Clinically-driven need for secondary interventions after endovascular revascularization of tibial arteries in patients with critical limb ischemia

PURPOSE To assess the need for clinically-driven secondary revascularization in critical limb ischemia (CLI) patients subsequent to tibial angioplasty during a 2-year follow-up. METHODS Between 2008 and 2010, a total of 128 consecutive CLI patients (80 men; mean age 76.5±9.8 years) underwent tibial angioplasty in 139 limbs. Rutherford categories, ankle-brachial index measurements, and lower limb oscillometries were prospectively assessed. All patients were followed at 3, 6, 12 months, and annually thereafter. Rates of death, primary and secondary sustained clinical improvement, target lesion (TLR) and target extremity revascularization (TER), as well as major amputation, were analyzed retrospectively. Primary clinical improvement was defined as improvement in Rutherford category to a level of intermittent claudication without unplanned amputation or TLR. RESULTS All-cause mortality was 8.6%, 14.8%, 22.9%, and 29.1% at 3, 6, 12, and 24 months. At the same intervals, rates of primary sustained clinical improvement were 74.5%, 53.0%, 42.7%, and 37.1%; for secondary improvement, the rates were 89.1%, 76.0%, 68.4%, and 65.0%. Clinically-driven TLR rates were 14.6%, 29.1%, 41.6%, 46.2%; the rates for TER were 3.0%, 13.6%, 17.2%, and 27.6% in corresponding intervals, while the rates of major amputation were 1.5%, 5.5%, 10.1%, and 10.1%. CONCLUSION Clinically-driven TLR is frequently required to maintain favorable functional clinical outcomes in CLI patients following tibial angioplasty. Dedicated technologies addressing tibial arterial restenosis warrant further academic scrutiny.

Magma differentiation fractionates Mo isotope ratios: Evidence from the Kos Plateau Tuff (Aegean Arc)

We investigated high temperature Mo isotope fractionation in a hydrous supra-subduction volcano-plutonic system (Kos, Aegean Arc, Greece) in order to address the debate on the δ98/95Mo variability of the continental crust. In this igneous system, where differentiation is interpreted to be dominated by fractional crystallization, bulk rock data from olivine basalt to dacite show δ98/95Mo ratios increasing from +0.3 to +0.6‰ along with Mo concentrations increasing from 0.8 to 4.1 μg g−1. Data for hornblende and biotite mineral separates reveal the extraction of light Mo into crystallizing silicates, with minimum partition coefficients between hornblende- silicate melt and biotite-silicate melt of 0.6 and 0.4 δ98/95Mo, respectively. Our data document significant Mo isotope fractionation at magmatic temperatures, hence, the igneous contribution to continental runoff is variable, besides probable source-related variability. Based on these results and published data an average continental δ98/95Mo of +0.3 to +0.4‰ can be derived. This signature corresponds more closely to the average of published data of dissolved Mo loads of large rivers than previous estimates and is consistent with an upper limit of δ98/95Mo = 0.4‰ of the Earth's upper crust as derived from the analysis of molybdenites.

Early recoil after balloon angioplasty of tibial artery obstructions in patients with critical limb ischemia.

PURPOSE To assess the extent of early recoil in patients with critical limb ischemia (CLI) undergoing conventional tibial balloon angioplasty. METHODS Our hypothesis was that early recoil, defined as lumen compromise >10%, is frequent and accounts for considerable luminal narrowing after tibial angioplasty, promoting restenosis. To test this theory, 30 consecutive CLI patients (18 men; mean age 76.2±12.1 years) were angiographically evaluated immediately after tibial balloon angioplasty and 15 minutes later. Half the patients were diabetics. Target lesions included anterior and posterior tibial arteries and the peroneal artery with / without the tibioperoneal trunk. Mean tibial lesion length was 83.8 mm. Early elastic recoil was determined on the basis of minimal lumen diameter (MLD) measurements at baseline (MLDbaseline), immediately after tibial balloon angioplasty (MLDpostdilation), and 15 minutes thereafter (MLD15min). RESULTS Elastic recoil was observed in 29 (97%) patients with a mean luminal compromise of 29% according to MLD measurements (MLDbaseline 0.23 mm, MLD postdilation 2.0 mm, and MLD15min 1.47 mm). CONCLUSION Early recoil is frequently observed in CLI patients undergoing tibial angioplasty and may significantly contribute to restenosis. These findings support the role of dedicated mechanical scaffolding approaches for the prevention of restenosis in tibial arteries.

Response of subfossil Cladocera in Gerzensee (Swiss Plateau) to early Late Glacial environmental change

Sub-fossil Cladocera were studied in a core from Gerzensee (Swiss Plateau) for the late-glacial periods of Oldest Dryas, Bølling, and Allerød. Cladocera assemblages were dominated by cold-tolerant littoral taxa Chydorus sphaericus, Acroperus harpae, Alonella nana, Alona affinis, and Alonella excisa. The rapid warming at the beginning of the Bølling (GI-1e) ca. 14,650 yr before present (BP: before AD 1950) was indicated by an abrupt 2‰ shift in carbonate δ18O and a clear change in pollen assemblages. Cladocera assemblages, in contrast, changed more gradually. C. sphaericus and A. harpae are the most cold-tolerant, and their abundance was highest in the earliest part of the record. Only 150–200 years after the beginning of the Bølling warming we observed an increase in less cold-tolerant A. excisa and A. affinis. The establishment of Alona guttata, A. guttata var. tuberculata, and Pleuroxus unicatus was delayed by ca. 350, 770, and 800 years respectively after the onset of the Bølling. The development of the Cladocera assemblages suggests increasing water temperatures during the Bølling/Allerød, which agrees with the interpretation by von Grafenstein et al. (2013-this issue) that decreasing δ18O values in carbonates in this period reflect increasing summer water temperatures at the sediment–water interface. Other processes also affected the Cladocera community, including the development and diversification of aquatic vegetation favourable for Cladocera. The record is clearly dominated by Chydoridae, as expected for a littoral core. Yet, the planktonic Eubosmina-group occurred throughout the core, with the exception of a period at ca. 13,760–13,420 yr BP. Lake levels reconstructed for this period are relatively low, indicating that the littoral location might have become too shallow for Eubosmina in that period.

Translocal Practices on the Tibetan Plateau: Motorised Mobility of Pastoralists and Spatial Transformations

Tibetan pastoralist communities in Amdo, the north-eastern region of the Tibetan plateau, have undergone tremendous change due to a number of state induced modernisation processes. Road infrastructure is but one development that aims to facilitate transition from subsistence to a market economy and to link remote pastoralist production into the global or regional market. This paper starts from the local perspective and examines how the expansion of road infrastructure and increased ownership of motorised vehicles has impacted on the mobility of pastoralists. It argues that motorisation and the increased availability of roads creates an interface for pastoralists through which they negotiate a newly emerging translocality. Roads are embedded into everyday movements and provide pastoralists with ways to integrate new developments into their lives.

Comparison of theoretical fixation stability of three devices employed in medial opening wedge high tibial osteotomy: a finite element analysis.

BACKGROUND Medial open wedge high tibial osteotomy is a well-established procedure for the treatment of unicompartmental osteoarthritis and symptomatic varus malalignment. We hypothesized that different fixation devices generate different fixation stability profiles for the various wedge sizes in a finite element (FE) analysis. METHODS Four types of fixation were compared: 1) first and 2) second generation Puddu plates, and 3) TomoFix plate with and 4) without bone graft. Cortical and cancellous bone was modelled and five different opening wedge sizes were studied for each model. Outcome measures included: 1) stresses in bone, 2) relative displacement of the proximal and distal tibial fragments, 3) stresses in the plates, 4) stresses on the upper and lower screw surfaces in the screw channels. RESULTS The highest load for all fixation types occurred in the plate axis. For the vast majority of the wedge sizes and fixation types the shear stress (von Mises stress) was dominating in the bone independent of fixation type. The relative displacements of the tibial fragments were low (in μm range). With an increasing wedge size this displacement tended to increase for both Puddu plates and the TomoFix plate with bone graft. For the TomoFix plate without bone graft a rather opposite trend was observed.For all fixation types the occurring stresses at the screw-bone contact areas pulled at the screws and exceeded the allowable threshold of 1.2 MPa for at least one screw surface. Of the six screw surfaces that were studied, the TomoFix plate with bone graft showed a stress excess of one out of twelve and without bone graft, five out of twelve. With the Puddu plates, an excess stress occurred in the majority of screw surfaces. CONCLUSIONS The different fixation devices generate different fixation stability profiles for different opening wedge sizes. Based on the computational simulations, none of the studied osteosynthesis fixation types warranted an intransigent full weight bearing per se. The highest fixation stability was observed for the TomoFix plates and the lowest for the first generation Puddu plate. These findings were revealed in theoretical models and need to be validated in controlled clinical settings.

Complete rupture of the popliteal artery complicating high tibial osteotomy.

We present two cases of high tibial osteotomies performed at our institution. Both cases were complicated with the immediate postoperative occurrence of an ischaemic syndrome of the lower leg. Urgent diagnostics revealed a complete rupture of the popliteal artery that required re-operation and a vascular repair. Although neurovascular complications during high tibial osteotomies are rare the awareness of this potentially catastrophic complication should be present when performing this common procedure. All precautions to minimize the harm to the neurovascular bundle should be put into practice. A summary of the surgical precautions is presented and discussed in this paper.

Social networks, mobility, and exchange systems during the Neolithic and Bronze Age of the Swiss Plateau

Excavations of Neolithic (4000 – 3500 BC) and Late Bronze Age (1200 – 800 BC) wetland sites on the northern Alpine periphery have produced astonishing and detailed information about the life and human environment of prehistoric societies. It is even possible to reconstruct settlement histories and settlement dynamics, which suggest a high degree of mobility during the Neolithic. Archaeological finds—such as pottery—show local typological developments in addition to foreign influences. Furthermore, exogenous lithic forms indicate far reaching interaction. Many hundreds of bronze artefacts are recorded from the Late Bronze Age settlements, demonstrating that some wetland sites were centres of bronzework production. Exogenous forms of bronzework are relatively rare in the wetland settlements during the Late Bronze Age. However, the products produced in the lake-settlements can be found widely across central Europe, indicating their continued involvement in interregional exchange partnerships. Potential motivations and dynamics of the relationships between sites and other regions of Europe will be detailed using case studies focussing on the settlements Seedorf Lobsigensee (BE), Concise (VD), and Sutz-Lattrigen Hauptstation innen (BE), and an initial assessment of intra-site connectivity through Network Analysis of sites within the region of Lake Neuchâtel, Lake Biel, and Lake Murten.

Mobilities, Entanglements and Transformations in Neolithic societies on the Swiss Plateau (3900-3500 BC)

The material culture of Neolithic settlements – especially pottery – was often taken as key argument to distinguish „Neolithic cultures“ like Cortaillod, Pfyn, Michelsberg, Munzingen, NMB, Altheim. „Foreign influences“ in these pottery styles point to complex entanglements between social groups and highly mobile people, bluring the supposed cultural boundaries. The two PhD-projects aim at a critical revision of former notions of „culture“ by focussion on similarities and differences in pottery practecies of dedrodated key sites on the Swiss Plateau (3900 -3500 BC).

Quaternary uplift rates of the Central Anatolian Plateau, Turkey: insights from cosmogenic isochron-burial nuclide dating of the Kızılırmak River terraces

The Central Anatolian Plateau (CAP) in Turkey is a relatively small plateau (300 × 400 km) with moderate average elevations of ∼1 km situated between the Pontide and Tauride orogenic mountain belts. Kızılırmak, which is the longest river (1355 km) within the borders of Turkey, flows within the CAP and slowly incises into lacustrine and volcaniclastic units before finally reaching the Black Sea. We dated the Cappadocia section of the Kızılırmak terraces in the CAP by using cosmogenic burial and isochron-burial dating methods with 10Be and 26Al as their absolute dating can provide insight into long-term incision rates, uplift and climatic changes. Terraces at 13, 20, 75 and 100 m above the current river indicate an average incision rate of 0.051 ± 0.01 mm/yr (51 ± 1 m/Ma) since ∼1.9 Ma. Using the base of a basalt fill above the modern course of the Kızılırmak, we also calculated 0.05–0.06 mm/yr mean incision and hence rock uplift rate for the last 2 Ma. Although this rate might be underestimated due to normal faulting along the valley sides, it perfectly matches our results obtained from the Kızılırmak terraces. Although up to 5–10 times slower, the Quaternary uplift of the CAP is closely related to the uplift of the northern and southern plateau margins respectively.

Late Glacial and Holocene vegetational changes on the Ulagan high-mountain plateau, Altai Mountains, southern Siberia

Three well-dated pollen diagrams from 1985 m, 2050 m, and at the tree line at 2150 m asl show the vegetational succession in the central Altai Mountains since 16 cal ka BP. Pioneer vegetation after deglaciation was recorded first at the lowest site. Subsequently, dense dry steppe vegetation developed coincident with the change from silt to organic sediments at the two lower sites, but silt lasted longer at the highest site, indicating the persistence of bare ground there. Forests of Pinus sibirica, Pinus sylvestris, Picea obovata, Larix sibirica, Abies sibirica, and Betula pendula started to develop about 12 cal ka BP with the change to a warmer and wetter climate at the beginning of the Holocene. Results indicate that the timberline did not rise above the highest site. Mesophilous dark-coniferous forests were fully developed by 9.5 cal ka BP. The role of Abies and Picea decreased by about 7.5 cal ka BP suggesting cooler climate, after which the forests changed little until today. The vegetational development in this portion of the central Altai Mountains is compatible with that described in neighbouring areas of the Altai, southern Siberia, Mongolia, and Kazakhstan.

Non-surgical treatment of pain associated with posterior tibial tendon dysfunction: study protocol for a randomised clinical trial

BACKGROUND Symptoms associated with pes planovalgus or flatfeet occur frequently, even though some people with a flatfoot deformity remain asymptomatic. Pes planovalgus is proposed to be associated with foot/ankle pain and poor function. Concurrently, the multifactorial weakness of the tibialis posterior muscle and its tendon can lead to a flattening of the longitudinal arch of the foot. Those affected can experience functional impairment and pain. Less severe cases at an early stage are eligible for non-surgical treatment and foot orthoses are considered to be the first line approach. Furthermore, strengthening of arch and ankle stabilising muscles are thought to contribute to active compensation of the deformity leading to stress relief of soft tissue structures. There is only limited evidence concerning the numerous therapy approaches, and so far, no data are available showing functional benefits that accompany these interventions. METHODS After clinical diagnosis and clarification of inclusion criteria (e.g., age 40-70, current complaint of foot and ankle pain more than three months, posterior tibial tendon dysfunction stage I & II, longitudinal arch flattening verified by radiography), sixty participants with posterior tibial tendon dysfunction associated complaints will be included in the study and will be randomly assigned to one of three different intervention groups: (i) foot orthoses only (FOO), (ii) foot orthoses and eccentric exercise (FOE), or (iii) sham foot orthoses only (FOS). Participants in the FOO and FOE groups will be allocated individualised foot orthoses, the latter combined with eccentric exercise for ankle stabilisation and strengthening of the tibialis posterior muscle. Participants in the FOS group will be allocated sham foot orthoses only. During the intervention period of 12 weeks, all participants will be encouraged to follow an educational program for dosed foot load management (e.g., to stop activity if they experience increasing pain). Functional impairment will be evaluated pre- and post-intervention by the Foot Function Index. Further outcome measures include the Pain Disability Index, Visual Analogue Scale for pain, SF-12, kinematic data from 3D-movement analysis and neuromuscular activity during level and downstairs walking. Measuring outcomes pre- and post-intervention will allow the calculation of intervention effects by 3×3 Analysis of Variance (ANOVA) with repeated measures. DISCUSSION The purpose of this randomised trial is to evaluate the therapeutic benefit of three different non-surgical treatment regimens in participants with posterior tibial tendon dysfunction and accompanying pes planovalgus. Furthermore, the analysis of changes in gait mechanics and neuromuscular control will contribute to an enhanced understanding of functional changes and eventually optimise conservative management strategies for these patients. TRIAL REGISTRATION ClinicalTrials.gov Protocol Registration System: ClinicalTrials.gov ID NCT01839669.

Synchronous Holocene climatic oscillations recorded on the Swiss Plateau and at timberline in the Alps

Eight synchronous pre-Roman cold phases were found at 9600–9200, 8600–8150, 7550–6900, 6600– 6200, 5350–4900, 4600–4400, 3500–3200 and 2600–2350 radiocarbon years BP by reconstructing past climate at two sites on the Swiss Plateau and at timberline in the Alps. The cooling events during the early-and mid-Holocene represent temperature values similar to today, and apparently the onset of cooling events represents a deviation from today's mean annual temperature of about 1°C and is triggered at a 1000-year periodicity. At Wallisellen-Langachermoos (440 m), a former oligotrophic lake near Zürich, the correlation between sum mertime lake levels and the seed production of the amphi-Atlantic aquatic plantNajas flexilis was used to reconstruct lake levels over a 3000-year period during the first part of the Holocene. At Lake Seedorf on the western Swiss Plateau (609 m) the sedimentological, palynological and macrofossil record revealed fluctuations of lake levels for the complete Holocene. From Lago Basso in the southern Alps (2250 m, Val San Giacomo near Splügen Pass, Northern Italy) the terrestrial plant macrofossils – especiallyPinus cembra andLarix – allowed the reconstruction of timberline fluctuations controlled by climate. A similar climatic pattern was found at Gouillé Rion pond in the central Swiss Alps (2343 m, Val d'Hérémence) with plant macrofossils and pollen concentrations and percentages. We postulate that these climatic events are detectable throughout central Europe by independent methods in combination with precise AMS-radiocarbon datings on terrestrial plant remains. Our data fit other proxy records of regional climatic change, such as cool intervals from Greenland ice cores, glacier movements in the Swiss and Austrian Alps, and dendro-densitometry on subfossil wood, as well as the palaeoclimatic data from the Jura Mountains of France obtained by sedimentological analyses. Thus our data indicate that the Northern Hemisphere climate was less stable during the Holocene than previously believed.