excised down to the level of the deep muscle fascia from the knee to the dorsum of the foot. The wound was covered with 12-to 16/1000-inch split thickness skin grafts harvested from the ipsilateral leg. For those who underwent elective toe amputations, toe disarticulation at the metatarsalphalangeal joint was combined with removal of the articular cartilage from the metatarsal heads. Average follow-up was 3.5 years. During follow-up, 20% of the patients who underwent combined Charles procedure and elective toe amputation experienced recurrent bouts of cellulitis of the foot or leg, 50% required at least one operation for excision of crypts within the skin-grafted areas, and none required more proximal amputations. In those patients who did not undergo elective toe amputation, 83% had multiple episodes of foot or leg cellulitis and 54% underwent at least one operation for foot or leg excision of crypts, and 80% subsequently required amputation of toes secondary to chronic ulceration, infection, or drainage from web spaces. Two patients required more proximal amputation, including one below knee amputation.Comment: Those who care for patients with advanced lymphedema realize that appropriate foot hygiene is the mainstay to reduce interdigital entry lesions, but such care can be ineffective in the terminal stages of lymphedema. These patients have deformity of the toes and limited mobility. The increased weight and volume of the affected limbs prevents them from performing appropriate foot hygiene. This is an aggressive approach to the treatment of end-stage lymphedema. Nevertheless, if a decision has been made to perform a Charles procedure, the authors' data suggest the addition of toe amputations is reasonable.

It may be prudent to give anticoagulants not only to patients in atrial fibrillation and patients with previous systemic embolism but also to those showing a left atrial thrombus or significant aortic regurgitation on echocardiography. Early percutaneous balloon mitral commissurotomy may also help prevent systemic embolism in patients with mitral stenosis.

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Our results suggest that MICS is a good option for surgical closure of ASD.

BackgroundPlatelet activation is relevant to a variety of coronary heart diseases. Our previous studies revealed that sesamol possesses potent antiplatelet activity through increasing cyclic AMP formation. Although platelets are anucleated cells, they also express the transcription factor, NF-κB, that may exert non-genomic functions in platelet activation. Therefore, we further investigated the inhibitory roles of sesamol in NF-κB-mediated platelet function.MethodsPlatelet aggregation, Fura 2-AM fluorescence, and immunoblotting analysis were used in this study.ResultsNF-κB signaling events, including IKKβ phosphorylation, IκBα degradation, and p65 phosphorylation, were markedly activated by collagen (1 μg/ml) in washed human platelets, and these signaling events were attenuated by sesamol (2.5~25 μM). Furthermore, SQ22536 and ODQ, inhibitors of adenylate cyclase and guanylate cyclase, respectively, strongly reversed the sesamol (25 μM)-mediated inhibitory effects of IKKβ phosphorylation, IκBα degradation, and p65 phosphorylation stimulated by collagen. The protein kinase A (PKA) inhibitor, H89, also reversed sesamol-mediated inhibition of IκBα degradation. Moreover, BAY11-7082, an NF-κB inhibitor, abolished IκBα degradation, phospholipase C (PLC)γ2 phosphorylation, protein kinase C (PKC) activation, [Ca2+]i mobilization, and platelet aggregation stimulated by collagen. Preincubation of platelets with the inhibitors, SQ22536 and H89, both strongly reversed sesamol-mediated inhibition of platelet aggregation and [Ca2+]i mobilization.ConclusionsSesamol activates cAMP-PKA signaling, followed by inhibition of the NF-κB-PLC-PKC cascade, thereby leading to inhibition of [Ca2+]i mobilization and platelet aggregation. Because platelet activation is not only linked to hemostasis, but also has a relevant role in inflammation and metastasis, our data demonstrating that inhibition of NF-κB interferes with platelet function may have a great impact when these types of drugs are considered for the treatment of cancer and various inflammatory diseases.