Mid-long Term Research Articles

The mid-long term follow-up of endovascular embolization treatment of intracranial aneurysms

Objective To observe the mid-long term follow-up results of endovascular embolization treatment of intracranial aneurysms and to investigate the factors related to post-operative recurrence. Methods A total of 69 patients (80 aneurysms) were angiographically followed up by DSA over 18 months who were admitted to Department of Interventional Radiology, Huashan Hospital Affiliated to Fudan University, between June 2006 and August 2015 and enrolled in this retrospective study. All those patients underwent endovascular embolization treatment and studied for clinical prognosis and related factors of the recurrence. Results The follow-up period lasted 18-133 months with an average of 39.0±22.6 months. Out of 69 patients, 65 (94.2%) reported good outcomes with modified Rankin scale score < 2. There was no death in this series. Out of 80 aneurysms, 21(26.3%) had recurrence. Univariate analysis demonstrated that the recurrence rate was the highest (83.3%, 5/6) in the giant aneurysm group, the lowest (16.7%, 9/54)in the small aneurysm group, and 35.0%(7/20) in the large aneurysm group. The difference was statistically significant (P=0.002). Incomplete embolization group had higher recurrence rate than complete embolization group [58.8% (10/17) vs. 17.5% (11/63), P=0.001]. Recurrence rate of wide-necked aneurysms was higher than narrow-necked ones [36.2% (17/47) vs. 12.1%(4/33), P=0.032]. However, the location and treatment approach of aneurysms seemed to have little effect on the recurrence. Multivariate regression analysis suggested that the aneurysm size was the independent risk factor of recurrence (OR=3.828, 95%CI: 1.674-8.754, P<0.001). Conclusions The overall clinical effects of endovascular embolization treatment on intracranial aneurysms seem to be satisfactory. The aneurysm size was the independent risk factor of recurrence. The shape of aneurysm neck and extent of embolization may affect the recurrence of aneurysm. Key words: Intracranial aneurysm; Embolization, therapeutic; Recurrence; Treatment outcome; Follow-up studies

Locally Adapt Risks Minimizing

The significant excess of the price of risk, research question in the version paper, [S. Chule, in Applied Mathematical Finance, submitted June 2016], is space-domain form re-evaluated into the stochastic problem objective of the premium risk. The adapts of the conventional generic replication method for the volatility risk is dissipative on the structure of the quadratic hedging approach. The computations performed, quantum composite for k=1 K financial assets over, the K geometric states, perfect sub-state sparsity of the functional-form adapt in the generated Weiner process and the mid-long term period of 58 months. The relative, state-space dependence adversity are deduced in the JSE-FINI index (J212) using the risk-free Repo interest rates.

Immediate implant placement and restoration in the anterior maxilla: Tissue dimensional changes after 2-5 year follow up.

Immediate implant placement followed by an immediate restoration has proven to be a viable technique in the anterior maxillary region. This prospective study evaluated the mid-long term (2-5 years) tissue changes around immediately placed and restored implants in the anterior maxilla using flapless surgery and simultaneous hard tissue augmentation. Thirty AstraTech implants were immediately placed in 30 patients, followed by the delivery of an immediate provisional restoration on the same day. All participating 30 patients underwent the same treatment strategy that involved flapless removal of a failing maxillary anterior tooth, immediate implant placement, simultaneous augmentation with a deproteinized particulate xenograft, followed by the connection of a screw-retained provisional restoration. Radiographs and photographs were used to measure hard and soft tissue changes. Aesthetic evaluation was performed using the Pink Esthetic Score (PES). All implants remained osseointegrated during the follow up period of 2-5 years (mean 47 ± 15 months). Twelve of the thirty patients completed the 5 year follow up. Radiographic evaluation revealed average gains in bone levels of 0.18 and 0.34 mm mesially and distally, respectively. Soft tissue evaluation showed a mean tissue loss of 0.05 ± 0.64 mm and 0.16 ± 0.63 mm at the mesial and distal papillae, respectively, while mid-facial mucosal recession was 0.29 ± 0.74 mm. A significant improvement in the Pink Esthetic Scores was seen at the final follow-up (mean PES 11.50), as compared to the baseline (mean PES 10.27) (P = .001). In addition to a favorable implant success rate and peri-implant bony response, the soft tissue levels and overall aesthetics around single immediately placed and restored implants can also be maintained in the mid-long term.

Topping-off surgery versus double-segment fusion for treatment of lumbar degenerative disease with mid-long term follow-up

Objective: To compare the mid-long term clinical effect of Topping-off surgery and lumbar fusion surgery for two-segmental lumbar degenerative disease. Methods: From March 2009 to March 2012, one hundred and twenty-six consecutive patients (Topping-off surgery and two-segment PLIF surgery) were studied in Orthopedics Department, Beijing Chao-Yang Hospital, Capital Medical University.The VAS and ODI were used to assess clinical symptoms.All patients underwent flexion/extension radiographs examinations before surgery, 1, 2 years and last follow-up postoperatively.Lumbar lordosis, sacral slop, data of Coflex segment and adjacent segment (disc height index, range of motion, foraminal height, foraminal width and Pfirrmann classification of intervertebral disc in MRI) were recorded.The paired double-tailed t test was used to analyze the differences in the results from baseline to each postoperative time point.The paired double-tailed t test was used in both groups to analyze the differences in the results from baseline to each postoperative time point.The Chi-square test was used to evaluate the differences between the incidences of adjacent segment degeneration(ASD) in the groups. Logistic regression analysis was used to analyze risk factors for developing radiographic ASD. Results: In topping-off group, 60 patients, average operation time was (134.5±10.2) min. The average blood loss was (301.5±64.6) ml.In fusion group, 68 patients, average age (58.3±4.6) years.The average follow-up time was (47.5±5.1) months.The average operation time was (158.6±19.3) min (P=0.000). The average blood loss was (413.6±131.3) ml (P=0.000). Sex, age, body mass index and intervertebral disc grading were matched between the two groups.Better improvement in VAS back pain score was noted in the topping-off group over the fusion group (P=0.030). Both groups achieved good recovery in ODI and improvement in VAS leg pain and back pain scores at last follow-up postoperatively.In the Topping-off group, FH increased from 10.5 mm at baseline to 11.8 mm at 1 year after surgery (P=0.000) and then decreased mildly in the third postoperative year, while in the fusion group, showed no significant change at all postoperative time points.In the fusion group, the disc height and FW at the same segment were no significant change after first year follow-up, while ROM was significantly decreased after surgery (P=0.000). Foraminal height, foraminal width and intervertebral disc height of adjacent segment of Coflex implant level were found decreased at the end of the postoperative follow-up, while compared with preoperative data no significant difference (P>0.05). At last follow-up, eight patients (13.3%) in the Topping-off group and eighteen patients (26.5%) in the fusion group developed ASD (P=0.033). Conclusions: Topping-off surgery compared with two-segment lumbar fusion surgery can achieve a good result in cases with pre-existing mild or moderate adjacent segment degeneration, restrict the adjacent segment's range of motion and reduce the adjacent segment degeneration. Under strict indications, Topping-off surgery is an acceptable alternative to fusion surgery for the treatment of two-segment lumbar disease.

Coronary artery calcium score as a predictor for incident stroke: Systematic review and meta-analysis

BackgroundCoronary artery calcium score (CACS) is a well-established test for risk stratifying asymptomatic patients for overall cardiovascular or coronary events. However; the prognostic value for incident stroke remains controversial. The objective of this study was to investigate the predictive value of CACS obtained by non-contrast electrocardiogram-gated computed tomography for incident stroke. MethodsWe searched PubMed, EMBASE, Cochrane databases for prospective longitudinal studies of CACS which reported the incidence of stroke. Incidence of stroke was compared in patients with and without coronary calcification. ResultsThree studies evaluated 13,262 asymptomatic patients (mean age=60years, 50% men) without apparent cardiovascular diseases. During a follow-up of 7.2years (median 5years, range 4.4–9.5years, 95,434patient-years), the overall pooled incidence of stroke was 0.26%/year. The pooled risk ratio of CACS>0 for incident stroke was 2.95 (95% CI: 2.18–4.01, p<0.001) compared to CACS=0. The heterogeneity among studies was low (I2=0%). The pooled incidence rate of stroke categorized by CACS was 0.12%/year for CACS 0, 0.26%/year for CACS 1–99, 0.41%/year for CACS 100–399 and 0.70%/year for CACS ≥400. ConclusionsIn asymptomatic patients without apparent cardiovascular diseases, the incidence of stroke was overall low. The presence and severity of coronary artery calcification were associated with incident stroke over mid-long term follow-up.

Parma tracheostomy technique: a hybrid approach to tracheostomy between classical surgical and percutaneous tracheostomies.

The aim of our study is to compare the classical surgical tracheostomy (TT) technique with a modified surgical technique designed and created by the cardiothoracic surgery staff of our department to reduce surgical trauma and postoperative complications. This modified technique combines features of percutaneous TT and surgical TT avoiding the use of specialized tools, which are required in percutaneous TT. From October 2008 to March 2014 we performed 67 tracheostomies using this New Modified Surgical Technique (NMST) and 56 TT with the Classical Surgical Technique (CST). We collected data about the early clinical complications, deaths TT-related, deaths due to other complications and the presence of late TT's complications were performed by a telephone follow-up. SPSS software (IMB version 21) was used for the statistical analysis. Categorical data were treated with chi-square test and continuous data were treated with t-test for independent samples. NMST group had a significant lower number of early complications (P=0.005) compared to CST group (5 vs. 15). In-hospital mortality was significantly higher in CST group (18 deaths vs. 4 in NMST group, P=0.001) but we registered only one case of TT-related mortality in CST group (P=0.280). We did not note other differences between the two groups regarding short or mid-long term complications. In our experience the NMST demonstrated to be easily safe and reproducible with an amount of early, mid- and long-term complications similar to the CST; furthermore the aesthetic results of the procedure appear similar to those of percutaneous TT.

Technique of Injection of Hyaluronic Acid as a Prostatic Spacer and Fiducials Before Hypofractionated External Beam Radiotherapy for Prostate Cancer

To describe a technique combining the implantation of fiducials and a prostatic spacer (hyaluronic acid [HA]) to decrease the rectal toxicity after an image-guided external beam radiotherapy (EBRT) with hypofractionation for prostate cancer and to assess the tolerance and the learning curve of the procedure. Thirty patients with prostate cancer at low or intermediate risk were included in a phase II trial: image-guided EBRT of 62 Gy in 20 fractions of 3.1 Gy with intensity-modulated radiotherapy. A transrectal implantation of 3 fiducials and transperineal injection of 10 cc of HA (NASHA gel spacer, Q-Med AB, Uppsala, Sweden) between the rectum and the prostate was performed by 1 operator. The thickness of HA was measured at 10 points on magnetic resonance imaging to establish a quality score of the injection (maximum score = 10) and determine the learning curve of the procedure. The quality score increased from patients 1-10, 11-20, to 21-30 with respective median scores: 7 [2-10], 5 [4-7], and 8 [3-10]. The average thicknesses of HA between the base, middle part, and apex of the prostate and the rectum were the following: 15.1 mm [6.4-29], 9.8 mm [5-21.2], and 9.9 mm [3.2-21.5]. The injection of the HA induced a median pain score of 4 [1-8] and no residual pain at mid-long term. Creating an interface between the rectum and the prostate and the implantation of fiducials were feasible under local anesthesia with a short learning curve and could become a standard procedure before a hypofractionated EBRT for prostate cancer.

Tratamiento de lesiones bifurcadas con stent farmacoactivo autoexpandible específico para lesiones bifurcadas (Axxess): experiencia inicial unicéntrica

Introduction and AimsThe Axxess stent is a nitinol self-expanding Biolimus A9™ eluting stent, that deploys at the carina, providing easy access to the distal branches. The aim of this study was to evaluate the acute performance of the device and the type of strategy intended. Methods and resultsA total of 33 ambispective consecutive patients with 34 lesions (69±9 years, 76% men, 60% smokers, 46% diabetics, 76% hypertensives, 54% hyperlipidemics, AF 27%, 36% previous IHD and 24% previous PCI) were included in our center. A percentage of 33 had depresed LVEF. The clinical presentation was ACS in all cases (45.5% UA; 36.4% NSTEMI, 18.2% STEMI). The access was 97% by radial approach (7F or 6F). The bifurcation treated was: 70.6% LAD-Diagonal; 11,8% ACx-OM; 2,9% RCA-PLB; 14,7% LM-LAD-ACx. There were 80.6% of true bifurcations lesions and the most frequent type was Medina 1,1,1 (74%). The bifurcation angle was less than 70° in 70.6% of patients. In 29.4% (n=10) only an Axxess was implanted, 35.3% Axxess+MB stent, 20.6% Axxess+SB stent and in only 14.7% were necessary implant Axxess+MB+SB stents. All stents used were Biolimus eluting stents. Predilatation/postdilatation was done in 100/97% respectively. During a mean follow-up of 494±229 days there was a MACE rate of 2.9% (TLR). ConclusionsThe Axxess stent performed well, offering a unique approach to bifurcation treatment and excellent results in a mid-long term follow up.

Mid-Long Term Load Forecasting using Multi-Model Artificial Neural Networks

Electrical load is a major input factor in a country's economic development. To support economic growth and meet future demands for electricity, Load forecasting has become a very important task for electrical power management and planning. Several techniques have been employed to accomplish this task. One of those that is mostly used is Artificial Neural Networks (ANNs) method, which have seen the largest number of studies in the field. the load time series data are auto-correlated and are influenced by other variables, such as temperature and population, etc. Furthermore, a large data sample is needed to perform mid-long term forecasts. For the latter purpose and in order to overcome both the lack of data and the high complexity of adding exogenous variables, a multi-model method, based on neural networks, is proposed for the mid-long term load consumption forecasting. The proposed model decomposes, the initial time series into three components using the X12- ARIMA algorithm, and performs a forecast for each component using three Nonlinear Auto Regressive (NAR) neural networks, with a Feed Forward neural network combining the outputs of the NARs. The experiments that were conducted showed that the proposed model provided good performance even when using a small sample of available data when compared to benchmark models.

Power load forecasting by wavelet least squares support vector machine with improved fruit fly optimization algorithm

As is affected by many factors, mid-long term power load forecasting has become the nonlinear and multi-dimension complex problem, and its accuracy affects the decision and layout of power generation sector. In order to improve the accuracy and convergence ability of the single least square support vector machine (LSSVM), this paper proposes the improved fruit fly optimization algorithm applied to wavelet least square support vector machine (IFOA-w-LSSVM). Firstly, the Gaussian kernel function of LSSVM is replaced by the wavelet kernel function and wavelet least square support vector machine (w-LSSVM) is built. Secondly, the ordinary fruit fly optimization algorithm (FOA) is improved from three aspects: (1) dividing fruit fly group into two parts: (2) improving the taste detection function; (3) using Cauchy mutation process to make fruit fly individuals variant. Finally, w-LSSVM is optimized by IFOA for seeking the optimal parameters and achieving the forecasting accuracy. Additionally, the example verification results show that the proposed model outperforms other alternative methods and has a strong effectiveness and feasibility in mid-long term power load forecasting.

Global oceanic wind speed trends

This study presents the regional and seasonal climatic trends of the global oceanic sea surface wind speed for the period 1988–2011 using Cross-Calibrated, Multi-Platform (CCMP) wind data. The relationship between important factors (nino3 and soi index) and occurrences of wind speed is also calculated, in hope of providing references for the analysis of global climate change, development of offshore wind energy resources, air–sea interactions, and the basic reference helping for the mid-long term prediction of sea surface wind speed and occurrences of wind speed. The analysis results show that (1) The global oceanic sea-surface wind speeds increased at a significant overall rate of 3.35 cm s−1 yr−1 for the period 1988–2011; the maximal rate of increase, 4.15 cm s−1 yr−1, was attained between 1991 and 2007. (2) Globally, the sea-surface wind speeds significantly increased from 1988 to 2011. Only a few sporadic small water bodies exhibited decreasing wind speeds without significant variation over the 24-year interval. (3) The sea-surface wind speeds displayed obvious regional variability. The increasing wind speeds were more noticeable over the Pacific low-latitude waters than over waters of higher latitude. Wind speeds trends over the western Atlantic waters were stronger than those over the eastern Atlantic waters, while the south Indian Ocean winds were stronger than that those over the north Indian Ocean. (4) The variation in sea-surface wind speeds demonstrated noticeable seasonal differences. The increasing wind speed trend over the winter hemisphere was stronger than the one over the summer hemisphere. The variation in wind speeds over different waters was seasonally dominated. The increasing trend over the coastal waters of southern Greenland was dominated by the MAM and SON, was dominated by DJF in the Davis Strait and the Mediterranean, and was dominated by the SON 10° N over the Pacific Ocean and over the high-latitude waters in the southern Indian Ocean.

Bioprosthetic versus mechanical prostheses for valve replacement in end-stage renal disease patients: systematic review and meta-analysis.

Patients with end-stage renal disease (ESRD) indicated for dialysis are increasingly requiring cardiac valve surgery. The choice of bioprosthetic or mechanic valve prosthesis for such patients requires careful risk assessment. A systematic review and meta-analysis was performed to assess current evidence available. A comprehensive search from six electronic databases was performed from their inception to February 2015. Results from patients with ESRD undergoing cardiac surgery for bioprosthetic or mechanical valve replacement were identified. Sixteen studies with 8,483 patients with ESRD undergoing cardiac valve replacement surgery were included. No evidence of publication bias was detected. Prior angioplasty by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery was significantly higher in the bioprosthetic group compared to the mechanical group (16.0% vs. 12.0%, P=0.04); all other preoperative baseline patient characteristics were similar. There was no significant difference in 30-day mortality or all-cause mortality between the two comparisons. Compared with the mechanical group, the frequency of bleeding (5.2% vs. 6.4%, P=0.04) and risk of thromboembolism (2.7% vs. 12.8%, P=0.02) were significantly lower in the bioprosthetic group. There were similar rates of reoperation and valve endocarditis. The present study demonstrated that patients with ESRD undergoing bioprosthetic or mechanical valve replacement had similar mid-long term survival. The bioprosthetic group had lower rates of bleeding and thromboembolism. Further studies are required to differentiate the impact of valve location. The presented results may be applicable for ESRD patients requiring prosthetic valve replacement.

Interspinous dynamic stabilization adjacent to fusion versus double-segment fusion for treatment of lumbar degenerative disease with a minimum follow-up of three years.

The aim of this study was to assess the outcome of symptomatic lumbar degenerative disease treated with topping-off technique (Coflex(™) combined with fusion) and compare two-segment fusion at mid-long term follow-up; and find out whether the topping-off technique can reduce the rate of adjacent segment degeneration (ASD) after fusion. One hundred and fifty-four consecutive patients who received topping-off surgery (76 patients) and two-segment fusion surgery (88 patients) from March 2009 to March 2012 were studied. All patients included in the analysis had a minimum of threeyears of follow-up. Radiographic and clinical outcomes between the two groups were compared. A logistic regression analysis was used to analyze risk factors for developing radiographic ASD. Significant differences in clinical outcomes were observed between these two groups at three post-operative years (all, p < 0.05). Compared with the fusion group, the topping-off group showed preserved mobility at the Coflex(™) level (p = 0.000), which is associated with less blood loss (p = 0.000), shorter duration of surgery (p = 0.000) and lower incidence of ASD (Chi-square test, rate topping-off vs fusion = 13.2 vs 26.1%, p = 0.039). There were no differences in complications between the two groups. Mid-long term follow-up efficacy and safety between topping-off and fusion were similar, while topping-off reduced the rate of ASD. Under strict indications, topping-off surgery is an acceptable alternative to fusion surgery for the treatment of two-segment lumbar disease.

SSA-LSSVM在中长期径流预测中的应用研究

为提高中长期径流预测精度，利用奇异谱分析(SSA)对输入资料进行数据预处理，消除噪声，得到重建序列。以水布垭水库1951~2009年的入库月径流资料为依据，选用季节性一阶自回归模型、支持向量机模型和最小二乘支持向量机模型作为径流预测模型，对原始序列和重建序列进行模拟预测。结果表明，基于奇异谱分析的最小二乘支持向量机的模拟预测精度最高，率定期和检验期的模型效率系数分别高达89%和84%。说明采用SSA对资料进行预处理可以显著提高中长期径流预报的精度。 To improve the accuracy of runoff prediction, Singular Spectrum Analysis (SSA) is applied to preprocess the original flow series and a new reconstructed series is obtained. The monthly inflow data of the Shui-buya Reservoir from 1951 to 2009 were selected as a case study. Seasonal Autoregressive (SAR) model, support vector machine (SVM) and least square support vector machine (LSSVM) are used to simulate and predict the original and reconstructed data series. The results show that SSA-LSSVM performs the best among these models, in which the model efficiency coefficients reach 89% and 84% during the verification and testing periods, respectively. It is shown that the accuracy of mid-long term runoff prediction can be significantly improved by using SSA.

Impact of Midline Devices on Outcomes among Elderly Patients

In recent years, we have witnessed significant developments in the intravenous drug administration sector. This is especially true in the case of patients whose therapy is expected to last longer than three days, and the infusion still meets the criteria for a peripheral line. In this clinical situation we have the availability of midline catheters, devices able to remain in place for the duration of therapy for mid-long term IV therapy, both for in and out of hospital therapies and both for continuous and discontinuous therapies.

Organic Agriculture as a Paradigm of Sustainability: Italian Food and its Progression in the Global Market

Abstract The limits of the conventional model of industrial agriculture, which is typified by negative externalities affecting both the environment and public health, are now manifest. A model that is more environmentally friendly and respectful of public health is today both a necessity and a great opportunity for Italian producers. Acting with a view to mid-long term sustainability is the right choice also in terms of economic results. The current crisis has accelerated quality enhancement: quality has become an essential strategic element for being competitive. In the international markets there is a large and growing demand for Italian produce, which covers the entire agri-food sector. The growing attention towards aspects of health connected with food consumption places organic products in a privileged position. In this context, organic produce is found at the highest end of the top-quality products that Italy has to offer.

Endoscopic saphenous vein and radial harvest: state-of-the-art.

Over the past decade, there has been an increased adoption of minimally invasive techniques for saphenous vein and radial artery procurement during coronary artery bypass surgery, albeit concerns have been raised about the potential detrimental effects of the endoscopic approach when compared with the conventional 'open' technique. The aim of the present review is to analyse the current available techniques and evidence about the impact of an endoscopic approach on conduit quality and clinical outcomes. At present, the available techniques for endoscopic vessel harvesting can be based on a sealed or non-sealed concept, for both saphenous vein and radial artery procurement. Despite the proven advantages of a minimally invasive approach in terms of reduced incidence of wound complications, pain reduction and improved cosmetic results, some studies questioned the impact of this technique in terms of potential graft damage, thus impairing the longevity of the graft itself. Endoscopic conduit harvesting can be performed safely and effectively with the currently available techniques, albeit a careful knowledge of the pitfalls of each technique is mandatory. Since there is ample evidence in literature that a minimally invasive approach for saphenous vein and radial artery procurement is not associated with an increased risk of graft damage and related failure in the mid-long term, the endoscopic technique should be adopted as the approach of choice for saphenous vein and radial artery harvesting in coronary artery bypass graft surgery.

P064. 12 years of Master Degree in Headache Medicine at Sapienza University of Rome.

The Master in Headache Medicine has accomplished its 12th cycle of life [1]. At the time of its activation we acknowledged the necessity of an academic education thought to support the growth of a subspecialty included in major disciplines like neurology, internal medicine, emergency medicine, pharmacology and pain medicine. The challenge then was to reunite multidisciplinary skills in a common formative path recognized by National Health Systems [2]. The internationalization of the Faculty, the endorsement of the European Headache Federation, the educational arm of Lifting The Burden - The Global Campaign against Headache and the tight collaboration with the European Federation of Pain - Joint Campaign against Headache has allowed to complete an innovative project that has been heavily criticized for its uncertain utility in a contest where this educational strategy was considered only a redundant subspecialty [3, 4]. The educational offer over time included frontal lectures, clinical seminar with tutorial support and mid-term evaluations available on the Moodle platform. The attendance in the outpatient and daily hospitalization wards of a University Hospital with a solid national experience avant-garde on these diseases completed the educational frame. Foreign students could benefit from distance e-learning platform and bursaries for those coming from developing countries. The qualified international profile of the Faculty guaranteed the excellence of the formative offer. Today, after 12 years of academic education, Sapienza University of Rome has released 119 master degree diplomas in headache medicine to as many students coming from all the six WHO geographical areas: Africa, Americas, Europe, Eastern Mediterranean, South-East Asia, Western Pacific. The Train-The-Trainers model, a top-down educational activity, has accomplished its path allowing all the master degree physicians to teach headache medicine locally in favour of GPs. The same Sapienza distance e-learning platform served also as source for this second level of education. This experience has shown to be fruitful in a mid-long term and particularly useful in geographical areas with a low presence of area experts. After more than 10 years the received feedbacks show the efficacy of this educational spreading model thought to reach the control of headache disorders now ranked as third most disabling disease in the world [5].

Technical exploration and efficacy observation of stepwise multiple embolization treatment for refractory hemoptysis

Objective To explore main technical points and clinical efficacy of individualized stepwise multiple embolization treatment for refractory hemoptysis. Methods To retrospectively analyze materials of 103 patients treated by individualized stepwise multiple embolization. According to disease categories, individualized stepwise multiple embolization treatment with polyvinyl alcohol and loaded sodium alginate microspheres as basic embolization agent were performed, after the type, number, abnormal branches, pulmonary circulation and systematic pulmonary shunt of targeted vessels were confirmed through radiography. To judge short(less than 3 months), medium(3 to 6 months) and long term(more than 6 months) efficacy, resolution of hemoptysis after operation were assessed. To evaluate efficacy of individualized stepwise multiple embolization treatment for refractory hemoptysis, Kaplan-Meier survival curves were used. According to the features of target vessels to supply blood, patients were classified into with SPS and without SPS. By using Log-Rank test, the effective rates of one-year were compared between them. Results Out of 103 patients, 215 target vessels were demonstrated, among which individualized stepwise multiple embolization was for 196 target vessels, peripheral embolization for 8 vessels, and main trunk embolization in 11 patients. The visits after operation were made to 103 patients after 6 to 50 months, with the medium of 21 months. Hemoptysis was instantly resolved in 97.1% (100/103). The effective rates were 94.5%,93.2%, 89.7%,88.9%,85.2% and 76.6% for one, three, six months and one, two and three years after operation. In 103 patients, patients with SPS were 22 and without SPS were 81. One-year effective rates with and without SPS were (69.50 ±0.11)% and (98.30 ±0.03)% , respectively (χ2=11.662,P<0.01). Conclusion Individualized stepwise multiple embolization treatment shows excellent short-term and mid-long term efficacy in the treatment of refractory hemoptysis. Key words: Hemoptysis; Bronchial arteries; Embolization,therapeutic

Adaptive management and debarking schedule optimization of Quercus suber L. stands under climate change: case study in Chamusca, Portugal

Cork oak stands are one of the major sources of income from Portuguese Mediterranean forests. Future climate is projected to increase temperatures, reduce precipitation and decrease current forests’ productivity and therefore, adapting management, is a key strategy to mitigate impacts of future climate on cork supply. The central objective of this research was to compare conventional and adaptive management regimes under scenarios of climate change. The adaptive management focussed on adopting optimal harvest schedules while considering different management objectives. The study focused on the Chamusca region, one of the most productive areas of cork, and considered four distinct spatial scales for analysis. For each scale, the management objective was defined according to field information and considered the maximization of cork production while targeting different cork harvesting flows: (a) more frequent and regular or (b) less frequent and concentrated. A forest growth model was used to simulate climate change impact on future yield of cork oak stands under different forest management alternatives. A mixed integer programming model was developed to find the most adequate cork debarking cycle calendar for cork oak stands. Our results suggest that (1) business as usual management under climate change scenarios could decrease cork supply and carbon stock in the tree component of the forests by up to 20 and 30 %, respectively, (2) the development of adaptive management strategies, including cork extraction schedule optimization, to address climate change has advantages over traditional practices and (3) may contribute further to increase cork production (up to double productivity in mid-long term) while addressing concerns with the regulation of cork extraction flows through the adaptation of debarking periods. The mixed integer programming allowed the spatial visualization of the debarking cycle delay. Furthermore, results underline the relevance of an approach to develop adaptive management strategies that can consider different management goals, with different constraints to address climate change.