing partial or complete intestinal obstruction. This retrospective study describes the clinical, laboratory and ultrasonographic findings, treatment and outcome of 60 cows with intestinal strangulation.The general condition was abnormal in all cows (60/60), 23.3% (14/60) had nonspecific signs of pain, 40.0% (24/60) had signs of colic and 48.3% (29/60) had signs of somatic  pain. The most common digestive tract abnormalities were, in decreasing frequency, reduced or absent intestinal motility , reduced or absent faecal output , reduced or absent rumen motility , dilated small intestines on transrectal palpation , positive ballottement and swinging auscultation (BSA) and/or percussion and simultaneous auscultation (PSA) on the right side of the abdomen  and at least one positive foreign body test, most commonly the back grip, in 33.9% (20/59) of the cows. Other common findings were reduced skin surface temperature , reduced skin turgor , prolonged capillary refill time , enophthalmus  and moderate to severe scleral injection . The most common laboratory findings were hypokalaemia , haemoconcentration , base excess , hyperproteinaemia , hyperbilirubinaemia , acidosis  and azotaemia . The principal ultrasonographic findings were subjectively reduced or absent small intestinal motility and dilated small intestines, but the strangulation could not be visualised by ultrasonography. With one exception, all cows underwent a right flank laparotomy to resolve the strangulation by transection or resection of the impinging tissue. Forty-nine (81.7%) cows were discharged and 11 (18.3%) were euthanized before, during or after surgery.Without laparotomy, intestinal strangulation could be clinically  diagnosed in only 10% of the cows. A laparotomy is therefore essential for the correct diagnosis. The prognosis is good with prompt surgical treatment. Intestinal strangulation is an impingement of the intestine by tissue bands of various origins that extend between two abdominal organs or between an organ and the abdominal wall or are freely floating in the abdominal cavity, causing a partial or complete intestinal obstruction . IntestiThe clinical manifestation of SIS depends on the extent, degree and anatomic location of the constriction . ProvideTreatment of intestinal strangulation is surgical , 13 and Even though most veterinary textbooks cover SIS, large numbers of cattle with the disorder have not been analysed. The above-mentioned publications describe 1 to a maximum of 3 cases. In addition, the published cases underwent only clinical and laboratory analyses before laparotomy. In only one case was ultrasonography carried out . TherefoAll methods were performed in accordance with relevant guidelines and regulations.As part of a Master’s thesis , the medFor inclusion in the study, only the records of cows that were a minimum of one year of age and had SIS at the time of admission were reviewed. The diagnosis of SIS had to have been confirmed unequivocally during laparotomy or postmortem examination. Two records were excluded from analysis because they had been published previously . AnotherThere were 51 mature cows (85.0%) and 9 heifers  that were between 1.1 and 11 years of age (median = 4 years). For the purpose of this report, all were referred to as cows. Breeds included Swiss Braunvieh , Holstein , Swiss Fleckvieh  and Hereford . Of the cows, 45.0% (27/60) were pregnant , 28.3% (17/60) were open, and in the remaining 26.7% (16/60), the pregnancy status was not known at the time of admission. The last calving date was known for 25 cows and was between 1 and 26 weeks before admission (mean ± sd = 11.3 ± 7.6 weeks). Nine (15.0%) animals had never calved. The duration of illness before admission ranged from 4 to 120 h (median = 24 h). A history of complete anorexia occurred in 68.3% (41/60) of the cows and 31.7% (19/60) had a reduced appetite. Thirty-two (53.3%) had a history of colic before admission.All cows underwent the same structured clinical examination procedure conducted by the first author or under the supervision of the first or second author. Clinical examination was done according to published standards –18 and aEach cow was observed for signs of pain. Signs of pain were divided into non-specific, somatic  and visceral . Non-specific signs of pain included muscle fasciculations, bruxism and spontaneous grunting. Signs of somatic  pain were a tense abdominal wall, arching of the back and a tucked-up abdomen. Visceral  signs consisted of shifting of weight in the hind limbs, lordosis, restlessness, kicking at the abdomen, sweating, tail swishing, frequent lying down and rising. The number and severity of signs of colic/abdominal pain were determined. Signs of mild colic included mild restlessness, shifting of weight in the hind limbs, looking at the flank, lifting the tail, lifting of individual limbs and tail swishing. Signs of moderate colic were moderate restlessness, brief periods of recumbency, kicking with the hind limbs, arching of the back and marked tail swishing. Signs of severe colic consisted of marked restlessness, frequent lying down and rising, sweating, grunting and violent kicking at the abdomen.The following blood samples were collected from all cattle: 5 ml of EDTA blood for haematological analysis, 10 ml of whole blood for serum biochemistry and 2 ml of whole blood mixed with 0.2 ml heparin for venous blood gas analysis. The variables were measured as described previously . Haemato9, Roche, Basel, Switzerland) and a refractometer  to measure specific gravity. A sample of rumen fluid was collected using a Dirksen probe and assessed for colour, odour, consistency and pH (data not shown). In addition, the concentration of chloride was determined .Urine samples were analysed using a test strip  given intramuscularly once daily for 2 to 6 days, in most cases for 3 or 4 days . Fifty-four cows received a daily injection of a non-steroidal anti-inflammatory drug  or a pyrazolone preparation  given intravenously once daily for 2 to 5 days (median = 3 days). Forty-nine cows received 10 to 15 L of a solution containing 50 g glucose and 9 g sodium chloride per litre daily for 2 to 7 days (median = 3 days) administered as a slow intravenous drip (20 ml/kg/day) via an indwelling jugular vein catheter . Fourteen cows with hypocalcaemia  received 500 ml of 40% calcium borogluconate supplemented with 6% magnesium hypophosphite  intravenously for 1 to 2 days (mean = 1 day). Hypokalaemia (potassium < 4.0 mmol/l) was treated in 15 cows with daily oral doses of 60 to 100 g of potassium chloride until normokalaemia was achieved . Cows with hypophosphataemia (inorganic phosphorus < 1.0 mmol/L) or hypomagnesaemia (magnesium < 0.7 mmol/L) were treated orally with monocalcium phosphate, sodium dihydrogen phosphate and/or magnesium oxide. Prokinetic drugs were used in 43 cows for a duration of 1 to 9 days . Thirty-four cows received intramuscular metoclopramide (30 mg) usually given seven to nine times at eight-hour intervals intramuscularly before its use in farm animals was discontinued in Switzerland, and 7 received neostigmine  administered via continuous intravenous drip infusion. Five cows received additional antiparasitic treatment for fascioliasis and gastrointestinal nematodes including netobimin  or nitroxinil . Two cows received 1 to 3 L of rumen fluid collected from a clinically healthy cow, 2 cows received 20 to 40 g dry yeast and 1 cow received 2 L mineral oil, administered orally.When indicated, cattle were slaughtered at the slaughter facility of the Veterinary Hospital, and the meat used for zoo-animal feeding, or they were euthanized using pentobarbital .All cows that died or were euthanized underwent postmortem examination. Only the internal organs were inspected in slaughtered cows.polynomial contrasts with difference. Means and standard deviations, medians and the 25th to 75th percentiles were calculated for the different anatomic locations of the strangulating lesion  and differences in medians were analysed using the Kruskal-Wallis test. The outcomes after transection and resection of tissue bands were compared using Fisher’s exact test because case numbers were small. P values < 0.05 were considered significant.The program SPSS Statistics 25.0  was used for analysis. Frequencies were determined for all variables, and the Shapiro-Wilk test was used to test the data for normality. Normal data are presented as means ± standard deviations and non-normal data as medians. The variables heart rate and rectal temperature over time (day 0 to day 7) were analysed using the general linear model choosing repeated measures (ANOVA with repeated measures) and replacing The general condition was mildly abnormal in 18.3% (11/60), moderately abnormal in 63.3% (38/60) and severely abnormal in 18.3% (11/60) of the cows. Bilateral abdominal distension occurred in 21.7% (13/60) of the cows, and 3.3% (2/60) had unilateral right-sided abdominal distension. Non-specific signs of pain occurred in 23.3% (14/60) of the cows and included twitching of the anconeus muscles , bruxism  and grunting . Abdominal guarding  as an expression of somatic  pain was seen in 48.3% (29/60) of the cows. One cow (1.7%) had an arched back, and another had a tucked-up abdomen. Signs of visceral pain (colic) were seen in 40.0% (24/60) of the cows and manifested as lowering of the back , treading , restlessness , kicking at the abdomen , sweating  and frequent lying down and rising . Of the cows with visceral pain, 21.7% (13/60) had one sign, 8.3% (5/60) had two signs and 6.7% (4/60) had four signs. Visceral pain was judged to be mild , moderate  or severe .Of these vital signs, the most common abnormalities were tachycardia , decreased rectal temperature  and tachypnoea  , reduced or absent faecal output , reduced or absent rumen motility , dilated small intestines on transrectal palpation , positive BSA and/or PSA on the right side of the abdomen . Of the foreign body tests, positive results were seen with the back grip in 13.6% (8/59) of the cows, the pole test in 5.1% (3/59), percussion of the reticular area in 1.7% (1/59) and several of these tests in 13.6% (8/59). At least one foreign body test was positive in 33.9% (20/59) of the cows , reduced skin turgor , prolonged capillary refill time , enophthalmus , moderate to severe scleral injection , foul or ammonia-like breath , dry cool muzzle , pale oral mucosa  and droopy ears .The urine pH of 52 samples ranged from 5.0 to 9.0  and was acidic (5.0 to 6.9) in 34.6% (18/52) and alkaline (8.1 to 9.0) in 17.3% (9/52) of the cows. Specific gravity ranged from 1.002 to 1.060 (mean ± sd = 1.028 ± 13) and was < 1.020 in 25.5% (13/51) and > 1.040 in 13.8% (7/51) of the cows. Ketonuria (10 to > 150 mg/dL urine) occurred in 25.5% (13/51), haemoglobinuria/haematuria (5 to 250 erythrocytes/μl urine) in 24.0% (12/50), glucosuria (50-1000 mg/dL urine) in 19.6% (10/51) and proteinuria (100 to 500 mg protein/dL urine) in 3.9% (2/51) of the cows.The major abnormalities were hypokalaemia , haemoconcentration , base excess 51.1%, 24/47), hyperproteinaemia , hyperbilirubinaemia , acidosis , azotaemia  and hypercapnia    Fig. D, highesThe principal findings were subjectively reduced or absent small intestinal motility  and dilated loops of small intestines 100.0%, 43/43) with a diameter of 3.6 to 10.2 cm and fluid between the loops  (Table 3/43 withFifty-one (85.0%) cows had no comorbidities identified. Clinical, intraoperative and/or postmortem examinations indicated 1 comorbidity in 11.7% (7/60) of the cows and multiple concomitant diseases in 3.3% (2/60), which included abomasal and duodenal ulcers, non-penetrating reticular foreign body, chronic peritonitis, chronic intraabdominal adhesions, bronchopneumonia and abscess.Fasciola hepatica eggs, which were accompanied by gastrointestinal nematode or Dicrocoelium dendriticum eggs in 5 cows. Seven other samples had only gastrointestinal nematodes, 3 had only Dicrocoelium dendriticum eggs and 4 had mixed infestation of these parasites. Five faecal samples contained no parasite eggs.Six of 25 faecal samples contained tentative diagnosis of ileus was made in 26.7% (16/60) of the cows, a diagnosis of ileus was made in 48.3% (29/60) and a diagnosis of ileus attributable to strangulation was made in 10.0% (6/60) of the cows. In 15.0% (9/60) of the cows, no diagnosis was made or conditions such as caecal dilatation (4/60) or right displaced abomasum (1/60) were diagnosed.Based on the clinical findings, a Based on the ultrasonographic findings, a diagnosis of ileus was made in 86.0% (37/43) of the cows examined via ultrasonography; intestinal motility (37/37) was examined as well as the small intestines in cross-section (43/43). In 6 cows that were examined ultrasonographically, no diagnosis was made (n = 1) or other conditions such as dilatation of the abomasum (n = 1), duodenum  or caecum (n = 2) were diagnosed.A definitive diagnosis of strangulation was made in 100% (60/60) of cases based on the findings at laparotomy (n = 59) or postmortem examination (n = 1).One cow with ambiguous findings was treated medically for 2 days, after which time she was euthanized because the owner declined surgical exploration of the abdomen Fig. . Fifty-nThe jejunum was most often involved in the strangulation , followed by the ileum  and duodenum . In 15.0% (9/60) of the cows, the jejunum and the ileum and in 1.6% (1/60), the jejunum, ileum and caecum were involved. The location of the strangulation was not noted in 5.0% (3/60) of the cows. The strangulation was caused by a single tissue band in 76.7% (46/60) of the cows, by two bands in 6.7% (4/60) and by three or more bands in 16.7% (10/60) of the cows.The tissue band consisted of connective tissue in 40.0% (24/60) of the cases, a ligament in 18.3% (11/60), fibrin in 15.0% (9/60), a persistent umbilical artery in 1.7% (1/60) and a persistent urachus in 1.7% (1/60). In 23.3% (14/60) of the cows, the nature of the tissue band was not specified. Various abdominal and pelvic organs and structures were identified as origins and insertions of the tissue bands including omentum , mesentery , abdominal wall  and small intestines . In 25.0% (15/60) of the cows, the origin and the insertion of the tissue bands could not be identified or were not noted in the medical record. The intestines that were involved in the strangulation were normal in 45.0% (27/60) of the cows, mildly to moderately abnormal in another 45.0% (27/60) and severely abnormal in 10.0% (6/60).Other intraoperative findings were adhesions , increased abdominal fluid  or other abnormalities including fibrin between the intestines (1/60), intestinal rupture (1/60), persistent umbilical vein (1/60) and nodular changes of the intestinal wall (1/60). In 51.7% (31/60) of the cows, no other changes were found in the abdomen. Eight point three per cent (5/60) of the 60 operated cows went down during surgery. Intestinal contamination did not occur, but one cow had bowel prolapse, which could not be replaced and therefore the cow had to be euthanized.The general condition of the 49 successfully treated cows normalised within 1 to 6 days, appetite returned to normal within 1 to 7 days and faecal output (with one exception) within 1 to 8 days  after surgery. Between admission and 7 days postoperatively, the median rectal temperature ranged from 38.6 to 38.7 °C (P > 0.05) and the heart rate from 70 to 77 bpm (P > 0.05). These cows were discharged from the clinic in good health 2 to 15 days (median = 5 days) after surgery. Four cows deteriorated postoperatively and were euthanized 1 to 6 days (median = 2.5 days) after surgery.The long-term outcome was determined 2 years after discharge. Of the discharged cattle, 46.9% (23/49) had remained in the herd and were still productive, 1 cow had been slaughtered as a result of the original strangulation, 2 because of other illnesses and 11 for economic or unknown reasons. The long-term outcome of 12 cows was unknown.Eleven cows underwent postmortem examination. The principal findings in the small intestine were necrosis (7/60), haemorrhagic infarction (6/60), dilatation (2/60) and congestion (1/60) in the region of the strangulation. In two cows, severe proliferation of the greater omentum was seen. The strangulation was visible in one cow that was euthanized intraoperatively and in one cow that had received medical treatment. Intestinal rupture seen intraoperatively in one cow was confirmed. Two cows had non-perforating abomasal ulcers, which were accompanied by a duodenal ulcer in one cow. Another cow had a circular jejunal ulcer, conceivably attributable to a previous penetrating foreign body. A jejunal mucosal ulceration caused by the strangulation was seen in one cow, and another had a jejunal diverticulum at the site of the strangulation. Eight cows had peritonitis, two had enteritis and three cows had petechial haemorrhages in the intestines (2/60), heart (2/60), lungs (1/60), larynx (1/60), liver (1/60) and peritoneum (1/60). Multiple renal and liver infarcts, biliary fibrosis, hepatic lipidosis, oedema of the abomasum and colon, ruminal abscess, bronchopneumonia and oesophageal hyperkeratosis were seen in one cow each.Based on the intraoperative, postmortem and/or parasitological findings, we surmised that the cause of the strangulation was peritonitis in 11 cows, fascioliasis in six , persistent urachus in one, persistent umbilical artery in one and an anomaly of unknown origin in one.colic phase, may only last from 2 to about 12 h, followed by the next phase, the indolence stage [Only 40% 24/60) of cows had signs of visceral pain (colic) at the initial examination. This may have been related to the observation that signs of pain occur intermittently in cattle with SIS  and thatce stage . Signs oce stage , 10, 13.0 of cowsce stage . This wace stage . Shiftince stage . A sunkece stage . Abdomince stage . Non-speA decreased rectal temperature was recorded in all cows (18/18) with experimental ligation of the small intestines , but onlChanges in abdominal contour may be caused by retrograde accumulation of ingesta , 10. TheBSA and PSA were positive on the right side in 58.3% 35/60) of the cows. Both findings were considered important indications of ileus resulting from intestines distended by gas and/or fluid . Dilated0 of the The haematocrit and total protein concentration were increased in 57.6% (34/59) and 45.8% 27/59) of the cows, respectively, and there was considerable overlap between these two findings suggesting that haemoconcentration attributable to dehydration was the underlying cause. This caused prerenal azotaemia with increased serum urea concentration in 38.3% (23/60) of the cows. Cows with intussusception had a slightly higher haematocrit  and total protein concentration , which could explain the higher rate of prerenal azotaemia  . There wDilated loops of small intestines and reduced or absent intestinal motility were the principal ultrasonographic findings, which are typical of ileus , but notstrangulation as the cause of the ileus in another 10% (6/60). Although a comprehensive ultrasonographic examination of intestinal motility and diameter was done in only 37 of the 60 cows, the variables reduced or absent intestinal motility and dilated small intestines, which are obligatory for a diagnosis of ileus, could be confirmed ultrasonographically in all 37 cows. This demonstrates clearly that abdominal ultrasonography facilitates the diagnosis of ileus. Thus, ultrasonography should be part of the examination of all cows with severe gastrointestinal disorders.The clinical examination facilitated a diagnosis of ileus in 48.3% (29/60) of the cows and intestinal Surgical treatment with mechanical resolution of the strangulation is the treatment of choice for intestinal strangulation and a necessity for the survival of the cow , 2. The Overall, intestinal strangulation is a rare cause of ileus and has a relatively good prognosis. Even though the site of the strangulation itself and the involved tissue bands could not be visualised, ultrasonography was useful for establishing a tentative diagnosis. As in all cases of ileus with a mechanical intestinal obstruction, immediate surgical treatment is of utmost importance for cow survival.


Teeth may have additional roots and a different number of root canals. Overlooked root canals may cause endodontic failure. The aim of this study was to investigate the prevalence of root canals and the number of roots of premolars in a selected Turkish population.A total of 2,570 teeth from 1,438 patients were evaluated. The cone-beam computed tomography scans of 1,055 maxillary and 1,515 mandibular premolars were examined.Type IV root canal morphology was observed most frequently in maxillary first premolars (77%), and the rates of single and double channel formations were very similar . Of the second maxillary premolars, 57.4% had Type I morphology, and 89.9% of the teeth were single-rooted, while 68.6% had a single root canal. The most common formation was Type I (85%) among mandibular first premolars, and a single root was observed in 95.6% of these teeth. In addition, 87% of the mandibular first premolars had a single root canal. The second mandibular premolars mostly had Type I (95.4%) formation, and 99.3% of the teeth were single-rooted, while 96.9% had a single root canal.According to our findings, 51% of maxillary first premolars had a single root, 79.4% had two root canals, and 77% had Type IV (77%) formation. Maxillary second premolars mostly had Type I formation. In addition, a single root and single root canal formation were most common. Mandibular first premolars generally had a single root and single root canal formation, but 13% had two root canals, and 6.4% had Type V formation. More than 95% of mandibular second premolars had Type I formation. It can be challenging for dentists to perform adequate shaping and disinfection of root canals due to the complex structure and diversity of root canal anatomy. Good knowledge of root and root canal morphology is important and essential for successful long-term results and a good prognosis . VertuccIn recent years, various techniques have been described to explore root canal complexes, such as staining and clearing, radiography techniques, and micro-computed tomography (µCT) imaging –9. TradiAccording to the findings of previous studies, premolar teeth have extremely variable root and canal morphologies according to race and geographic origin , 14. TheThis study was approved by the ethical board of the university . A total of 2,570 mandibular and maxillary premolar teeth, for which CBCT images were taken for surgical dental operation planning between 2000 and 2017 at the Faculty of Dentistry, were evaluated. The digital radiographic images of the patients were obtained from the hospital’s database. The patients’ personal information was also recorded. Premolar teeth of good periapical health that had complete root formation and had not received any dental treatment were included in the study. Images with digital defects were excluded.The CBCT images of the patients were taken using an i-CAT17–19 imaging system  with a standardized scanning protocol and a voxel size of 0.25 mm, according to the manufacturer’s recommendations. All volumes were acquired at 120 kVp and 20.27 mAs using a 16 cm × 11 cm field of view.Morphologies were examined by two endodontists and one radiologist with at least 10 years of experience. In order to calibrate the observers, 10 of the obtained data points were randomly selected and examined by two endodontists twice at 10-day intervals. In cases where a different decision existed, a consensus was reached further by consulting an oral diagnosis and radiology specialist. Cohen’s Kappa coefficient for the interobserver agreement was determined as 0.75.A series of images were viewed from the cementoenamel junction to the root apex, and the root canal complex was classified according to the Vertucci classification shown in Fig. p value was < 0.05.IBM SPSS Statistics v. 22 software  was used to analyze the data obtained from the study. In the comparison of qualitative data and analysis of differences according to gender, the chi-square test was used. The differences between the parameters were evaluated to be statistically significant when the The examination was carried out on 2,570 teeth of 1,438 patients, of whom 604 (42%) were male and 834 (58%) female, with an age range of 13 to 81 years. The ratio of women was significantly higher than that of men (p < 0.05). The mean age was 40.02 ± 13.63 years. The ages of the men varied between 13 and 81 years, with a mean value of 41.17 ± 13.91 years. The ages of the women varied between 16 and 74, with an average value of 39.18 ± 13.37 years. The number of maxillary teeth was 1,055 (41.1%), and the number of mandibular teeth was 1,515 (58.9%). Of the teeth examined, 1,282 (49.9%) were on the right side, and 1,288 (50.1%) were on the left. In addition, 521 (49.4%) teeth were on the right side of the maxilla, and 534 (50.6%) were on the left side of the maxilla, while 761 (50.2%) teeth were on the right side of the mandibula, and 754 (49.8%) were on the left side of the mandibula . The incidence of double roots in males (16.8%) was significantly higher than in females (11.8%). A single root canal was present in 72.1% of all teeth, and two root canals in 27.9%. There was no statistically significant difference between the genders in terms of the number of root canals (p > 0.05).Considering the distribution of Vertucci classes, of all teeth, 66.6% were Type I, 23.9% were Type IV, 3.5% were Type II, 3% were Type V, 2.1% were Type III, 0.6% were Type VIII, and 0.3% were Type VI , and single root formation was more common (51%). Of the maxillary first premolars, 79.4% had two root canals. In the maxillary second premolar teeth, the most common canal formation was Type I (57.4%), and 89.9% of these teeth were single-rooted, while 68.6% had a single root canal.Among the mandibular first premolar teeth, the most common canal formation was Type I (85%), 95.6% of the teeth were single-rooted, and 87% had a single root canal. When the mandibular second premolar teeth were evaluated, the most common canal formation was Type I (95.4%), and 99.3% of these teeth were single-rooted, while 96.9% had a single root canal Table .The current study evaluated the premolar teeth using CBCT in a local Turkish population. A total of 2,570 teeth belonging to 604 male (42%) and 834 female (58%) patients aged 13–81 years were included in the study, and 1,055 maxillary and 1,515 mandibular premolars were examined.In this study, it was found that the root canal formation in the premolars was generally Vertucci Type IV (77%), followed by Type I 10.2%). The rate of Type IV formation in the maxillary premolars was higher than reported in previous studies. Vertucci reported 62% Type IV formation in the maxillary premolars, while Peiris reported this rate to range from 45.7 to 64% %. The ra. On the In terms of the root canal number of maxillary first premolars, we found that double-rooted canal formation was most common 79.4%) and was seen at a higher rate than reported by Pineda and Kuttler (73.3%)  and lowe9.4% and In our evaluation, the maxillary second premolars mostly had a single root (89.9%) and a single root canal (68.6%). Similarly, Bürklein et al.  reportedIn the current study, the mandibular first premolars mostly had a single root and single canal formation (85%) (Type I). This rate is higher than reported by Vertucci (70%) , CaliskaWe observed that 95.4% of the mandibular second premolar teeth had Type I formation. The second most common morphological type was Type V 1.7%). These findings are in agreement with those reported by Cleghorn et al. (99.6%) . Root an.7%. ThesDifferent methodologies are used to investigate root and root canal anatomy, and they are basically divided into invasive and non-invasive techniques. µCT imaging is very effective in describing root canal anatomy but can only be performed on extracted teeth , 11. CBCAccording to the evidence provided by our study, the incidence of two root canals was significantly higher in men, while the incidence of Type I canal formation was significantly higher in women. When we evaluated the root canal morphology of the four different types of premolars (maxillary first and second premolars and mandibular first and second premolars), we determined that the most common canal formation in both jaws was Type I, except in the maxillary first premolars (Type IV). We consider that the results we obtained from a total of 2,570 teeth of 1,438 patients provide a more comprehensive evaluation of the root canal complex of both the maxillary and mandibular premolar teeth than previous studies that only evaluated one jaw (maxilla or mandible) and will assist clinicians in their decisions related to optimal diagnosis and treatment planning.


This single-center prospective study shows the feasibility of significantly decreasing the doses delivered to the lung functional volumes in the lung SBRT using 68Ga-perfusion PET/CT while still respecting target volume coverage and doses to other organs at risk.Lung stereotactic body radiation therapy (SBRT) has become a real alternative treatment for inoperable stage I-II non-small cell lung cancer and lung oligometastases with a high local tumor control rate. However, SBRT remains associated with significant pulmonary toxicity. Perfusion positron emission tomography/computed tomography (PET/CT) with 68Ga-perfusion PET/CT imaging in lung SBRT planification. Sixty patients that planned to receive SBRT for primary or secondary lung tumors were prospectively enrolled. Lung functional volumes were defined as the minimal volume containing 50% (FV50%), 70% (FV70%) and 90% (FV90%) of the total activity within the anatomical volume. All patients had a treatment planning carried out in 2 stages: an anatomical planning blinded to the PET results and then a functional planning respecting the standard constraints but also incorporating “lung functional volume” constraints. The mean lung dose (MLD) in functional volumes and the percentage of lung volumes receiving xGy (VxGy) within the lung functional volumes using both plans were calculated and compared. SBRT planning optimized to spare lung functional regions led to a significant reduction (p < 0.0001) of the MLD and V5 to V20 Gy in all functional volumes. Median relative difference of the MLD in the FV50%, FV70% and FV90% was −8.0% (−43.0 to 1.2%), −7.1% (−34.3 to 1.2%) and −5.7% (−22.3 to 4.4%), respectively. Median relative differences for VxGy ranged from −12.5% to −9.2% in the FV50%, −11.3% to −7.2% in the FV70% and −8.0% to −5.3% in the FV90%. This study shows the feasibility of significantly decreasing the doses delivered to the lung functional volumes using 68Ga-perfusion PET/CT while still respecting target volume coverage and doses to other organs at risk.The aim of this study was to assess the feasibility of sparing functional lung areas by integration of pulmonary functional mapping guided by  Lung cancer is the leading cancer in terms of mortality, with more than 1.6 million deaths per year .For patients with distant metastases secondary to solid tumors, systemic treatment remains the therapeutic standard . HoweverIn these indications, local tumor control rate is higher than 90%. However, lung SBRT remains associated with significant pulmonary toxicity. Grade ≥ 3 pulmonary complications are reported in 10% of cases and grade ≥ 2 in up to 20% of cases Ga-MAA suspensions were prepared in the radiopharmacy using an automated process with a miniAIO® module and disposable cassettes from Trasis . The fully automated process was performed from a commercial MAA kit used for 99mTc labelling  were purchased from CIS Bio International ). Details on [68Ga]Ga-MAA preparation and protocol acquisition are provided in All patients underwent lung perfusion PET/CT scan acquired on a digital Biograph Vision 600 PET/CT scanner . [The lung volumes were contoured using MIMimage analysis software . An automatic contouring of the whole lung anatomical volume (AV) based on Hounsfield unit value was initially performed and then visually adjusted to match normal contours if required. Within the AV, lung functional volumes (FV) were defined using an adaptative-absolute-threshold algorithm delineating the minimal volume containing 50% (FV50%), 70% (FV70%) and 90% (FV90%) of the total activity within the AV, respectively. ® linear accelerator equipped with Varian RPM gating system . Image guidance with cone beam CT was used to confirm the position of the tumor immediately before each treatment.All patients were planned to receive three fractions of 18 Gy each , or if the tumour was less than 2 cm from the chest wall, four fractions of 12 Gy each  or if the tumor was central or ultracentral, eight fractions of 7.5 Gy each . Radiotherapy planning scans were performed with patients positioned supine with both arms elevated above the head. A respiratory-sorted 4-dimensional computed tomography (4DCT) data set was generated using the planning CT  coupled with the Varian real-time position management (RPM) gating system. The 4DCT scans were acquired in helical mode and binned into 8 phases for image reconstruction. From the respiratory-sorted imaging phases, average (AVG) and maximum intensity projection (MIP) series were reconstructed. The internal target volume was delineated on the basis of a four-dimensional CT planning scan to take account of tumour motion on a MIM workstation. The internal target volume was expanded 3 mm in all plans to create the planning target volume. The lung organ at risk (OAR) was defined as the volume of both lungs minus the volume of the internal target volume (ITV). Treatment planning was performed on the Pinnacle V16.2 planning system using the AVG series. Treatment was prescribed such that 99% of the planning target volume (PTV) received at least 99% of the prescribed dose. The maximum dose at the PTV should be <140% of the prescribed dose. Dose constraints to OARs respected the international guidelines . All treAll patients had a treatment planning carried out in 2 stages. First, an anatomical planning was carried out, blinded to the PET results. Then, a functional planning, respecting the standard constraints applied during anatomical planning, but also incorporating “lung functional volume” constraints defined by pulmonary PET , was carried out.Dose to OAR and target volumes were computed for both treatment plans. The mean lung dose (MLD) in functional volumes  using the anatomical and functional plans were calculated and compared using the paired samples Wilcoxon test. The percentage of lung volumes receiving 5, 10, 15 and 20 Gy  within the lung functional volumes  were also calculated and compared using the paired samples Wilcoxon test. Median absolute  and relative  differences and their respective range were reported. Results were also analyzed in patients with and without preexisting airway disease (FEV1/FVC < 0.7 or DLCO < 60%) . All anaBetween July 2021 and January 2022, 60 consecutive patients with primary or secondary lung tumors were enrolled into this prospective study. The median (range) age of patients was 69 (51–84) years old. Patient characteristics and dose target volumes are outlined in p = 0.01), but with similar ITV coverage 100% (83.4–100%) vs. 100% (83.3–100%) (p = 0.38). Only one patient had insufficient PTV and ITV coverage for both treatment plans to meet the constraints at the main bronchi in the case of an ultra-central tumor. Mean relative volume of FV50%, FV70% and FV90% was 32% (SD 3%), 50% (SD 4%) and 75% (SD 4%) of the AV.For all patients, both anatomical and functional plans met the OARs and target dose constraints . There wp < 0.0001) of the MLD in functional volumes.MLD in functional volumes are presented in Median absolute difference of the MLD in the FV50%, FV70%, FV90% and anatomical volumes (AV) between the anatomical and functional plans was −0.2 Gy for FV and −0.1 Gy for AV See . Twelve Median relative difference of the MLD in the FV50%, FV70%, FV90% and AV was −8.0% (−43.0 to 1.2%), −7.1% (−34.3 to 1.2%), −5.7% (−22.3 to 4.4%), and −4.7% (−15.8 to 8.5%), respectively See . Twenty-p = 0.23, p = 0.32 and p = 0.59, respectively).For 17 patients without a preexisting airway disease, median relative difference of the MLD in the FV50%, FV70% and FV90% was −8.2% (−20.7 to 1.2%), −7.6% (−18.6 to 1.2%) and −5.7% (−16.2 to 4.4%). For 31 patients with a preexisting airway disease, median relative difference of the MLD in the FV50%, FV70% and FV90% was −7.5% (−43.0 to 0%), −6.9% (−34.3 to 0%) and −5.2% (−22.3 to 1.3%). There was no significant difference between the 2 subgroups (p < 0.0001) of the V5 to V20 Gy in all functional volumes   See . Median 68Ga-perfusion PET/CT imaging.p < 0.0001) in dose to functional lung volumes using functionally adapted radiotherapy plans while still respecting target coverage or dose constraints to other OARs. Indeed, the MLD to the functional volumes was reduced by 6 to 8% and the irradiated volumes by 5 to 12%.This is the first study incorporating the use of perfusion-PET in lung SBRT planning and demonstrating proof of principle that this technology may be used for functional lung avoidance. Our study demonstrated a statistically significant improvement  in the meta-analysis of 19 studies mentioned above, while it ranged from 5.3% to 9.2% in our series .Furthermore, if these overall results demonstrate the global performance of the technique, it is also important to note the major reduction of the dose in lung functional volumes in some individual patients. Thus, 10% of patients had a decrease greater than 20% of the MLD in the FV50%, and 27% had a decrease greater than 20% of the V5Gy within the FV50% volume. In that respect, we performed the analysis in patients with and without preexisting airway disease (FEV1/FVC < 0.7 or DLCO < 60%), on the assumption that patients with pulmonary disease are more likely to have heterogenous lung function distribution and thus to benefit from functionally adapted radiotherapy. However, we did not observe a major difference between both groups and found that optimization of radiation treatment plans was also possible in patients without preexisting pulmonary condition.Lung functional sparing is an increasing concern because SBRT has become the gold standard RT technique for stage I-II NSCLC and for secondary lung tumors in oligometastatic patients ,6,7,8,9.68Ga-MAA allows one to perform 68Ga-perfusion PET/CT for 6 patients, making the test very convenient to implement in a daily PET/CT program. This advantage is especially evident during the hour (uptake time) between the first injections of 18F-FDG, the most-used tracer in oncology, and its first acquisition on the PET tomograph. Finally, 68Ga-MAA is very convenient radiotracer for clinical use, and 68Ga generators are increasingly available in nuclear medicine departments due to growing use of 68Ga-based tracers for prostate cancer and neuroendocrine tumour imaging.Perfusion PET/CT imaging is a very attractive test for functional lung avoidance during radiotherapy planning ,14,17. B68Ga-perfusion PET/CT. However, it would be valuable to evaluate the prognostic impact in terms of RILI of doses delivered to the lung functional volumes. Indeed, a meta-analysis including 6 studies showed that the dose to functional volume had better predictive values than the dose to anatomical volume, including V20, V5 and MLD [p = 0.01). However, the PTV coverage was respected with similar ITV coverage between the 2 treatment plans.Our study has several limitations. Firstly, we only assessed the feasibility of personalizing radiation planning to lung functional mapping using  and MLD , but all and MLD . Thirdly68Ga-perfusion PET/CT in the lung SBRT planning process in preserving functional lung volumes while respecting target volume coverage and doses to other OARs.This is the first study to evaluate and demonstrate the benefits of


Frailty is a condition marked by accumulation of biological deficits and dysfunctions that come with aging and it is correlated with high morbidity and mortality in patients with cardiovascular diseases, particularly hypertension. Hypertension continues to be a leading cause of cardiovascular diseases and premature death globally. However, there is dearth of literature in sub‐Saharan Africa on frailty syndrome among hypertensives on medication. This study evaluated frailty syndrome and its associated factors among Ghanaian hypertensives.p‐value of < 0.05 and 95% confidence interval (CI) were considered statistically significant.This cross‐sectional study recruited 303 patients with hypertension from the University Hospital, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana. Data on sociodemographic, lifestyle and clinical factors were collected using a well‐structured questionnaire. Medication adherence was measured using Adherence in Chronic Disease Scale, and frailty was assessed by Tilburg Frailty Indicator. Statistical analyses were performed using SPSS Version 26.0 and GraphPad prism 8.0. p < 0.0001), unmarried , having confirmed hypertension complications , medium  and low antihypertensive drug adherence  were independent predictors of increased odds of developing frailty syndrome.The prevalence of frailty was 59.7%. The proportion of high, medium and low medication adherence was 23.4%, 64.4% and 12.2%, respectively. Being ≥ 70years (adjusted odds ratio [aOR]: 8.33, 95% CI [3.72–18.67], Approximately 6 out of 10 Ghanaian adult patients with hypertension experience frailty syndrome. Hypertension complications, older age, being unmarried, and low antihypertensive drug adherence increased the chances of developing frailty syndrome. These should be considered in intervention programmes to prevent frailty among patients with hypertension. It is one of the most common conditions among the general population, contributing negatively to worldwide health and financial issues.Patients' adherence to antihypertensives is crucial to achieve their effects of reduction in stroke incidence, prevention of heart failure exacerbation and low risk of mortality.Frailty is a syndrome marked by the aggregation of biological deficiencies and dysfunctions resulting from ageing and disrupts the organism's homeostatic balance.Frailty syndrome in older individuals has received a lot of attention lately. It is estimated 15%–20% of people over 60% and 30% of patients over 80 are affected by frailty syndrome.22.1This study was a cross‐sectional study design. The study sought to determine the prevalence and factors associated with frailty syndrome among patients with hypertension from Janury 2022 to September 2022.2.2The study was conducted at the University Hospital, Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi, Ghana. Kumasi is the regional capital of the Ashanti Region of Ghana, with an estimated population of 200,000 Figure . The hos2.3The study population included adult patients (40 years and above) with clinically diagnosed hypertension in the outpatient department (OPD) at the University Hospital, KNUST, Kumasi.2.4The sample size was estimated using the Cochran formula;n=Z2p(1−p)e2; where: Z is the standard normal variate at a confidence interval (CI) of 95% = 1.96, p is the estimated prevalence of hypertension (16.6%) in Ashanti region,e is the margin of error (0.05).The minimum number of participants required was 213. However, we enrolled 303 participants into the study to increase the statistical power.2.5The study enrolled clinically diangosed hypertensives aged 40 years and above, who were on at least one antihypertension medication. Patients below the age of 40 years, patients with no history of hypertension, and patients who had not been treated with any antihypertensive drug or with cognitive impairments were excluded from the study.2.6Ethical approval was sought from the Committee on Human Research, Publication and Ethics, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology (CHRPE/SMS/KNUST/CHRPE/AP/421/22). We sought the voluntary participation of individuals and obtained written informed consent from each participant.2.7α.We used a well‐structured questionnaire to collect sociodemographic, lifestyle, and clinical data from participants. In addition, standardized instruments, which included Adherence in Chronic Disease Scale (ACDS)2.8To assess study participants' compliance with medication adherence, we employed the ACDS. The underlying assumption of ACDS is that in pharmacology, only great adherence is indicative of an effective therapeutic plan. There were seven questions on the scale, and each had five options. Questions 1–5 dealt with behaviors that directly influence adherence, whereas questions 6–7 dealt with circumstances and viewpoints that do the same. The ACDS score ranges from 0 to 28 points. Higher results mean higher adherence. Thus, above 26 points indicated good adherence, between 21 and 26 points indicated medium adherence, and below 21 points indicated low adherence.2.9The TFI was created by Gobbens et al.2.10α.The questionnaire was designed based on validated questions from previous studies. Before the study commenced, the questionnaire was pre‐tested in different hypertensive populations at the Suntreso Hospital in Kumasi, and all misleading and ambiguous questions were corrected. Moreover, the internal consistency for the reliability of the ACDS and TFI questionnaire was computed using Cronbach's 2.11www.graphpad.com). Categorical variables were presented as frequencies and percentages. Univariate and multivariate logistic regression prediction models were employed to predict the association between study variables and frailty syndrome using frailty syndrome as the dependent variable. A p‐value of < 0.05 and a 95% CI were considered statistically significant.Data obtained from participants were coded into Microsoft Excel 2019 and analyzed using Statistical Package for Social Sciences (SPSS) Version 26.0 and GraphPad prism version 8.0  were 70 years and above, and most (57.8%) of them were females. Over two‐third 71.6%) of the study participants were married. Considering educational level, 35.3% had primary education, with 50.5% having secondary to tertiary education (Table .6% of th3.2The majority (61.1%) of the study participants were taking other medications besides the antihypertensives. Over two‐thirds 78.2%) of the study participants had no confirmed hypertension complications. Most of the participants (61.4%) answered yes to the presence of other medical conditions. A good majority of the study participants had diabetes in addition to hypertension (59.1%). They formed 96.2% (179 of 186) of those with other known medical. Approximately half (50.8%) of the study participants visited the hospital every 3 months, with 63.0% not engaging in physical exercise. For those who engaged in physical exercise, 59.8% exercised occasionally, followed by weekly (27.7%), whilst few (12.5%) engaged in daily exercises. Regarding the timing of meals and snack intake,63.7% of the participants did not take snacks in between meals, and 64.4% took meals late at night (Table % of the 3.3The majority (64.4%) of the study participants had medium adherence to their antihypertensive drugs, followed by high adherence (23.4%), and 12.2% had low adherence Figure . On the 3.4p < 0.0001) had higher odds of experiencing frailty. Also, those unmarried  and participants who had a family history of hypertension , p = 0.0050) had higher odds of frailty. However, gender, educational level, occupation, ethnicity, and religion, all had p > 0.05, and these were excluded from the multivariate logistic regression model analyses.In a univariate logistic regression model, compared to participants within 40–49 years, those who were 70 years and above  and being unmarried  were independently associated with increased odds of developing frailty syndrome , having confirmed hypertension complications , p < 0.0001), having other medical conditions , history of diabetes  and having both hypertension and diabetes  were associated with increased odds of developing frailty syndrome. However, engaging in exercises , taking snacks in between meals  and not regularly taking meals late at night  were respectively associated with 31%, 48%, and 42% lower chances of developing frailty syndrome.In a univariate logistic regression model, taking any medication apart from the antihypertensives , p = 0.0080) was independently increased the odds of developing frailty syndrome  and low antihypertensive adherence  were associated with higher odds of having frailty syndrome compared to high adherence  and low antihypertensive drug adherence  independently increased odds of developing frailty syndrome compared to high adherence  have been explained.


Background: The endovascular treatment of symptomatic benign prostate hypertrophy (BPH) by prostatic artery embolization (PAE) is one of the new treatments proposed. PAE is a minimally invasive alternative that has been shown to successfully treat lower urinary tract symptoms in BPH patients by causing infarction and necrosis of hyperplastic adenomatous tissue, which decompresses urethral impingement and improves obstructive symptoms. The aim of this study was to evaluate the effectiveness and efficacy of PAE in relieving symptoms in patients with symptomatic BPH. Materials and Methods: The material for the study was collected from 2019 to 2022. A total of 70 men with BPH and PAE were studied. Patients underwent an urological examination to measure the International Prostate Symptom Score (IPSS), Quality of Life score (QoL), International Index of Erectile Function short form (IIEF-5), uroflowmetry with Qmax, prostatic volume (PV), and post-void residual volume (PVR) measurements. Statistical analysis for dependent samples was applied. Measured parameters at 2 months and 6 months follow-up were compared to baseline. Results: At baseline, the age of the male (N = 70) subjects was 74 ± 9.6 years with a median of 73.8, but fluctuated from 53 to 90 years. The mean of PV was almost 111 mL and the Qmax was close to 7.7 mL/s. The average PVR was 107.6 mL. The IPSS score mean was 21.3 points and the QoL score was 4.53 points. The IIEF-5 questionnaire score was almost 1.8 points, which shows severe erectile dysfunction. The mean value of the PSA level was 5.8 ng/mL. After 2 and 6 months of PAE, all indicators and scores except erectile function significantly improved. Conclusions: The outcomes of our study show promising results for patients with benign prostatic hyperplasia after PAE. The main prostate-related parameters  improved significantly 6 months after embolization. Benign prostatic hyperplasia (BPH) is common in men, ranging from 50% in 50-year-olds to 90% in 90-year-olds. Benign prostatic hyperplasia is frequently associated with troublesome lower urinary tract symptoms (LUTS). For decades now, transurethral resection of the prostate (TURP) has been the gold standard surgical intervention for LUTS associated with BPH . BPH presents with lower urinary tract symptoms, mainly obstructive symptoms such as weak urine stream, incomplete bladder emptying, and frequent urinating at night ,3. To elWhen surgical management is necessary, there are three general types to choose from: transurethral surgery, simple prostatectomy, and minimally invasive surgical therapies . PatientSurgical treatment using TURP is the gold standard for the treatment of BPH. The patient’s age, baseline prostate volume, degree of obstruction, international prostate symptom score, peak urine flow rate, serum prostate-specific antigen level, and residual urine volume are important prognostic markers ,9. DespiOne of the new treatments proposed was the endovascular treatment of symptomatic BPH by prostatic artery embolization (PAE). Currently, PAE is a minimally invasive alternative that has been shown to successfully treat LUTS in BPH patients by causing infarction and necrosis of hyperplastic adenomatous tissue, which decompresses urethral impingement and improves obstructive symptoms . This trThe aim of this study was to evaluate the effectiveness and efficacy of PAE in relieving symptoms in patients with symptomatic benign prostatic hyperplasia.The material for the study was collected from 2019 to 2022. A total of 70 men with BPH and PAE were studied. Due to the fact that not all patients with LUTS are suitable for PAE, inclusion and exclusion criteria were defined. Inclusion criteria were male patients older than 50 years with moderate to severe LUTS , who were refractory to pharmacotherapy  for at least 6 months, and whose prostatic volume was more than 60 mL. Exclusion criteria were prostatic cancer, bladder calculi, bladder diverticula, severe coagulation disorders, sensitivity to iodine, and chronic renal failure .Patients who were suitable for PAE underwent an urological examination to measure the international prostate symptom score (IPSS) with a score range: 0–7—mildly symptomatic, 8–19—moderately symptomatic, and 20–35—severely symptomatic ,15; qualThe study design is presented in The PSA density (PSAD) value was also evaluated according to the PSAD value calculation algorithm . 2, too low; 18.5–24.9 kg/m2, normal; 25.0–29.9 kg/m2, overweight; ≥30.0 kg/m2, obese.Some chronic disease risk factors such as body mass index (BMI), harmful lifestyle factors such as smoking and alcohol consumption (No and Yes), and sexual life as erectile function (No and Yes) were also assessed. Body mass index values are as follows: <18.5 kg/mIf prostatic cancer is suspected, a pelvic MRI is performed before embolization. All patients underwent the same examination routine: before the PAE procedure and then 2 months and 6 months after the procedure. Only PSA levels were measured after 6 months.This research was approved by the Kaunas Regional Biomedical Research Ethics Committee  (approved on 8 October 2018) and was performed in accordance with the Declaration of Helsinki. Informed consent was obtained from all patients for this study and all patients agreed in written form to participate in the study.An enrolled patient was usually admitted to the hospital on the morning of the day of the embolization procedure. A 16 F indwelling catheter was inserted into the bladder. The balloon of the indwelling catheter was filled with a 50/50 contrast medium and saline mix. We used this technique to see where the neck of the bladder is and to better visualize the prostatic gland. Before being transported to the interventional radiology suite, the patient was administered non-steroid anti-inflammatory drugs to manage the pain during the embolization  and was advised to take it the following days after the procedure if necessary. No antibiotics were used. PAE procedure was performed using GE Innova 4100 system. A nonionic contrast medium was used (Visipaque 320 mg/mL). Intervention was performed under local anesthesia (Procaine 1% 5 mL) using right femoral access. A 5 F vascular sheath was introduced to the common femoral artery. A 5 F flush catheter (pigtail type) was placed in the distal aorta and initial pelvic angiography was performed  with a power injector  to evaluate the anatomy of the internal iliac arteries and their branches. A 5 F Cobra-shaped catheter was used to perform the selective angiography of the anterior division of the left internal iliac artery  to better visualize the origin of the left prostatic artery, which was then super selectively catheterized with 1.9 F microcatheter. The tip of the microcatheter was placed as distally into the prostatic artery as safely possible, trying to avoid vasospasm from the catheter or guiding wire. If any arterial collaterals to surrounding organs were suspected, a rotational cone-beam CT angiography was performed, and, if confirmed, those arteries were embolized with microcoils to prevent non-target embolization. A two-syringe system with spherical 400 µm in size embolization particles was prepared. Using a 2 mL syringe, the embolization material was slowly injected under fluoroscopy guidance. The endpoint of embolization was near stasis in the prostatic artery . A rightPost-PAE patients remained in the hospital till the next day and had their indwelling catheters left during this period to prevent acute urinary retention caused by post-procedural prostate tissue swelling. Appropriate hydration and pain management (if needed) were administered. Minor post-procedural complications such as injection site hematoma, reaction to contrast material, dysuria, pain after the procedure, urinary tract infection, hematuria, hematospermia, and acute urinary retention, and major complications such as non-targeted embolization , vessel rupture due to catheterization, and radiodermatitis were also evaluated .The PAE procedure is considered technically successful if at least one side of the prostatic gland is embolized. Unilateral embolization can be an endpoint of the procedure if the branches of pelvic arteries are very tortuous and it is technically difficult and almost impossible to selectively catheterize them. Another reason for unilateral embolization is advanced atherosclerosis—one of the prostatic arteries can be occluded and the ipsilateral side of the prostatic gland obtains the blood supply from the collaterals. Based on similar studies ,23,24,25p-value <0.05 was considered statistically significant.Statistical calculations were performed using SPSS v.29 software (IBM). Variables were checked for normality using the Shapiro–Wilk test. Descriptive statistics were used to evaluate the data: means, statistical deviations, median, interquartile deviation, confidence intervals, minimum and maximum values, and statistical analysis for dependent samples was also applied. Measured parameters  at 2 months and 6 months follow-up were compared to baseline using paired Wilcoxon signed-rank tests and for 3 groups these parameters were evaluated using Friedman signed-rank test. A The baseline characteristics of PAE patients are shown in When evaluating the frequencies of body mass index (BMI), it was determined that 4.5% had too low a BMI. We found that 39.4% of the examined persons were overweight, five (7.6%) were obese, and almost half (48.5%) of the subjects had a normal BMI. The vast majority (80.0%) of the examined male patients had erectile dysfunction. When assessing harmful behavioral lifestyle factors, it was found that 40.9% of the studied men smoked, but only 13.6% consumed alcoholic beverages.Technical success  was 63/70 (90.0%), and 6/63 (9.5%) of those patients who underwent unilateral embolization due to atherosclerotic damaged arteries or anatomical difficulties. In one patient (1.43%) with severe pelvic arteries tortuousness, embolization was not performed because placing a diagnostic catheter into the anterior division of the internal iliac artery on both sides was technically impossible. Five patients (7.94%) had collateral vessels coiling to prevent non-target embolization. In these patients, the collateral vessel was identified as connecting the prostatic artery to the rectal artery branches. Two patients not satisfied with the outcome of embolization had TURP performed 1 month after the PAE. Out of 63 technically successful patients, we already have 59 (93.7%) patients with 2 and 51 (81.0%) patients with 6 months of follow-up data. On both post-procedural follow-up visits, prostate volume (PV) with transrectal ultrasound, peak urinary flow (Qmax), post-void residual volume (PVR) with transabdominal ultrasound, international prostate symptom score (IPSS), quality of life score (QoL) and international index of erectile function (IIEF) were measured. Overall, 29 of 66 (25.8%) embolized patients had cystostomy catheters prior to PAE due to chronic retention. These twenty-nine patients are excluded from further statistical calculations, and their results are presented separately: 2 months (n = 20) after prostatic artery embolization, the mean Qmax velocity was 15.0 mL/s, PVR was 47.5 mL, and IPSS was 12.5 points, while 6 months (N = 25) after the procedure, the corresponding indicators were as follows: 18.1 mL/s, 44.2 mL, and 9.3 points. After the PAE, BPH-related LUTS and the majority of measured parameters improved statistically significantly . p < 0.0001), the Qmax significantly increased by 126.1% from the baseline with a mean of 15.0 ± 4.5 mL/s (95% PI 13.7–16.3) (p < 0.0001), the PVR significantly decreased by 45.9% from the baseline with a mean of 46.9 ± 38.2 mL (95% PI 36.1–57.8) (p < 0.0001), the IPSS score significantly decreased by 33.3% from the baseline with a mean of 12.6 ± 5.5 (95% PI 11.0–14.2) (p < 0.0001), the QoL score significantly decreased by 60.0% from the baseline with a mean of 2.6 ± 1.2 (95% PI 2.3–3.0) and the IIEF-5 score was without significant changes. After 2 months of PAE, in investigated males (N = 59), the PV significantly decreased by 30.2% from the baseline level with a mean of 77.4 ± 29.0 mL (95% PI 69.9–85.0) (p < 0.0001), the Qmax significantly increased by 171.0% from the baseline with a mean of 18.1 ± 5.3 mL/s (95% PI 16.5–19.6) (p < 0.0001), the PVR significantly decreased by 47.1% from the baseline with a mean of 464.4 ± 34.9 mL (95% PI 34.2–54.7) (p < 0.0001), the IPSS score significantly decreased by 57.1% from the baseline with a mean of 9.3 ± 4.9 (95% PI 7.8–10.7) (p < 0.0001), the QoL score significantly decreased by 60.0% from the baseline with a mean of 1.8 ± 1.3 (95% PI 1.5–2.2) and the IIEF-5 score was without significant changes. The PSA levels also significantly decreased by 28.4% six months after the PAE.After 6 months of PAE, in investigated males (N = 51), the PV significantly decreased by 39.6% from the baseline level with a mean of 65.1 ± 21.3 mL (95% PI 59.1–71.1) (p = 0.24).After performing the PSA density (PSAD) evaluation, it was found that the average value of PSAD before and after the intervention in the studied patients (N = 35) did not differ significantly and was 0.051 ± 0.042 and 0.057 ± 0.042, respectively  ,25,26,27As for future perspectives, we consider that one of the most important factors in PAE should be patient selection, especially the size of the prostatic gland. In this study, there were patients with higher volume prostates (>60 mL), when the prostatic arteries usually are more hypertrophied and easier to access. According to our early results, we observe a tendency that the bigger the prostate, the better the outcome, but more data are needed to statistically prove it. Literature data insufficiently describe the outcomes after PAE of smaller glands—this factor is also important for patients for whom surgical therapy is contraindicated because of comorbidities . Most stOne of the possible limitations of this study was the relatively small number of patients. However, even with the small number, quite significant results were obtained. As already mentioned, the volume of the prostate at the starting point is an important factor that can determine the obtained results. In this study, comorbidities were also not evaluated, which could lead to one or another evaluation of the patient’s quality of life. Some lifestyle factors  and risk factors for chronic non-infectious diseases  could also distort the research data.This study shows promising results for patients with benign prostatic hyperplasia after prostatic artery embolization. The main prostate-related parameters  improved significantly 6 months after embolization. Studies demonstrate that this technique is not only safe for the patient, with minimal complications rate, but it also has a competitive value compared to typical gold standard surgical procedures. PAE could be especially important for comorbid patients who are not suitable candidates for surgery due to high-risk mortality and complications after TURP. More studies and especially longer follow-ups are needed to analyze the longevity of LUTS improvement after prostatic artery embolization.