Search results for: bypass graft

Authors: Nicholas Bayfield, Liam Bibo, Charley Budgeon, Robert Larbalestier, Tom Briffa

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Introduction: Stress hyperglycaemia is common following cardiac surgery. Its optimal management is uncertain and may differ by diabetic status. This study assesses the in-hospital glycaemic management of cardiac surgery patients and associated postoperative outcomes. Methods: A retrospective cohort analysis of all patients undergoing cardiac surgery at Fiona Stanley Hospital from February 2015 to May 2019 was undertaken. Management and outcomes of hyperglycaemia following cardiac surgery were assessed. Follow-up was assessed to 1 year postoperatively. Multivariate regression modelling was utilised. Results: 1050 non-diabetic patients and 689 diabetic patients were included. In the non-diabetic cohort, patients with mild (peak blood sugar level [BSL] < 14.3), transient stress hyperglycaemia managed without insulin were not at an increased risk of wound-related morbidity (P=0.899) or mortality at 1 year (P=0.483). Insulin management was associated with wound-related readmission to hospital (P=0.004) and superficial sternal wound infection (P=0.047). Prolonged or severe stress hyperglycaemia was predictive of hospital re-admission (P=0.050) but not morbidity or mortality (P=0.546). Diabetes mellitus was an independent risk factor 1-year mortality (OR; 1.972 [1.041–3.736], P=0.037), graft harvest site wound infection (OR; 1.810 [1.134–2.889], P=0.013) and wound-related readmission (OR; 1.866 [1.076–3.236], P=0.026). In diabetics, postoperative peak BSL > 13.9mmol/L was predictive of graft harvest site infections (OR; 3.528 [1.724-7.217], P=0.001) and wound-related readmission OR; 3.462 [1.540-7.783], P=0.003) regardless of modality of management. A peak BSL of 10.0-13.9 did not increase the risk of morbidity/mortality compared to a peak BSL of < 10.0 (P=0.557). Diabetics with a peak BSL of 13.9 or less did not have significantly increased morbidity/mortality outcomes compared to non-diabetics (P=0.418). Conclusion: In non-diabetic patients, transient mild stress hyperglycaemia following cardiac surgery does not uniformly require treatment. In diabetic patients, postoperative hyperglycaemia with peak BSL exceeding 13.9mmol/L was associated with wound-related morbidity and hospital readmission following cardiac surgery.

Keywords: cardiac surgery, pulmonary embolism, pulmonary embolectomy, cardiopulmonary bypass

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Authors: Hakan Duger, Alparslan Ersoy, Canan Ersoy

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Diabetes mellitus is the most common etiology of end-stage renal disease (ESRD). Also, diabetic nephropathy is the etiology of ESRD in approximately 23% of kidney transplant recipients. A successful kidney transplant improves the quality of life and reduces the mortality risk for most patients. However, patients require close follow-up after transplantation due to medical complications. Diabetes mellitus can affect patient morbidity and mortality due to possible effects of immunosuppressive therapy on glucose metabolism. We compared the frequency of medical complications and the outcomes in diabetic and non-diabetic kidney transplant recipients. Materials and Methods: This retrospective study conducted in 498 patients who underwent kidney transplant surgery at our center in 10-year periods. The patients were divided into two groups: diabetics (46 ± 10 year, 26 males, 16 females) and non-diabetics (39 ± 12 year, 259 males, 197 females). The medical complications, graft functions, causes of graft loss and death were obtained from medical records. Results: There was no significant difference between recipient age, duration of dialysis, body mass index, gender, donor type, donor age, dialysis type, histories of HBV, HCV and coronary artery disease between two groups. The history of hypertension in diabetics was higher (69% vs. 36%, p < 0.001). The ratios of hypertension (50.1% vs. 57.1%), pneumonia (21.9% vs. 20%), urinary infection (16.9% vs. 20%), transaminase elevation (11.5% vs. 20%), hyperpotasemia (14.7% vs. 17.1%), hyponatremia (9.7% vs. 20%), hypotension (7.1% vs. 7.9%), hypocalcemia (1.4% vs. 0%), thrombocytopenia (8.6% vs. 8.6%), hypoglycemia (0.7% vs. 0%) and neutropenia (1.8% vs. 0%) were comparable in non-diabetic and diabetic groups, respectively. The frequency of hyperglycaemia in diabetics was higher (8.6% vs. 54.3%, p < 0.001). After transplantation, primary non-function (3.4% vs. 2.6%), delayed graft function (25.1% vs. 34.2%) and acute rejection (7.3% vs. 10.5%) ratios of in non-diabetic and diabetic groups were similar, respectively. Hospitalization durations in non-diabetics and diabetics were 22.5 ± 17.5 and 18.7 ± 13 day (p=0.094). Mean serum creatinine levels in non-diabetics and diabetics were 1.54 ± 0.74 and 1.52 ± 0.62 mg/dL at 6th month. Forty patients had graft loss. The ratios of graft loss and death in non-diabetic and diabetic groups were 8.2% vs. 7.1% and 7.1% vs. 2.6% (p > 0.05). There was no significant relationship between graft and patient survivals with the development of medical complication. Conclusion: As a result, medical complications are common in the early period. Hyperglycaemia was frequently seen following transplantation due to the effects of immunosuppressant regimens. However, the frequency of other medical complications in diabetic patients did not differ from non-diabetic one. The most important cause of death is still infections. The development of medical complications during the first 6 months did not significantly affect transplant outcomes.

Keywords: kidney transplantation, diabetes mellitus, complication, graft function

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Authors: Hami Ashraf, Farid Kosari

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Graft-versus-host disease (GvHD) is a common complication of allogeneic hematopoietic stem cell transplantation that can lead to significant morbidity and mortality. Histopathological examination of affected tissues is an essential tool for diagnosing and grading GvHD in animal models, which are used to study disease mechanisms and evaluate new therapies. In this systematic review, we identified and analyzed original research articles in PubMed, Scopus, Web of Science, and Google Scholar that described grading systems for GvHD in animal models based on histopathological features. We found that several grading systems have been developed, which vary in the tissues and criteria they assess, the severity scoring scales they use, and the level of detail they provide. Skin, liver, and gut are the most commonly evaluated tissues, but lung and thymus are also included in some systems. Our analysis highlights the need for standardized criteria and consistent use of grading systems to enable comparisons between studies and facilitate the translation of preclinical findings to clinical practice.

Keywords: graft-versus-host disease, GvHD, animal model, histopathology, grading system

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Authors: Komal Vig, Syamala Soumyakrishnan, Yadav Baral

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Bypass surgery, using the autologous vein has been one of the most effective treatments for cardiovascular diseases (CVD). More recently tissue engineering including engineered vascular grafts to synthesize blood vessels is gaining usage. Dacron and ePTFE has been employed for vascular grafts, however, these does not work well for small diameter grafts (<6 mm) due to intimal hyperplasia and thrombosis. In the present study PTFE was treated with LTP to improve the endothelialization of intimal surface of graft. Scaffolds were also modified with polyvinylpyrrolidone coated silver nanoparticles (Ag-PVP) and the antimicrobial peptides, p753 and p359. Human umbilical vein endothelial cells (HUVEC) were plated on the developed scaffolds and cell proliferation was determined by the MTT assay. Cells attachment on scaffolds was visualized by microscopy. mRNA expressions levels of different cell markers were investigated using quantitative real-time PCR (qPCR). X ray photoelectron spectroscopic confirmed the introduction of oxygenated functionalities from LTP air plasma. Microscopic and MTT assays indicated increase in cell viability in LTP treated scaffolds. Gene expression studies shows enhanced expression of cell adhesion marker Integrin- α 5 gene after LTP treatment. The KB test displayed a zone of inhibition for Ag-PVP, p753 and p359 of 19mm, 14mm, and 12mm respectively. To determine toxicity of antimicrobial agents to cells, MTT Assay was performed using HEK293 cells. MTT Assay exhibited that Ag-PVP and the peptides were non-toxic to cells at 100μg/mL and 50μg/mL, respectively. Live/dead analysis and plate count of treated bacteria exhibited bacterial inhibition on develop scaffold compared to non-treated scaffold. SEM was performed to analyze the structural changes of bacteria after treatment with antimicrobial agents. Gene expression studies were conducted on RNA from bacteria treated with Ag-PVP and peptides using qRT-PCR. Based on our initial results, more scaffolds alternatives will be developed and investigated for cell growth and vascularization studies.

Keywords: low temperature plasma, vascular graft, HUVEC cells, antimicrobial

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Authors: Fakhreia A. Al Sagheer, Enas I. Ibrahim, Khaled D. Khalil

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N-Acryloyl morpholine, NAM, was grafted onto chitosan utilizing homogeneous conditions with 1% acetic acid as the solvent, and potassium persulfate and sodium sulfite as the redox initiator. The effects of various reaction parameters, such as time, temperature, and monomer and initiator concentrations, on the percentage of grafting (G%) and the grafting efficiency (E%) were determined. The graft copolymer showed a remarkably improved crystallinity, as compared to the unmodified chitosan, based on the FESEM, XRD, and DSC results. Chitosan-g-poly(N-acryloyl morpholine) (Cs-PNAM), the copolymer obtained by using this procedure, was characterized by utilizing FTIR, FESEM, TGA, and XRD analysis. As expected, the results of an evaluation of antibacterial and antifungal activities show that the grafted chitosan copolymers exhibit stronger inhibitory effects against both types of microbes than does chitosan. Moreover, the size of the inhibition zone created by the graft copolymer was observed to be proportional to its G% corresponding to its morpholine content. Fortunately, the graft copolymer showed a marked growth inhibition against candidiasis (C.Albicans and C.Kefyr). We conclude that the graft copolymer may be highly effective in the prevention and treatment of candidiasis. In addition, the extent and pH dependence of uptake of different types of dyes (acidic: EBT, and MV; and basic: MB) by grafted chitosan in pH 6.5 aqueous solutions was determined. The results show that, the grafted copolymer exhibited a greater affinity to absorb the acid dyes more than the basic ones especially at relatively low temperature. Thus the modified chitosan can be used, in wastewater treatment, as efficient economic absorbent especially for anionic dyes from the industrial processing effluents.

Keywords: chitosan, N-Acryloyl morpholine, homogeneous grafting, antimicrobial activity, dye uptake

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Authors: Tugba Tosun, Mert Tosun

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Cooling system performance and energy consumption in the bypass two-circuit cycle have been studied experimentally to find optimum evaporator type and geometry, capillary tube diameter and capillary length. Two types of evaporators, such as wire on the tube and finned tube evaporators were used for the experiments in the fresh food compartment. As capillary tube inner diameter and total length; 0.66 mm and 0.8mm, and 3000 mm and 3500 mm were selected as parameters, respectively. Experiments were performed at the 25⁰C ambient temperature while the average temperature of the fresh food compartment is kept at 5⁰C and the highest package temperature of the freezer compartment is kept at -18⁰C, which are defined in IEC 62552 European standard. The Design of Experiments (DOE) technique which is six sigma method has been used to indicate of effective parameters in the bypass two-circuit cycle. The experimental results revealed that the most effective parameter of the system is the evaporator type. Finned tube evaporator with 12 tube passes was found as the best option for the bypass two-circuit refrigeration cycle among the 8 different opportunities. The optimum cooling performance and the lowest energy consumption were provided with 0.66 mm capillary tube inner diameter and 3500 mm capillary tube length.

Keywords: capillary tube, energy consumption, heat exchanger, refrigerator, separate cooling circuits

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Authors: Takaaki Nemoto

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Case presentation: A 69-year-old Japanese man presented with a low-grade fever and fatigue that had persisted for one month. The patient had an aortic dissection on the aortic arch 13 years prior, an abdominal aortic aneurysm seven years prior, and an aortic dissection on the distal aortic arch one year prior, which were all treated with artificial blood-vessel replacement surgery. Laboratory tests revealed an inflammatory response (CRP 7.61 mg/dl), high serum creatinine (Cr 1.4 mg/dL), and elevated transaminase (AST 47 IU/L, ALT 45 IU/L). The patient was admitted to our hospital on suspicion of prosthetic vascular graft infection. Following further workups on the inflammatory response, an enhanced chest computed tomography (CT) and a non-enhanced chest DWI (MRI) were performed. The patient was diagnosed with a pulmonary fistula and a prosthetic vascular graft infection on the distal aortic arch. After admission, the patient was administered Ceftriaxion and Vancomycine for 10 days, but his fever and inflammatory response did not improve. On day 13 of hospitalization, a lung fistula repair surgery and an omental filling operation were performed, and Meropenem and Vancomycine were administered. The fever and inflammatory response continued, and therefore we took repeated blood cultures. M. fortuitum was detected in a blood culture on day 16 of hospitalization. As a result, we changed the treatment regimen to Amikacin (400 mg/day), Meropenem (2 g/day), and Cefmetazole (4 g/day), and the fever and inflammatory response began to decrease gradually. We performed a test of sensitivity for Mycobacterium fortuitum, and found that the MIC was low for fluoroquinolone antibacterial agent. The clinical course was good, and the patient was discharged after a total of 8 weeks of intravenous drug administration. At discharge, we changed the treatment regimen to Levofloxacin (500 mg/day) and Clarithromycin (800 mg/day), and prescribed these two drugs as a long life suppressive therapy. Discussion: There are few cases of prosthetic vascular graft infection caused by mycobacteria, and a standard therapy remains to be established. For prosthetic vascular graft infections, it is ideal to provide surgical and medical treatment in parallel, but in this case, surgical treatment was difficult and, therefore, a conservative treatment was chosen. We attempted to increase the treatment success rate of this refractory disease by conducting a susceptibility test for mycobacteria and treating with different combinations of antimicrobial agents, which was ultimately effective. With our treatment approach, a good clinical course was obtained and continues at the present stage. Conclusion: Although prosthetic vascular graft infection resulting from mycobacteria is a refractory infectious disease, it may be curative to administer appropriate antibiotics based on the susceptibility test in addition to surgical treatment.

Keywords: prosthetic vascular graft infection, lung fistula, Mycobacterium fortuitum, conservative treatment

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Authors: Ahmed Bensreti, Mohamed Gouarsha

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This paper presents a review of the pressure surge simulations carried out for Phase III of the Man Made River project in Libya with particular emphasis on the transient generated by simultaneous pump trips at Al Gardabiya Pump Station. The omission of the surge vessel check valve and bypass system on the grounds of cost, ease of design, and construction will result in, as expected, increased surge fluctuations as the damping effect in the form was removed. From the hydraulic and control requirements, it is recommended for Al Gardabiya Pump station that the check valve and check valve bypass be included in the final surge vessel design.

Keywords: computational fluid dynamics, surge vessel design, transient surge analysis, water pipe hydraulics

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Authors: Mehmet Ali Kisaçam, P. Sema Temizer Ozan, Ayşe Doğan, Gonca Ozan, F. Sarper Türker

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Cardiovascular disease which is one of the most common health problems worldwide has crucial importance because of its’ morbidity and mortality rates. Nitric oxide synthase and arginase use L-arginine as a substrate and produce nitric oxide (NO), citrulline and urea, ornithine respectively. Endothelial dysfunction is characterized by reduced bioavailability of vasodilator and anti-inflammatory molecule NO. The purpose of the study to assess endothelial function via arginase activity and NO levels in patients undergoing coronary artery bypass grafting (CABG) surgery. The study was conducted on 26 patients (14 male, 12 female) undergoing CABG surgery. Blood samples were collected from the subjects before surgery, after the termination and after 24 hours of the surgery. Arginase activity and NO levels measured in collected samples spectrophotometrically. Arginase activity decreased significantly in subjects after the termination of the surgery compared to before surgery data. 24 hours after the surgery there wasn’t any significance in arginase activity as it compared to before surgery and after the termination of the surgery. On the other hand, NO levels increased significantly in the subject after the termination of the surgery. However there was no significant increase in NO levels after 24 hours of the surgery, but there was an insignificant increase compared to before surgery data. The results indicate that after the termination of the surgery vascular and endothelial function improved and after 24 hours of the surgery arginase activity and NO levels returned to normal.

Keywords: arginase, bypass, cordiopulmonary, nitric oxide

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Authors: Islam Sherif, Ahmed Ashour, Ahmed Hassan, Hatem Osman

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Anterior Cruciate Ligament (ACL) injuries are common among athletes and individuals participating in sports with sudden stops, pivots, and changes in direction. Arthroscopic surgery is the gold standard for ACL reconstruction, aiming to restore knee stability and function. Recent years have witnessed significant advancements in arthroscopic surgery techniques, graft materials, and technological innovations, revolutionizing the field of ACL reconstruction. This presentation delves into the latest advancements in arthroscopic surgery techniques for ACL reconstruction and their potential impact on patient outcomes. Traditionally, autografts from the patellar tendon, hamstring tendon, or quadriceps tendon have been commonly used for ACL reconstruction. However, recent studies have explored the use of allografts, synthetic scaffolds, and tissue-engineered grafts as viable alternatives. This abstract evaluates the benefits and potential drawbacks of each graft type, considering factors such as graft incorporation, strength, and risk of graft failure. Moreover, the application of augmented reality (AR) and virtual reality (VR) technologies in surgical planning and intraoperative navigation has gained traction. AR and VR platforms provide surgeons with detailed 3D anatomical reconstructions of the knee joint, enhancing preoperative visualization and aiding in graft tunnel placement during surgery. We discuss the integration of AR and VR in arthroscopic ACL reconstruction procedures, evaluating their accuracy, cost-effectiveness, and overall impact on surgical outcomes. Beyond graft selection and surgical navigation, patient-specific planning has gained attention in recent research. Advanced imaging techniques, such as MRI-based personalized planning, enable surgeons to tailor ACL reconstruction procedures to each patient's unique anatomy. By accounting for individual variations in the femoral and tibial insertion sites, this personalized approach aims to optimize graft placement and potentially improve postoperative knee kinematics and stability. Furthermore, rehabilitation and postoperative care play a crucial role in the success of ACL reconstruction. This abstract explores novel rehabilitation protocols, emphasizing early mobilization, neuromuscular training, and accelerated recovery strategies. Integrating technology, such as wearable sensors and mobile applications, into postoperative care can facilitate remote monitoring and timely intervention, contributing to enhanced rehabilitation outcomes. In conclusion, this presentation provides an overview of the cutting-edge advancements in arthroscopic surgery techniques for ACL reconstruction. By embracing innovative graft materials, augmented reality, patient-specific planning, and technology-driven rehabilitation, orthopedic surgeons and sports medicine specialists can achieve superior outcomes in ACL injury management. These developments hold great promise for improving the functional outcomes and long-term success rates of ACL reconstruction, benefitting athletes and patients alike.

Keywords: arthroscopic surgery, ACL, autograft, allograft, graft materials, ACL reconstruction, synthetic scaffolds, tissue-engineered graft, virtual reality, augmented reality, surgical planning, intra-operative navigation

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Authors: Ramanish Ravishankar, Azar Hussain, Mahmoud Loubani, Mubarak Chaudhry

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Background and Aims: Currently, there are no strict guidelines in cardiopulmonary bypass temperature management in cardiac surgery not involving the aortic arch. This study aims to compare patient outcomes undergoing mild hypothermia and normothermia. The aim of this study was to compare patient outcomes between mild hypothermia and normothermia undergoing on-pump cardiac surgery not involving the aortic arch. Methods: This was a retrospective cohort study from January 2015 until May 2023. Patients who underwent cardiac surgery with cardiopulmonary bypass temperatures ≥32oC were included and stratified into mild hypothermia (32oC – 35oC) and normothermia (>35oC) cohorts. Propensity matching was applied through the nearest neighbour method (1:1) using the risk factors detailed in the EuroScore using RStudio. The primary outcome was mortality. Secondary outcomes included post-op stay, intensive care unit readmission, re-admission, stroke, and renal complications. Patients who had major aortic surgery and off-pump operations were excluded. Results: Each cohort had 1675 patients. There was a significant increase in overall mortality with the mild hypothermia cohort (3.59% vs. 2.32%; p=0.04912). There was also a greater stroke incidence (2.09% vs. 1.13%; p=0.0396) and transient ischaemic attack (TIA) risk (3.1% vs. 1.49%; p=0.0027). There was no significant difference in renal complications (9.13% vs. 7.88%; p=0.2155). Conclusions: Patient’s who underwent mild hypothermia during cardiopulmonary bypass have a significantly greater mortality, stroke, and transient ischaemic attack incidence. Mild hypothermia does not appear to provide any benefit over normothermia and does not appear to provide any neuroprotective benefits. This shows different results to that of other major studies; further trials and studies need to be conducted to reach a consensus.

Keywords: cardiac surgery, therapeutic hypothermia, neuroprotection, cardiopulmonary bypass

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Authors: Constantinos S. Mammas, Andreas Lazaris, Adamantia S. Mamma-Graham, Georgia Kostopanagiotou, Chryssa Lemonidou, John Mantas, Eustratios Patsouris

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The process to build a better safety culture, methods of error analysis, and preventive measures, starts with an understanding of the effects when human factors engineering refer to remote microscopic diagnosis in surgery and specially in organ transplantation for the evaluation of the grafts. Α high percentage of solid organs arrive at the recipient hospitals and are considered as injured or improper for transplantation in the UK. Digital microscopy adds information on a microscopic level about the grafts (G) in Organ Transplant (OT), and may lead to a change in their management. Such a method will reduce the possibility that a diseased G will arrive at the recipient hospital for implantation. Aim: The aim of this study is to analyze the ergonomics of digital microscopy (DM) based on virtual slides, on telemedicine systems (TS) for tele-pathological evaluation (TPE) of the grafts (G) in organ transplantation (OT). Material and Methods: By experimental simulation, the ergonomics of DM for microscopic TPE of renal graft (RG), liver graft (LG) and pancreatic graft (PG) tissues is analyzed. In fact, this corresponded to the ergonomics of digital microscopy for TPE in OT by applying virtual slide (VS) system for graft tissue image capture, for remote diagnoses of possible microscopic inflammatory and/or neoplastic lesions. Experimentation included the development of an OTE-TS similar experimental telemedicine system (Exp.-TS) for simulating the integrated VS based microscopic TPE of RG, LG and PG Simulation of DM on TS based TPE performed by 2 specialists on a total of 238 human renal graft (RG), 172 liver graft (LG) and 108 pancreatic graft (PG) tissues digital microscopic images for inflammatory and neoplastic lesions on four electronic spaces of the four used TS. Results: Statistical analysis of specialist‘s answers about the ability to accurately diagnose the diseased RG, LG and PG tissues on the electronic space among four TS (A,B,C,D) showed that DM on TS for TPE in OT is elaborated perfectly on the ES of a desktop, followed by the ES of the applied Exp.-TS. Tablet and mobile-phone ES seem significantly risky for the application of DM in OT (p<.001). Conclusion: To make the largest reduction in errors and adverse events referring to the quality of the grafts, it will take application of human factors engineering to procurement, design, audit, and awareness-raising activities. Consequently, it will take an investment in new training, people, and other changes to management activities for DM in OT. The simulating VS based TPE with DM of RG, LG and PG tissues after retrieval, seem feasible and reliable and dependable on the size of the electronic space of the applied TS, for remote prevention of diseased grafts from being retrieved and/or sent to the recipient hospital and for post-grafting and pre-transplant planning.

Keywords: digital microscopy, organ transplantation, tele-pathology, virtual slides

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Authors: W. G. Kim, J. M. Chang, W. S. Kim

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Immunologically non-treated and acellularized porcine xenografts were implanted as an arterial graft in goats and comparatively analyzed for the explanted grafts with gross observation, as well as light microscopy and immunohistochemistry, following the predetermined periods. For immunologically non-treated xenografts, bilateral porcine carotid arteries were harvested, and after short-term freezing at -70°C, were implanted into goats. The preparation of acellularized xenograft vessels has been performed with Nacl-SDS solution and stored at the freezer until use. The goats were randomly assigned for three periods of observation (3, 6, and 12 months after implantation), four animals were observed at each of these times. Periodic ultrasonographic examinations were performed during observation period. Following the predetermined periods, the explanted grafts were analyzed. Among 12 animals, one goat died prematurely, and a total of 22 grafts were evaluated. Gross observations revealed non-thrombotic patent smooth lumens. Microscopic examinations of the explanted grafts showed satisfactory cellular reconstruction up to the 12-month observation period. The proportions of CD3 positive T lymphocytes among inflammatory cells infiltrations were very low. In conclusion, these findings, as a whole, suggest that porcine vessel xenografts can be clinically acceptably implanted in the goats as a form of small-diameter vascular graft, regardless of the acellularized xenograft or immunologically non-treated xenograft.

Keywords: xenograft, arterial graft, long-term survival animals, immunology

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Authors: Shu-Chuan Liao, Chia-Ti Chang, Ko-Shao Chen

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Titanium and its alloy are widely used in many fields such as dentistry or orthopaedics. Due to their high strength low elastic modulus that chemical inertness and bio inert. The micro-arc oxidation used to formation a micro porous ceramic oxide layer film on Titanium surface and also to improve the resistance corrosion. For improving the biocompatibility, micro-arc oxidation surfaces bio-inert need to introduce reactive group. We introduced boundary layer by used plasma enhanced chemical vapor deposition of hexamethyldisilazane (HMDS) and organic active layer by UV light graft reactive monomer acrylic acid (AAc) therefore we can immobilize Chondroitin sulphate on surface easily by crosslinking EDC/NHS. The surface properties and composition of the modified layer were measured by scanning electron microscopy (SEM), X-ray photoelectron spectroscopy (XPS) and X-ray diffraction (XRD) and water contact angle. Water contact angle of the plasma-treated Ti surface decreases from 60° to 38°, which is an indication of hydrophilicity. The results of electrochemical polarization analysis showed that the sample plasma treated at micro-arc oxidation after plasma treatment has the best corrosion resistance. The result showed that we can immobilize chondroitin sulfate successful by a series of modification and MTT assay indicated the biocompatibility has been improved in this study.

Keywords: MAO, plasma, graft polymerization, biomedical application

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Authors: Sushil Kumar Singh, Vivek Tewarson, Sarvesh Kumar, Shobhit Kumar

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Objective: ‘Beating Heart coronary artery bypass grafting on Intermittent Pump Support’ is a more reliable method of coronary revascularization that takes advantage of off and on-pump CABG while eliminating the disadvantage of both techniques. Methods: From January 2015 to December 2021, a new technique, “Intermittent On pump beating heart CABG” using a suction stabilizer was used by putting aortic and venous cannulas electively in all the patients. Patients were supported by a pump intermittently, as and when required (Group 1, n=254). Retrospective data were collected from our record of the patients who underwent off-pump CABG electively by the same surgeon and team (Group 2, n=254). Results: Significant advantage was noted in Group 1 patients in terms of the number of grafts (3.31 ± 1.16 vs. 2.30 ±0.66), grafting of lateral vessels (316 vs.202), mean operating time (1.37 ± 0.23 hrs vs. 2.22 ± 0.45 hrs) and postoperative blood loss (406.30 ± 257.90 ml vs. 567.41 ± 265.20 ml).CPB support time was less than 15 minutes in the majority of patients (n=179, 70.37 %), with a mean of 16.81 minutes. It was required, particularly during the grafting of lateral vessels. A rise in enzymes level (CRP, CKMB, Trop I, and NTPro BNP) was noted in Group 1 patients. But, these did not affect the postoperative course in patients. There was no mortality in Group 1 patients, while four patients in Group 2 died. Coclusions: Intermittent on-pump CABG technique is a promising method of surgical revascularization for all patients requiring CABG. It has shown its superiority in terms of safety, the number of grafts, operating time, and better perioperative course.

Keywords: cardiopulmonary bypass, CABG, beating heart CABG, on-pump CABG

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Authors: Sarah Bouayyad, Ajay Nigam, Meera Beena

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Acquired benign tracheoesophageal fistula is a rare medical condition that usually results from trauma, foreign bodies, or granulomatous infections. This is an unusual presentation of a male patient with a history of laryngectomy who had had over a period of several years inappropriately and vigorously used valve cleaning brushes to clean tracheal secretions, which had led to the formation of a tracheoesophageal fistula. Due to the patient’s obsessive habit, we couldn’t manage him using conventional surgical methods. Instead, we opted for the placement of a salivary bypass tube, which yielded good results and recovery. To the best of our knowledge, no other case of similar etiology has been published. We would like to highlight the importance of appropriate patient selection and education prior to performing a tracheoesophageal puncture to avoid developing life-threatening complications as demonstrated in our case report.

Keywords: tracheoesophageal fistula, speech valve, endoscopic insertion of salivary bypass tube, head and neck malignancies

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Authors: Sarah Hamdan Al-Jahdali, Khaled Alsaad, Abdullah Al-Sayyari

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Objectives: To study the prevalence, clinicopathological features, risk factors and outcome of biopsy proven polyoma (BK) virus infection among Saudi kidney transplant recipients and compare them to negative BK virus group. Methods: We retrospectively reviewed the charts of all the patients with biopsy-proven polyoma (BK) virus infection in King Abdulaziz Medical City in Riyadh between 2005 and 2011. The details of clinical presentation, the indication for kidney biopsy, the laboratory findings at presentation, the natural history of the disease, thepathological findings, the prognosis as well as the response to therapy were all recorded. Results: Kidney biopsy was performed in 37 cases of unexplained graft dysfunction. BK virus was found in 10 (27%). Out of those 10, 3 (30%) ended with graft failure. BK virus occurred in all patients who received ATG induction therapy 100% versus 59.3% in the non BK virus patients (p=0.06). Furthermore, the risk of BK virus was much less in those who received acyclovir as an anti-viral prophylaxis as compared to those who did not receive it (p=0.01). Also, patients with BK virus weighed much less (mean 46.7±20.6 Kgs) than those without BK virus at time of transplantation (mean 64.3±12.1). Graft survival was better among deceased donor kidneys compared to living ones (P=0.016) and with older age (P=0.005). Conclusion: Our findings suggest the involvement of ATG induction therapy, the lack of antiviral prophylaxis therapy and lower weight at transplant as significant risk factors for the development of BK virus infection.

Keywords: BKVAN, BKV, kidney transpant, Saudi Arabia

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Authors: Rassoli Aisa, Abrishami Movahhed Arezu, Faturaee Nasser, Seddighi Amir Saeed, Shafigh Mohammad

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Cardiovascular diseases are one of the most common causes of mortality in developed countries. Coronary artery abnormalities and carotid artery stenosis, also known as silent death, are among these diseases. One of the treatment methods for these diseases is to create a deviatory pathway to conduct blood into the heart through a bypass surgery. The saphenous vein is usually used in this surgery to create the deviatory pathway. Unfortunately, a re-surgery will be necessary after some years due to ignoring the disagreement of mechanical properties of graft tissue and/or applied prostheses with those of host tissue. The objective of the present study is to clarify the viscoelastic behavior of human saphenous tissue. The stress relaxation tests in circumferential and longitudinal direction were done in this vein by exerting 20% and 50% strains. Considering the stress relaxation curves obtained from stress relaxation tests and the coefficients of the standard solid model, it was demonstrated that the saphenous vein has a non-linear viscoelastic behavior. Thereafter, the fitting with Fung’s quasilinear viscoelastic (QLV) model was performed based on stress relaxation time curves. Finally, the coefficients of Fung’s QLV model, which models the behavior of saphenous tissue very well, were presented.

Keywords: Viscoelastic behavior, stress relaxation test, uniaxial tensile test, Fung’s quasilinear viscoelastic (QLV) model, strain rate

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Authors: Jia Li, Huacong Li, Xiaobao Han

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Due to the more variable geometry parameters of VCE (variable cycle aircraft engine), presents an adaptive controller method based on the full-state linear model of VCE and has simulated to solve the multivariate controller design problem of the whole flight envelops. First, analyzes the static and dynamic performances of bypass ratio and other state parameters caused by variable geometric components, and develops nonlinear component model of VCE. Then based on the component model, through small deviation linearization of main fuel (Wf), the area of tail nozzle throat (A8) and the angle of rear bypass ejector (A163), setting up multiple linear model which variable geometric parameters can be inputs. Second, designs the adaptive controllers for VCE linear models of different nominal points. Among them, considering of modeling uncertainties and external disturbances, derives the adaptive law by lyapunov function. The simulation results showed that, the adaptive controller method based on full-state linear model used the angle of rear bypass ejector as input and effectively solved the multivariate control problems of VCE. The performance of all nominal points could track the desired closed-loop reference instructions. The adjust time was less than 1.2s, and the system overshoot was less than 1%, at the same time, the errors of steady states were less than 0.5% and the dynamic tracking errors were less than 1%. In addition, the designed controller could effectively suppress interference and reached the desired commands with different external random noise signals.

Keywords: variable cycle engine (VCE), full-state linear model, adaptive control, by-pass ratio

Procedia PDF Downloads 306

Authors: G. K. Guseynova, V. V. Krylov, L. T. Khamidova, N. A. Polunina, V. A. Lukyanchikov

Abstract:

The report presents complex ultrasound diagnostics in patients with symptomatic steno-occlusive lesions of extra- and intracranial branches of brachiocephalic arteries (BCA). The tasks and possibilities of ultrasound diagnostics at different stages of treatment of patients with symptomatic occlusion of internal carotid artery (ICA) are covered in detail; qualitative and quantitative characteristics of blood flow; parameters of the wall and lumen of the main arteries of the head; methods of ultrasound examination of indirect assessment of the functional status are presented. Special attention is paid to the description of indicators that are predictors of the consistency of formed extra-intracranial low-flow shunts, examples of functioning and failed anastomoses are analyzed.

Keywords: CBF, cerebral blood flow; CTA, external carotid artery; ICA, internal carotid artery; MCA, middle cerebral artery; MRA, magnetic resonance angiography; OEF, oxygen extraction fraction; TIA, transient ischaemic attack, ultrasound, low-flow bypass, anastomoses

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Authors: Dahna Alkahtani, Faryal Suraya, Fadah Alanazi

Abstract:

Background: Buccal mucosal graft for urethral augmentation has surpassed other grafting options, and is now considered the standard of choice for substitution Urethroplasty. The graft has gained its popularity due to its excellent short and long-term results, easy harvesting as well as its ability in withstanding wet environments. However, although Buccal mucosal grafts are an excellent option, it is not free of complications, potential intraoral complications are bleeding, pain, swelling, injury to the nerve resulting in numbness, lip deviation or retraction. Objectives: The current study aims to evaluate the intraoral complications of buccal mucosa grafts harvested from one cheek, and used in Augmentation Urethroplasty. Methodology: The study was conducted retrospectively using the medical records of patients who underwent open augmentation urethroplasty with a buccal mucosa graft at King Khalid University Hospital, Saudi Arabia. Data collection of demographics included the type of graft used, presence or absence of strictures and its etiological factors. Pre-operative and post-operative evaluations were carried out on the subjects including the medical history, physical examination, uroflowmetry, retrograde urethrography, voiding cystourethrography and urine cultures were also noted. Further, the quality of life and complications of the procedure including the presence or occurrence of bleeding within 3-days post-procedure, the severity of pain, oral swelling after grafting, length of return to normal daily diet, painful surgical site, intake of painkillers, presence or absence of speech disturbance, numbness in the cheeks and lips were documented. Results: Thirty-two male subjects with ages ranging from 15 years to 72 years were included in the current study. Following the procedure, a hundred percent of the subjects returned to their normal daily diet by the sixth postoperative day. Further, the majority of the patients reported experiencing mild pain accounting for 61.3%, and 90.3% of the subjects reported using painkillers to control the pain. Surgical wound Pain was reportedly more common at the perineal site as 48.4% of the subjects experienced it; on the other hand, 41.9% of the patients experienced pain in the oral mucosa. The presence of speech disorders, as assessed through medical history, was found to be present in 3.2% of patients. The presence of numbness in the cheeks and lips was found in 3.2% of patients. Other complications such as parotid duct injury, delayed wound healing, non-healing wound and suture granuloma were rare as 90.3% of the subjects denied experiencing any of them, there were nonetheless reports of parotid duct injury by 6.5% of the patients, and non-healing wound by the 3.2% of patients. Conclusion: Buccal Mucosa Graft in Augmentation Urethroplasty is an ideal source of allograft, although not entirely painless; it is considerably safe with minimal intra-oral complication and undetectable strain on the patients’ quality of life.

Keywords: augmentation, buccal, graft, oral

Procedia PDF Downloads 159

Authors: Scott M. Black, Craig Maclean, Pauline Hall Barrientos, Konstantinos Ritos, Asimina Kazakidi

Abstract:

Aortic aneurysms and dissections are leading causes of death in cardiovascular disease. Both inevitably lead to hemodynamic instability without surgical intervention in the form of vascular stent-graft deployment. An accurate description of the aortic geometry and blood flow in patient-specific cases is vital for treatment planning and long-term success of such grafts, as they must generate physiological branch perfusion and in-stent hemodynamics. The aim of this study was to create patient-specific computational fluid dynamics (CFD) models through a multi-modality, multi-dimensional approach with boundary condition optimization to predict branch flow rates and in-stent hemodynamics in custom stent-graft configurations. Three-dimensional (3D) thoracoabdominal aortae were reconstructed from four-dimensional flow-magnetic resonance imaging (4D Flow-MRI) and computed tomography (CT) medical images. The former employed a novel approach to generate and enhance vessel lumen contrast via through-plane velocity at discrete, user defined cardiac time steps post-hoc. To produce patient-specific boundary conditions (BCs), the aortic geometry was reduced to a one-dimensional (1D) model. Thereafter, a zero-dimensional (0D) 3-Element Windkessel model (3EWM) was coupled to each terminal branch to represent the distal vasculature. In this coupled 0D-1D model, the 3EWM parameters were optimized to yield branch flow waveforms which are representative of the 4D Flow-MRI-derived in-vivo data. Thereafter, a 0D-3D CFD model was created, utilizing the optimized 3EWM BCs and a 4D Flow-MRI-obtained inlet velocity profile. A sensitivity analysis on the effects of stent-graft configuration and BC parameters was then undertaken using multiple stent-graft configurations and a range of distal vasculature conditions. 4D Flow-MRI granted unparalleled visualization of blood flow throughout the cardiac cycle in both the pre- and postsurgical states. Segmentation and reconstruction of healthy and stented regions from retrospective 4D Flow-MRI images also generated 3D models with geometries which were successfully validated against their CT-derived counterparts. 0D-1D coupling efficiently captured branch flow and pressure waveforms, while 0D-3D models also enabled 3D flow visualization and quantification of clinically relevant hemodynamic parameters for in-stent thrombosis and graft limb occlusion. It was apparent that changes in 3EWM BC parameters had a pronounced effect on perfusion distribution and near-wall hemodynamics. Results show that the 3EWM parameters could be iteratively changed to simulate a range of graft limb diameters and distal vasculature conditions for a given stent-graft to determine the optimal configuration prior to surgery. To conclude, this study outlined a methodology to aid in the prediction post-surgical branch perfusion and in-stent hemodynamics in patient specific cases for the implementation of custom stent-grafts.

Keywords: 4D flow-MRI, computational fluid dynamics, vascular stent-grafts, windkessel

Procedia PDF Downloads 166

Authors: Santosh Sharma Parajuli, Diwas Manandhar

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Background: Perioperative pain management plays an integral part in patients undergoing cardiac surgery. We studied the effect of Erector Spinae Plane block on acute postoperative pain reduction and 24 hours opioid consumption in adult cardiac surgical patients. Methods: Twenty-five adult cardiac surgical patients who underwent cardiac surgery with sternotomy in whom ESP catheters were placed preoperatively were kept in group E, and the other 25 patients who had undergone cardiac surgery without ESP catheter and pain management done with conventional opioid injection were placed in group C. Fentanyl was used for pain management. The primary study endpoint was to compare the consumption of fentanyl and to assess the numeric rating scale in the postoperative period in the first 24 hours in both groups. Results: The 24 hours fentanyl consumption was 43.00±51.29 micrograms in the Erector Spinae Plane catheter group and 147.00±60.94 micrograms in the control group postoperatively which was statistically significant (p <0.001). The numeric rating scale was also significantly reduced in the Erector Spinae Plane group compared to the control group in the first 24 hours postoperatively. Conclusion: Erector Spinae Plane block is superior to the conventional opioid injection method for postoperative pain management in CABG patients. Erector Spinae Plane block not only decreases the overall opioid consumption but also the NRS score in these patients.

Keywords: erector, spinae, plane, numerical rating scale

Procedia PDF Downloads 55

Authors: Kamil Ganaev, Elina Vlasova, Andrei Shiryaev, Renat Akchurin

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De novo atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is a common complication. To date, there are no data on the possible effect of diffuse lesions of coronary arteries on the incidence of postoperative AF complications. Methods. Patients operated on-pump under hypothermic conditions during the calendar year (2020) were studied. Inclusion criteria - isolated CABG and achievement of complete myocardial revascularization. Patients with a history of AF moderate and severe valve dysfunction, hormonal thyroid pathology, initial CHF(Congestive heart failure), as well as patients with developed perioperative complications (IM, acute heart failure, massive blood loss) and deceased were excluded. Thus 227 patients were included; mean age 65±9 years; 69% were men. 89% of patients had a 3-vessel lesion of the coronary artery; the remainder had a 2-vessel lesion. Mean LV size: 3.9±0.3 cm, indexed LV volume: 29.4±5.3 mL/m2. Two groups were considered: D (n=98), patients with diffuse coronary heart disease, and L (n=129), patients with local coronary heart disease. Clinical and demographic characteristics in the groups were comparable. Rhythm assessment: continuous bedside ECG monitoring up to 5 days; ECG CT at 5-7 days after CABG; daily routine ECG registration. Follow-up period - postoperative hospital period. Results. The Median follow-up period was 9 (7;11) days. POFP (Postoperative atrial fibrillation) was detected in 61/227 (27%) patients: 34/98 (35%) in group D versus 27/129 (21%) in group L; p<0.05. Moreover, the values of revascularization index in groups D and L (3.9±0.7 and 3.8±0.5, respectively) were equal, and the mean time Cardiopulmonary bypass (CPB) (107±27 and 80±13min), as well as the mean ischemic time (67±17 and 55±11min) were significantly longer in group D (p<0.05). However, a separate analysis of these parameters in patients with and without developed AF did not reveal any significant differences in group D (CPB time 99±21.2 min, ischemic time 63±12.2 min), or in group L (CPB time 88±13.1 min, ischemic time 58.7±13.2 min). Conclusion. With the diffuse nature of coronary lesions, the incidence of AF in the hospital period after isolated CABG definitely increases. To better understand the role of severe coronary atherosclerosis in the development of POAF, it is necessary to distinguish the influence of organic features of atrial and ventricular myocardium (as a consequence of chronic coronary disease) from the features of surgical correction in diffuse coronary lesions.

Keywords: atrial fibrillation, diffuse coronary artery disease, coronary artery bypass grafting, local coronary artery disease

Procedia PDF Downloads 202

Authors: Elena Petersen, Inna Kornienko, Svetlana Guryeva, Sergey Dobdin, Anatoly Skripal, Andrey Usanov, Dmitry Usanov

Abstract:

One of the most important unsolved problems in modern medicine is the increase of chronic diseases that lead to organ dysfunction or even complete loss of function. Current methods of treatment do not result in decreased mortality and disability statistics. Currently, the best treatment for many patients is still transplantation of organs and/or tissues. Therefore, finding a way of correct artificial matrix biofabrication in case of limited number of natural organs for transplantation is a critical task. One important problem that needs to be solved is development of a nondestructive and noninvasive method to analyze dynamic changes of mechanical characteristics of a matrix with minimal side effects on the growing cells. This research was focused on investigating the properties of matrix as a marker of graft condition. In this study, the collagen gel with human primary dermal fibroblasts in suspension (60, 120, 240*103 cells/mL) and collagen gel with cell spheroids were used as model objects. The stiffness and elasticity characteristics were evaluated by a semiconductor laser autodyne. The time and cell concentration dependency of the stiffness and elasticity were investigated. It was shown that these properties changed in a non-linear manner with respect to cell concentration. The maximum matrix stiffness was observed in the collagen gel with the cell concentration of 120*103 cells/mL. This study proved the opportunity to use the mechanical properties of matrix as a marker of graft condition, which can be measured by noninvasive semiconductor laser autodyne technique.

Keywords: graft, matrix, noninvasive method, regenerative medicine, semiconductor laser autodyne

Procedia PDF Downloads 333

Authors: Abhishek Dave, Manisha Singh

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Purpose: The study aims to evaluate the outcomes of combined Penetrating keratoplasty (PKP) and Vitreo-Retinal (VR) surgery in patients having endophthalmitis with poor corneal clarity. Methods: PKP with VR Surgery was performed in 43 eyes. This is a retrospective analysis of their preoperative, intraoperative and microbiological characteristics and anatomical and functional outcomes. Results: Corneal opacification was due to corneal ulcer in 30 (69.7%), graft infection in 8 (18.6%), bullous keratopathy in 4 and corneal scar in 1 eye. Postoperative visual acuity improved in 20 (46.5%), not changed in 14 (32.5%) and deteriorated in 9 eyes (20.9%). Poor anatomic success was seen in 15 (34.88%) eyes (9-phthisis bulbi, 6-eviscerated). Graft remained clear in 24 eyes (1 year). Microbiology revealed bacteria in 26, fungus in 14 and no growth in 3 eyes. Six out of 11 patients having poor vision in the fellow eye, too, achieved functional success. Conclusion: PKP with VR surgery is a complex but globe-salvaging procedure for poor prognosis eyes, which otherwise would need evisceration.

Keywords: penetrating keratoplasty, VR surgery, endophthalmitis, corneal ulcer

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Authors: Syazwani Ramli, Norhidayu Muhamad Zain

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Nowadays, the use of gelatin as biomaterials in tissue engineering are evolving especially in skin graft and wound dressing applications. Towards year 2018, Malaysia is in the way of planning to get the halal certification for biomedical device in order to cater the needs of Muslims and non-Muslims in Malaysia. However, the use of gelatins in tissue engineering are mostly derived from non-halal sources. Currently, gelatin production mostly comes from mammalian gelatin sources. Moreover, within these past years, just a few studies of the uses of gelatin in tissue engineering from halal perspective has been studied. Thus, this paper aims to give overview of the use of gelatin from different sources from halal perspectives. This review also discussing the current status of halal for the emerging biomedical devices. In addition, the different sources of gelatin used in tissue engineering are being identified and provides better alternatives for halal gelatin. Cold- water fish skin gelatin could be an effective alternative to substitute the mammalian sources. Therefore, this review is important because the information about the halal biomedical devices will delighted Muslim consumers and give better insight of halal gelatin in tissue engineering application.

Keywords: biomedical device, gelatin, halal, skin graft, tissue engineering

Procedia PDF Downloads 254

Authors: Azza A. Al-Ghamdi, Abir S. Abdel-Naby

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Cellulose acetate (CA) is a natural biodegradable polymer. It forms transparent films by the casting technique. CA suffers from high degree of water permeability as well as the low thermal stability at high temperatures. To adjust the CA polymeric films to the manufacture of food packaging, its thermal and mechanical properties should be improved. The modification of CA by grafting it with N-Amino phenyl maleimide (N-APhM) led to the construction of hydrophobic branches throughout the polymeric matrix which reduced its wettability as compared to the parent CA. The branches built onto the polymeric chains had been characterized by UV/Vis, ¹³C-NMR and ESEM. The improvement of the thermal properties was investigated and compared to the parent CA using thermal gravimetric analysis (TGA), differential scanning calorimetry (DSC), differential thermal analysis (DTA), contact angle and mechanical testing measurements. The results revealed that the water-uptake was reduced by increasing the graft percentage. The thermal and mechanical properties were also improved.

Keywords: cellulose acetate, food packaging, graft copolymerization, thermal properties

Procedia PDF Downloads 205

Authors: Parsa Naji

Abstract:

Following the Iran Islamic Revolution in 1979 and the subsequent formation of a theocratic regime, the new regime implemented stringent regulations and a complicated censorship system in the film industry. Thereupon, the screening of films showing the relationships between males and females encountered numerous limitations. Not only did these limits encompass the physical portrayal of the relationship between males and females, but also the dialogues containing explicit sexual or even passionate romantic themes, resulting in a film being permanently consigned to archival storage. However, despite these limitations, Iranian filmmakers persevered in creating their interesting cinematic works. Throughout the years after the revolution, Iranian directors have navigated a series of challenges and obstacles, employing innovative and unconventional methods to bypass the rigorous censorship system imposed by the government, ensuring the screening of their films. This study aims to analyze the creative approaches employed by Iranian filmmakers to circumvent governmental censorship regulations.

Keywords: censorship, Iranian cinema, Islamic revolution, male-female relationship

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Authors: Esmaeil Biazar

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A nanofibrous PHBV nerve conduit has been used to evaluate its efficiency based on the promotion of nerve regeneration in rats. The designed conduits were investigated by physical, mechanical and microscopic analyses. The conduits were implanted into a 30-mm gap in the sciatic nerves of the rats. Four months after surgery, the regenerated nerves were evaluated by macroscopic assessments and histology. This polymeric conduit had sufficiently high mechanical properties to serve as a nerve guide. The results demonstrated that in the nanofibrous graft with cells, the sciatic nerve trunk had been reconstructed with restoration of nerve continuity and formatted nerve fibers with myelination. For the grafts especially the nanofibrous conduits with cells, muscle cells of gastrocnemius on the operated side were uniform in their size and structures. This study proves the feasibility of artificial conduit with Schwann cells for nerve regeneration by bridging a longer defect in a rat model.

Keywords: sciatic regeneration, Schwann cell, artificial conduit, nanofibrous PHBV, histological assessments

Procedia PDF Downloads 313