The optimal technique for airway management in patients with cervical pathology remains unclear. Intubating laryngeal mask airway devices such as LMA CTrach and LMA Fastrach have not been compared for cervical spine (C-spine) movements in the context of cervical pathology. The present study aimed to determine upper C-spine movements by radiography during intubation with different devices as well as comparing the duration and success of intubation in cervical surgery.2 were excluded. Participants were randomized to one of the 3 groups: LMA CTrach, LMA Fastrach, or the Macintosh laryngoscope. C-spine motion was evaluated by measuring angles created by bordering vertebrae at cervical 1/2 and 2/3  segments on 2 lateral cervical radiographs for each patient. Intubation time, ease of intubation, number of attempts, and success rate were also documented. Sixty patients scheduled for elective cervical surgery were registered in this prospective, randomized study. Patients with cervical trauma/injury, previous neck surgery, and body mass index (BMI) of >35 kg/mDemographic data were similar in all the groups. The cervical movement with LMA CTrach and LMA Fastrach compared to the Macintosh laryngoscope were similar at C1/2. However, LMA CTrach significantly reduced extension compared to LMA Fastrach and Macintosh laryngoscopes at C2/3. Duration of intubation was significantly shorter with the Macintosh laryngoscope. The rate of successful intubation was 80% with LMA Fastrach and 100% with both LMA CTrach and the Macintosh laryngoscopes.The LMA CTrach laryngoscopy involves less upper C-spine movement than the LMA Fastrach and does not increase the duration of the intubation period.  Intubation with various airway devices causes cervical spine (C-spine) extension to some degree. The process gains importance especially in emergency situations with cervical injury and in C-spine surgeries . The main concerns of anesthesiologists for airway management both in cervical injury and C-spine surgeries include avoiding prolonged intubation time and preventing neurologic damage due to excess cervical movements .Conventional laryngoscopy with a Macintosh blade remains the most familiar way to enable tracheal intubation. However, maneuvering for intubation and adjustment of the oropharyngeal and laryngeal axes produces C-spine movement [4]. In a recent systemic review, alternative intubation techniques performed in patients with cervical immobilization were compared with the Macintosh laryngoscopy [5]. The authors concluded that evidence of the efficacy of alternative devices was missing. Fiberoptic intubation is still the most ideal technique to secure an airway in patients with predicted difficult intubation [2]. Fiberoptic laryngoscopy is considered to facilitate the least cervical movement during laryngoscopy but has several limitations like requiring a cooperative patient and lasting a long time, making it unsuitable for emergencies . However, as intubating laryngeal mask airways (ILMAs), LMA CTrach and LMA Fastrach are alternative techniques that may be useful when fiberoptic bronchoscope is not available. ILMAs have been validated for ventilation and as a conduit to tracheal intubation in patients with difficult airways. LMA CTrach was developed from LMA Fastrach with additional advantageous features like visualizing the glottis and intubation process . However, both devices require experience to operate and the administration may prolong intubation time. Previous radiographic and fluoroscopic studies, purporting to evaluate C-spine movement during intubation with various intubating techniques, were carried out. . Intubating laryngeal mask airways have been compared for the success of tracheal intubation . However, there have been no studies investigating C-spine movements using both ILMAs. Moreover, the effects of different intubation techniques on cervical movements were followed among healthy subjects in nonemergency situations not including neck, throat, or cervical surgeries in patients with cervical immobility due to manual in-line stabilization or cervical collars and in cadaveric models in most studies . Comparative studies performed on patients with cervical pathologies who undergo cervical surgery are lacking in the literature. Therefore, this prospective, randomized radiographic study was conducted to compare the movements of the upper C-spine  during laryngoscopy via LMA Fastrach, LMA CTrach, and Macintosh laryngoscopes in patients with lower cervical pathology undergoing C-spine surgery. The secondary outcomes were the comparison of the intubation success and the duration. The ethics committee of the School of Medicine of Erciyes University approved this prospective, randomized, and controlled study (reference number: 2011/177). All the patients were informed about the study and written consent was obtained. Inclusion criteria were American Society of Anesthesiologists (ASA) physical status of I–III, ages between 18 and 70 years old, and patients undergoing elective C-spine surgery. Patients with documented cervical trauma or injury, previous neck surgery, body mass index (BMI) of >35 kg/m2, the possibility of pregnancy, or failed tracheal intubation (more than 2 intubation attempts with a device) were excluded. All patients’ preoperative height, weight, ASA physical status, BMI, and Mallampati scores were documented. Electrocardiography, noninvasive blood pressure measurement, and pulse-oximeter were monitored in all patients in a standard fashion. Before anesthesia induction, the patients were positioned in a neutral position. Following preoxygenation, anesthesia was induced with intravenous (IV) 2 mg/kg propofol, 1 mg/kg lidocaine, 0.5 µg/kg remifentanil, and 0.6 mg/kg rocuronium, and maintenance was achieved with sevoflurane in an air-oxygen mixture and IV infusion of remifentanil. In the operating room, 63 patients were randomly assigned by a computer random number generator to one of the 3 groups, corresponding to the 3 airway devices: Macintosh laryngoscope (Group M), LMA Fastrach (Group F), or LMA CTrach (Group C). We did not stabilize the head and neck or apply cricoid pressure. In Group M patients, conventional direct laryngoscopy was performed. The diameter of the endotracheal tube (ETT) was 7 or 7.5 mm in females and 8 mm in males. In Group F, size 3, 4, or 5 LMA Fastrach  depending on the weight of the patient was applied in accordance with the manufacturer’s instructions. A silicone reinforced ETT was lubricated and inserted. If the right position of the tube was achieved without resistance, the ETT was advanced into the trachea and the cuff was inflated. The position of the ETT was determined by auscultation and capnography. Subsequently, a special stabilizing rod was used to remove the LMA Fastrach. In Group C, size 3, 4, or 5 LMA CTrach  was preferred depending on the weight of the patient. Initially, LMA CTrach was inserted without the viewer on, just as LMA Fastrach was applied. The cuff was inflated and the patient was ventilated. The viewer was then attached to the connector while holding the handle. When a clear image of the glottis and vocal cords was achieved, an ETT was inserted and intubation was visualized, and the ETT cuff was inflated. The viewer was then detached, and LMA CTrach was removed following the same procedure as for LMA Fastrach. The same experienced anesthesiologist, who had previously performed at least 100 intubations with each of LMA CTrach and LMA Fastrach and 500 intubations with the Macintosh laryngoscope, performed all laryngoscopies in order to minimize interoperator variability. The intubation techniques were recorded with a portable X-ray machine. Two recordings were performed a steady distance from the patient and the tube in the lateral position. The first was taken in a neutral position before the intubation process and the second was taken when the best view of the glottis was achieved with the LMA CTrach and Macintosh laryngoscopes. For the LMA Fastrach, if no resistance was felt as the ETT was advanced through the mask aperture into the trachea, it was thought to be at correct tube positioning and indicated time for the fluoroscopy. The movements of the cervical 1-2 and 2-3 segments were evaluated in radiographs. First we drew a reference line, which follows the cervical 2 dorsal alignment. Then we drew two more lines, which transected the driven reference line, the first one between the anterior and posterior arches of the cervical 1 and the other one through the cervical 3 basal plate of C3. Thus, there were two angles observable: one between the reference line and the arches of cervical 1, named alpha (α), while the second angle, named beta (β), was located between the reference line and the line passing through the cervical 3 basal plate. The lines were drawn and an investigator, who was unaware of the study group assignments, randomly measured angles using a goniometer in degree (°) unit. The duration of intubation, the number of attempts, and the intubation success rate were recorded. The duration of the intubation was recorded between the passage of the intubation device through the lips and inflation of the tracheal cuff. Intubation was considered successful if the patient was intubated in less than two attempts and failed in case of more than two. Estimated from the data of Watts et al. [15] (12.9 ± 2.1° extension) and based on the assumption of α = 0.05, β = 0.8 to detect 15% reduction in the movement of the upper C-spine, each group would need to include at least 18 patients. Therefore 20 patients per group were planned to be enrolled due to the probability of a 10% drop-out rate. SPSS 15.0 for Windows  was used for the statistical analysis. Data are expressed as mean ± standard deviation (mean ± SD), median (min–max), or numbers (n) and percentages (%). Discrete variables  were compared using the chi-square test. For numeric parameters of between-group comparisons, one-way analysis of variance (in the case of parametric test conditions) or the Kruskal–Wallis tests (if parametric test conditions could not be obtained) were used. Multiple comparisons of the Kruskal–Wallis test were done by Mann–Whitney U test with Bonferroni correction. Analysis of variance was used for repeated measures of arterial pressure, heart rate, and oxygen saturation and the angle measurements for both between-group and intergroup comparisons. P < 0.05 was considered statistically significant.Sixty-three patients were allocated to the intervention groups. For one patient, intubation with LMA Fastrach was not possible despite adequate manipulation, even after the third attempt. Following 3 esophageal intubations, correct intubation was achieved by direct laryngoscopy and this patient was excluded from the study. In Group C, the vocal cords of 1 patient could not be visualized despite all maneuvers and the patient was also excluded. One of the patients’ radiographic images could not be printed out so the angle measurement could not be analyzed in Group M. Subsequently, 20 patients per group were analyzed.2, remained stable in all groups and anesthesia was uneventful in all patients. None of the patients had hypertension or tachycardia as a response to laryngoscopy. The demographic data, Mallampati scores, and ASA physical status classification (P > 0.05) were similar in all groups (Table 1). The hemodynamic and ventilation parameters, such as arterial blood pressure, heart rate, oxygen saturation, and end-tidal COCervical alpha (α) angles in degrees at the C1/2 segment of the study patients are shown in Table 2. Baseline measurements were significantly different in Group M compared with the other groups (P = 0.004). According to the neutral baseline position, angulation of the C1/2 segment (α angle) decreased during intubation in Group F (P = 0.042) and in Group M (P = 0.001), whereas there was no significant difference in Group C (P = 0.159). The mean degree of the change in angulation compared with the preinduction baseline values at C1/2 1.2°, 1.1°, and 2.9° for Groups F, C, and M was not statistically significant.Cervical beta (β) angles of the studied patients are displayed in Table 3 in degrees. At the C2/3 segment (β angle) Groups F and M similarly showed a significant increase  in cervical motion, while there was no difference in Group C during intubation compared with the neutral position. The mean change in β angle during intubation was prominent in Groups F and M, but in Group C the extension was statistically less .The mean intubation time was 32 s in Group M, ranging from 10 to 120 s. It took the longest time to intubate patients in Group F and the shortest in Group M (P < 0.001) (Table 4). The mean duration of intubation was 98.8 and 61.0 s for the LMA Fastrach and LMA CTrach, respectively (P < 0.001). The numbers of patients intubated in the first attempt were 18 with the Macintosh laryngoscope, 15 with LMA CTrach, and 11 with LMA Fastrach while two attempts were required for 2, 5, and 5 patients, respectively (Table 4). The number of attempts significantly differed in Group F compared to Group M (P = 0.016). It required more than two attempts and was successful after repositioning the LMA Fastrach in 4 patients. The rate of successful tracheal intubation was 80% with LMA Fastrach and 100% with LMA CTrach and Macintosh laryngoscopes. Group F had the statistically lowest success rate (P = 0.009).The main result of this study is that the LMA CTrach significantly reduced extension compared to LMA Fastrach and Macintosh laryngoscopes at the C2/3 segment (β angle) without prolonging intubation time in patients undergoing elective C-spine surgery. According to our hypothesis, both LMA Fastrach and LMA CTrach would be associated with less cervical movement than Macintosh laryngoscopes, which was at least partially confirmed with LMA CTrach for the β angle. A study by Sawin et al. investigated the behavior of the intact C-spine during direct laryngoscopy with a Macintosh blade and proved the general assumption that a majority of cervical motions associated with laryngoscopy occur in the upper cervical region [4]. Subaxial segments (under C2) were displaced minimally. Thus, the present study was undertaken to quantify the motion of cervical segments 1/2 and 2/3. The times for radiography were chosen as once before induction and once during laryngoscopy immediately prior to insertion of the endotracheal tube or when the best view of the glottis was achieved as Hindman et al. reported maximal intubation biomechanics occurring at that stage [16]. A cadaver model of cervical instability found that supraglottic airways  caused less or equal C-spine movement compared to the conventional laryngoscopes  [9]. The authors therefore suggested that, due to the ease of training, supraglottic airways could be preferred in cervical trauma patients. Komatsu et al. tested ILMAs for controlling the airway in patients undergoing C-spine surgery who were wearing rigid cervical collars to simulate C-spine injury and found ILMAs a reasonable alternative for facilitating intubation [17]. Panjabi et al. defined the upper limits of the physiological motion as a rotation of over 20° in the sagittal plane [18]. The maximum cervical motion at C2/3 in our study was 15° for the Macintosh laryngoscope, 12.4° for LMA Fastrach, and 7.6° for LMA CTrach. In a video-fluoroscopic study, Sahin et al. observed a maximum movement of 18.5°, 16.7°, and 8.1° during direct laryngoscopy, intubation with ILMA, and fiberoptic laryngoscopy at C1/2 [6]. The maximum cervical motion produced with LMA Fastrach in both studies was close to the angle of the Macintosh laryngoscope. However, it was still lower than the instability limits argued by Panjabi et al. [18]. Even though the extension of the motion produced by LMA CTrach in the present study seems to be less than that produced by fiber optic laryngoscopy in Sahin’s study, it is actually difficult to compare the data of these similar studies. In the present study there was a significant difference in baseline angle measurements at C1/2. We do not recognize this as a study limitation because the initial position of the patient’s head cannot be standardized. However, the degree of cervical extension during laryngoscopy is important. The previous literature reported extension at C1/2 produced with ILMAs ranging from 1° to 5° and even as high as 7.4° . Our result is in line with this range. Nevertheless, variability of the results depends on the heterogeneity introduced by methodological and population differences of the studies and experiences of the investigators. The ability to intubate a trachea under glottis visualization with LMA CTrach was reported with higher first attempt success rates compared with LMA Fastrach [14]. Liu et al. found a 98.9% first attempt success rate for LMA CTrach in 100 patients, while Baskett et al. showed a 79.8% success rate for LMA Fastrach with the experience of 500 cases . Bilgin et al. demonstrated a first attempt success rate of intubation of 54% for ILMAs and 90% for C-Trach [13]. Our success rate, which is 75% with LMA CTrach and 55% with LMA Fastrach, is lower than those in the published literature. The diversity of these results is probably due to the methodological differences, the skills of the investigators, and the sample sizes of the mentioned studies. Nevertheless, in the current study, tracheal intubation was defined as successful only if the patient was intubated in two attempts at most with a device and the rate of successful tracheal intubation was 80% with LMA Fastrach, which statistically had the lowest rate.Secondary spinal injury during airway management is not only a result of the mechanical disruption of the unstable segments, but hypoxia is also likely to cause harm . Although both LMA CTrach and LMA Fastrach administrations may prolong intubation, they have established roles in difficult airway management since they do not interrupt ventilation . Obviously, duration of intubation lasts longer with devices that require different maneuvers compared to the laryngoscopes. In the present study, as the most familiar device for anesthetists, the Macintosh laryngoscope intubation was fastest, while the duration of intubation was significantly longer with LMA Fastrach. These findings are in line with those of Bilgin et al., who reported significantly longer mean intubation time with an ILMA compared to C-Trach and McCoy [13]. Nevertheless, none of the patients in our study presented hypoxia throughout the intubation process. Randomizing the patients without considering their Mallampati scores and evaluating airway difficulties might be a limitation of our study. If the selection of the airway device depended on the possibility of a difficult airway, a selection bias would occur for LMA CTrach over blind intubation using LMA Fastrach. Nevertheless, Mallampati scores were identical between the groups. Another possible shortcoming of the study is that it was impossible to blind the investigator to the airway device and only an independent radiologist who measured the angles was unaware of the study group assignments. Several investigators may have had different skill levels and experiences, so only one investigator performed all laryngoscopies in order to minimize any confounding effects. The third limitation is that tracheal intubations were facilitated with muscle relaxants. Sawin et al. [4] suggested that muscle relaxation using neuromuscular blockade might reduce the need for cervical extension during laryngoscopy. However, even in injury settings muscle relaxants are used to ease the insertion of the endotracheal tube. Finally, the study conclusions may be limited since this project examined only two X-ray graphics instead of dynamic fluoroscopy.In conclusion, airway management with minimal neck movement improves the success of the anesthetic management in C-spine surgery. Moreover, there are limited data that may help to understand C-spine kinetics of the patients with cervical pathologies, especially degenerative disorders requiring surgery. It is thus important to be familiar with the different intubation techniques. However, one should also be aware of their effects on cervical extension. We conclude that the reduced C-spine extension during intubation with LMA CTrach makes it a reasonable alternative compared to LMA Fastrach and Macintosh laryngoscopes in cervical surgery where cervical stability is a concern.


Wood-based TEMPO-oxidised cellulose nanofibrils (toCNF) are promising materials for biomedical applications. Cyclodextrins have ability to form inclusion complexes with hydrophobic molecules and are considered as a method to bring new functionalities to these materials. Water sorption and mechanical properties are also key properties for biomedical applications such as drug delivery and tissue engineering. In this work, we report the modification with β-cyclodextrin (βCD) of toCNF samples with different carboxyl contents viz. 756 ± 4 µmol/g and 1048 ± 32 µmol/g. The modification was carried out at neutral and acidic pH (2.5) to study the effect of dissociation of the carboxylic acid group. Films processed by casting/evaporation at 40 °C and cryogels processed by freeze-drying were prepared from βCD modified toCNF suspensions and compared with reference samples of unmodified toCNF. The impact of modification on water sorption and mechanical properties was assessed. It was shown that the water sorption behaviour for films is driven by adsorption, with a clear impact of the chemical makeup of the fibres . Modified toCNF cryogels (acidic pH and addition of cyclodextrins) displayed lower mechanical properties linked to the modification of the cell wall porosity structure. Esterification between βCD and toCNF under acidic conditions was performed by freeze-drying, and such cryogels exhibited a lower decrease in mechanical properties in the swollen state. These results are promising for the development of scaffold and films with controlled mechanical properties and added value due to the ability of cyclodextrin to form an inclusion complex with active principle ingredient (API) or growth factor (GF) for biomedical applications. Cellulose nanofibrils (CNFs) are high-aspect ratio nanoparticles formed by bundles of cellulose chains that are a succession of glucose subunits linked by β-1-4 glycosidic bonds. CNFs are produced from a cellulosic raw material, usually wood, the most abundant and renewable polymer available on earth. CNFs are produced by a combination of chemical/enzymatic pretreatments and mechanical treatment, usually using a homogeniser , or a grAs a natural, biodegradable, and abundant polymer with reactive surface chemistry and good biocompatibility, nanocellulose is a promising material within the medical field. In recent years, applications in wound healing ,21, drugThe utilisation of wood-based CNFs for tissue-engineering applications is encouraged by recent studies that confirmed the safety of CNFs ,28,29,30Cyclodextrins are cyclic oligosaccharides consisting of glucose subunits linked by α-1-4 glycosidic bonds. Due to their conformation, with a hydrophobic interior and a hydrophilic exterior, these macromolecules exhibit cage-like properties and can form an inclusion complex with hydrophobic compounds ,35. ThesThe aim of the present study is to modify toCNF with βCD  and to see what kind of effect this surface functionalisation has on the sorption and mechanical properties. Thus, a comparison with the same structures using unmodified toCNF is necessary. For that purpose, two suspensions of toCNF with different charge contents were prepared. Fibre modification with cyclodextrins was carried out at neutral and acidic (pH 2.5) to study the effect of the dissociation of the carboxylic acid group. Films, processed by casting/evaporation at 40 °C and cryogels, processed by freeze-drying were prepared from βCD-modified toCNF and compared with reference samples of unmodified toCNF. Water sorption was evaluated gravimetrically for both films and cryogels. The impact of density on the mechanical properties of the cryogels was assessed for cryogels obtained from unmodified toCNF and prepared by freeze-drying from suspensions at different dry matter contents for both charge contents. Compression tests in the dry and swollen state were performed on cryogels from all suspensions, and microscopic observation (SEM) was carried out to link the mechanical behaviour to the macroscopic structure of the materials.TEMPO-oxidised cellulose nanofibril suspensions were successfully produced. The amounts of carboxylic groups were determined to be 756 ± 4 µmol/g and 1048 ± 32 µmol/g. Films and cryogels were processed from the two different toCNF suspensions in four different conditions presented in The suspension with 756 µmol/g carboxyl content will be referred as L-toCNF in the text; hence, samples from L-toCNF will be labelled L1, L2, L3, and L4. Similarly, the suspension with 1048-µmol/g carboxyl content will be referred as H-toCNF; i.e., samples from H-toCNF will be labelled H1, H2, H3, and H4. Water sorption of films was assessed gravimetrically in a Percival climatic chamber at 25 °C and 90% relative humidity (RH) for 48 h. For each sample of both L-toCNF and H-toCNF, the sorption equilibrium was reached after approximately 4 h, which indicates that this property is not dependent of any of the variable parameters in this study. In addition, the sorption equilibrium was achieved within a relatively short period of time, with about 65% of the sorption equilibrium reached after 30 min for films cast in acidic conditions, up to around 80% for films containing cyclodextrins. The difference in sorption equilibrium observed between L-toCNF and H-toCNF can be linked to the number of carboxylic functions prone to form H-bonds with water molecules, which is higher for H-toCNF than for L-toCNF. The increase in sorption for films prepared under acidic conditions is explained by the acid form of the carboxylic groups, which is more prone to form H-bonds with water molecules than the carboxylate form at neutral pH. Finally, the decrease in sorption with the addition of cyclodextrin is thought to be due to the adsorption of β-CD on the surface of the fibres, which could decrease the amount of water bounded to the fibres. Water sorption is mainly driven by adsorption and chemical makeup-dependent. For a given drying temperature, the water sorption can be slightly tuned by varying the process parameters, which is an interesting property for drug delivery applications, where swelling and sorption properties are important for the delivery kinetics.Water sorption tests for cryogels were conducted gravimetrically. The cryogels were weighted and immersed in distilled water and then removed at different time intervals. Tissue paper was used to remove excess water prior to weighing. For both charge contents, the swelling equilibrium was reached after the first measurement at 15 min, as shown in Compression tests were carried out on cryogels of cylindrical shape. The density of each sample was determined by dividing the mass of each cryogel by its volume. The volume of the cryogels was measured from height and diameter measurements using a calliper. In each case, the compression curve can be divided into three different regions: For low-strain values, the compression stress increases linearly with the strain in the elastic domain up to the yield point. The compression modulus was calculated at a strain corresponding to half the yield stress in order to be reproducible between all samples. For strains higher than the yield point, the plastic region was reached. In this region the stress increases with the strain with significant residual deformation after unloading. For high compressive strains, the curves exhibited a sharp increase in the compressive stress, typical of a densification regime.This behaviour has previously been reported for cellulose-based foam materials ,16,18,193 (which corresponds to a relative density of 0.01). It is worth noting that the normalised compression modulus withstands a huge decrease for relative densities lower than 0.008. Density is of major importance for the mechanical behaviour of cryogels, and by controlling the density, it is possible to tailor the mechanical properties of the cryogel.Compression tests were carried out on cryogels with four different densities prepared from toCNF with both charge densities. Variations of the different properties  with the relative density are presented in Cryogels were prepared from the four compositions by freeze-drying the nanofibril suspensions. SEM images of the cross-section of the cryogels are presented in This specific orientation of porosity is due to the freeze-drying process. Indeed, freezing occurred from the bottom part of the freeze-dryer, resulting in the growth of ice in a specific direction, leading to anisotropy in the pore orientation.In addition, we can observe that the structure of the cell walls for modified toCNF cryogels presents more structural deflects (holes and folds) than the unmodified toCNF one. Compression tests were carried out on cryogels prepared from the four compositions for both charge contents. Typical stress-strain curves for each composition are presented in Unmodified toCNF cryogels (H1 and H2) exhibit clear elastomeric behaviours, with well-defined linear elastic zones up to a strain of about 0.2, followed by a compression plateau and a densification for higher strains. For modified toCNF cryogels (H3 and H4), the linear elastic zone is restrained to lower strain values, and the yield point is less marked. The deflects observed in An increase in density can be observed for cryogels cast under acidic pH and with cyclodextrins. The carboxyl content increases the interactions between the fibres in its carboxylic form, as it forms a more densely packed structure. The adsorption of cyclodextrins on the surface of the fibres also increases the interaction between fibres or creates local deflects in the fibres’ arrangement. Both mechanisms impact the mechanical properties. The mechanical properties decrease when the density increases, and the elastic region in the stress-strain curve also decreases for cryogels cast under acidic pH or when containing cyclodextrins. It is also worth noting that the yield point is lower for modified cryogels (pH and cyclodextrins) than for the unmodified one and that the plateau is less pronounced. Since elasticity of foams is linked to the stretching of the cell walls and the plastic behaviour prior to densification is linked to the compression of cells, the modification of fibre-fibre interactions under acidic pH and/or with adsorption of cyclodextrin on the fibre surface is responsible for the modification of the cell wall, thus the mechanical properties. Both charge contents exhibit a similar behaviour for toCNF, toCNF pH 2.5, and toCNF 10 wt% CD, but a noticeable difference is observed for toCNF 10 wt% CD pH 2.5. For L-toCNF, the density decreases between pH 2.5 and 10 wt% CD pH 2.5, while the normalised compression modulus and the maximum stress at deformation are quite similar. For H-toCNF, the density increases between pH 2.5 and 10 wt% CD pH 2.5, while the normalised compression modulus and the maximum stress at 70% deformation decrease. Under these conditions (10 wt% CD and pH 2.5), esterification occurred between the carboxylic acid of the toCNF and hydroxyl groups of cyclodextrins, as evidenced by the attenuated total reflectance-Fourier transform infrared (ATR-FTIR) spectra shown in −1 corresponds to the carboxylate ions present on the surface of the fibres introduced during TEMPO-mediated oxidation. For toCNF 10wt% CD pH 2.5, a peak at 1750 cm−1 can be observed which corresponds to the ester groups. The presence of this esterification peak only for toCNF 10wt% CD pH 2.5 indicates that the esterification reaction occurred between the hydroxyl groups of the cyclodextrins and the carboxylic acid groups of toCNF under acidic pH, suggesting that the lyophilisation process allows the reaction by the removal of water. Considering the respective charge contents for L-toCNF and H-toCNF, the efficiency of esterification might be higher for H-toCNF, which can explain the decrease in mechanical properties observed for H4.The peak observed at 1600 cmCryogels were immersed in water for 1 h prior to the experiment, and tissue paper was used to remove excess water before compression. The changes in mechanical properties between the dry and swollen states are summarised in Since no clear elastic deformation zone can be observed for swollen cryogels, the compression modulus was calculated at a low strain (< 0.1) for comparison with dry cryogels. The decrease in mechanical properties is more significant for H-toCNF , which can be explained by the higher charge content, making the fibres more sensitive to the adsorption of water molecules. It is also worth noting that the decrease in mechanical properties is reduced for H4 in comparison with L4, with respectively −49% and −77% decreases in the compression modulus compared to their dry state. This behaviour could be explained by the esterification between cyclodextrin and toCNF, cross-linking fibres, and making the structure less sensitive to water ad/absorption. Esterification of βCD with toCNF under acidic conditions by freeze-drying was proven. Nevertheless, some questions remain about the yield of grafting and the adsorption mechanism between unbound cyclodextrins and toCNF. Given the chemical similarity between toCNF and βCD, direct characterisation and quantification of grafting seems impossible, as a cyclodextrin with several hydroxyl functions is likely to bind with the carboxylic acid of toCNF. Nevertheless, the presence of multiple hydroxyl functions on both toCNF and βCD indicates a strong adsorption between these two components. However, some cyclodextrins might be trapped in the ice phase during the freezing process and, therefore, are not available for an esterification reaction during the freeze-drying phase. In order to better quantify this adsorption and to be able to confirm that no material will be released from the materials produced, further studies, in particular with the means of Quartz Crystal Microbalance with Dissipation monitoring (QCM-D) and Isothermal Titration Calorimetry (ITC), will be conducted. Additionally, a method adapted from  will be The compression modulus for swollen modified toCNF cryogels ranges between 6 and 9 kPa, i.e., in the range of mechanical stiffness of muscle tissue, and the high porosities obtained , which are mandatory to promote a good vascularisation, the diffusion of nutrients to the cells, and tissue growth, made this structurally suited for tissue engineering applications. Further studies will be focused on the mechanical properties of such materials under successive stress. Nevertheless, to confirm the potential for tissue-engineering applications, cytotoxicity and degradation studies need to be done in further work. However, βCD toCNF materials could be of a great interest for other applications, such as filtration or depollution, using cyclodextrins to capture molecules of interest rather than release them.A mixture of bleached and never-dried spruce (picea abies ca. 75%) and pine  cellulose pulp from Södra  was used as raw material. All chemicals used in this study were of laboratory-grade quality purchased from Sigma-Aldrich, St. Louis, MO, USA.TEMPO-oxidised cellulose nanofibrils were produced according to a protocol adapted from . Never-dThe carboxyl group content was determined by conductometric titration as described in previous studies e.g., ,32,65). ,65. 32,6Dry toCNF (0.25 g) was weighed and diluted with water to a total volume of 50 mL. The suspension was dispersed for 2 min at 7000 rpm with an UltraTurrax , at room temperature. βCD (0.025 g) and 0.1-M HCl (2 mL) were added to the relevant samples. The suspensions were magnetically stirred for 1 h and placed in an ultra-sonic bath for 3 min. The suspension was then cast in petri dishes (9-cm diameter) and stored in an oven at 40 °C for 18 h. The resulting films were stored in closed petri dishes at room temperature.Impact of pH, cyclodextrin, and comparison dry/swollen: Fifty millilitres of 0.8 wt% toCNF suspensions were prepared and dispersed 2 min at 7000 rpm with an UltraTurrax. βCD (0.04 g) and 0.1-M HCl (3 mL) were added if required. The suspensions were magnetically stirred for 1 h and placed in an ultra-sonic bath for 3 min. The suspensions were poured into a 24-well plate (3 mL per well) and freeze-dried for 24 h at −20 °C and 0.3 mbar . The resulting cryogels were stored in closed well plates.®, Osterode am Harz, Germany).Impact of density: Fifty millilitres of L-toCNF and H-toCNF suspensions at 1 wt%, 0.8 wt%, 0.6 w%, and 0.4 wt% were prepared and dispersed for 2 min at 7000 rpm with an UltraTurrax. The suspensions were magnetically stirred for 1 h and placed in an ultra-sonic bath for 3 min. The suspensions were then poured into a 24-well plate (3mL per well) and put in a freezer at −20 °C for 24 h before freeze-drying  and the weight after a certain time t (mt), according to Equation (1):Water sorption tests on films were carried out gravimetrically in a Percival climatic chamber at 25 °C and 90% RH (relative humidity). The samples were weighted every hour at the beginning of the experiment and at selected times thereafter. Water sorption experiments were conducted after 48 h, with at least 3 replicates for each sample. The samples were put in a desiccator for 16 h prior to the experiment. The water sorption was characterised by the weight change between the initial sample weight .® . The concentration of the suspension was adjusted to 10−3 wt% by diluting the CNF dispersion using the high shear mixer Ultra-Turrax. A drop of this suspension was deposited on a freshly cleaved mica plate before drying overnight under a fume hood at room temperature. The acquisition was performed in tapping mode using a silica-coated cantilever . Zones of 1.1*1.1 μm2 were analysed.Atomic force microscopy images were recorded on a Dimension iconScanning electron microscopy images were performed with ESEM . Film and cryogel cross-sections were cut with a razor blade. SEM observation was carried out on cross-sections after carbon sputter coating of 5 nm, with a tension of 10 kV and a spot size of 3.5. The working distance was set between 9.5 mm and 11.5 mm depending on the sample.For both microscopy techniques, at least 5 different images were performed to check the consistency in various zones of the sample, and the most representatives were selected for the discussion.Impact of density: Compression tests were performed using a TA Instruments RSA 3  dynamic mechanical analyser fitted with a 100-N load cell. Samples prepared as cylinders were individually measured and compressed with a crosshead speed of 0.1 mm/s at room temperature. At the least, triplicates were performed, and the average is presented.Impact of pH, cyclodextrin, and comparison dry/swollen: Compression tests were performed with a Stable Micro Systems TA-XT2 texture-analyser , equipped with a P/35 probe and with a crosshead speed of 0.1 mm/s, as previously described by Heggset et al., 2018 .c, where ρc is the density of cellulose, 1.5 g/cm3 [A minimum of 6 cryogels were tested for each sample. The compression modulus was calculated in the elastic region at half the strain of the beginning of the plateau region, and the stress at 70% strain was directly read from the data. The normalised compression modulus was calculated by dividing the compression modulus by the cryogel density. The cryogel density ρ was determined by dividing the mass of each cryogel by its volume. The volume of produced cryogels was measured from height and diameter measurements using a calliper. For each sample, the two extreme values were removed. The relative density of the cryogels was calculated from the ratio ρ/ρ.5 g/cm3 . The por−1, with 16 scans and a resolution of 4 cm−1. Since this technique is used to determine the possible esterification between the cyclodextrins and the toCNF, and given the proximity between the carboxylic peak and the ester peak , each cryogel was dipped in 0.05 M NaOH for 10 s to convert carboxylic acid groups to carboxylate groups (1600 cm−1) and dried in the oven for 30 min prior to analysis. As the control sample, the neat samples and neat samples after 30 min drying in the oven were also analysed to ensure that esterification was only due to the freeze-drying process. At least 5 different zones of the sample were analysed, and the most representative spectra were used for discussion.Infrared spectra were recorded in attenuated total reflectance (ATR) mode, using a Perkin Elmer Spectrum 65 . Spectra were recorded between 4000 and 600 cmIn this work, films and cryogels of β-cyclodextrin-modified TEMPO-oxidised cellulose nanofibrils were produced. Water sorption analysis and mechanical characterisation were conducted on both modified and unmodified materials under dry and wet conditions. Two unmodified nanofibrils suspensions were prepared with different charge contents (750 µmol/g and 1050 µmol/g), and modification was carried out under neutral and acidic conditions. The sorption equilibrium was reached after 4 h for all films tested, but the charge content and acidic casting pH were shown to increase the water sorption, while cyclodextrins decreased it. Density, process pH, and the addition of cyclodextrins had major impacts on the mechanical properties, related to the modification of the cell wall structure. Finally, covalent esterification binding between β-cyclodextrin and toCNF under acidic pH by freeze-drying was achieved and had an interesting impact on the mechanical properties in the swollen state. This study is a step towards the production of mechanically tailored cryogels containing cyclodextrin, making them promising materials for the sustained delivery of active principle ingredients.


Ecklonia cava and E. cava extract (ECE) decreases blood pressure by reducing inflammation; however, it has not been elucidated whether DK or ECE modulates the Treg/Th17 balance, changes the gut epithelial barrier, or decreases endothelial cell dysfunction. We evaluated the effects of ECE and DK on gut barrier and the Treg/Th17 balance in the intestine and aorta, with regard to endothelial dysfunction, using the spontaneously hypertensive rat (SHR) model. The level of Th17 cells increased and that of Treg cells decreased in the intestine of SHRs compared to normotensive Wistar Kyoto (WKY) rat. These changes were attenuated by ECE or DK treatment. Additionally, the serum IL-17A level increased in SHRs more than WKY; this was decreased by ECE or DK treatment. The level of Treg cells decreased and that of Th17 cells increased in the aorta of SHRs. These changes were attenuated by ECE or DK treatment. The NF-κB and IL-6 levels were increased in SHRs, but these changes were reversed by ECE or DK treatment. Endothelial cell dysfunction, which was evaluated using peNOS/eNOS, nitrate/nitrite ratio, and NADPH oxidase activity, increased in the aorta of SHRs, but was decreased by ECE or DK treatment. The Treg/Th17 balance in the intestine and aorta of SHRs was attenuated and endothelial cell dysfunction was attenuated through the Th17/NF-κB/IL-6 pathway by ECE or DK. Disruptions of the Treg/Th17 cell balance and gut barrier function are associated with endothelial dysfunction. Dieckol (DK) obtained from  As a physical barrier, the gut epithelial barrier, composed of epithelium, mucus lining, and junctional proteins, is involved in modulating the absorption of nutrients and limiting the passage of pathogens or unwanted molecules into the systemic circulation . StructuStudies have shown that gut permeability, which was evaluated by measuring fluorescein isothiocyanate (FITC)-dextran in the plasma, was increased in adult spontaneously hypertensive rat (SHR) compared with that in age-matched normotensive Wistar Kyoto (WKY) rat ,6. In ad+ T helper subset that produces interleukin (IL)-17A, which aggravates tissue inflammation [T helper 17 (Th17) cells are a unique CD4ammation ,9. Underammation , are invammation ,12. Howeammation .IL-17A binds to IL-17 receptor A (IL-17RA) and activates various signal pathways related to inflammation, such as nuclear factor-κB (NF-κB) . For NF-Modulation of Th17/Tregs balance by increasing Treg cells restored tight junction of intestinal epithelial cell barrier in the inflammatory bowel disease . It is kSerum/glucocorticoid-regulated kinase 1 (SGK1) is essential for regulating Th17/Treg balance . IL-23 sEcklonia cava, is known to exert antihypertensive effects by inhibiting angiotensin 1-converting enzyme [E. cava extract (ECE) attenuated endothelial cell dysfunction by reducing the inflammation of perivascular fat tissue [Meanwhile, dieckol (DK), a phlorotannin present in g enzyme . Previout tissue . AlthougE. cava was obtained from Aqua Green Technology Co., Ltd. . For extraction, E. cava was washed and air-dried at room temperature for 48 h, after which the blades were ground and 50% ethanol was added, followed by incubation at 85 °C for 12 h. ECE was filtered, concentrated, sterilized by heating to ≥85 °C for 40–60 min, and then spray-dried. DK, one of the representative phlorotannins present in ECE, was isolated using centrifugal partition chromatography (CPC). CPC was performed using a two-phase solvent system comprising water/ethyl acetate/methyl alcohol/n-hexane . The organic stationary phase was filled in the CPC column, followed by pumping of the mobile phase into the column in descending mode at the same flow rate used for separation (2 mL/min). We finally confirmed that the purity of the DK used in the study was 93.58% [s 93.58% .n = 25, n = 5 for each of the 5 groups) and WKY rats  were obtained from Orient Bio  and housed at a constant temperature of approximately 23 °C, relative humidity of 50%, and a dark/light cycle of 12/12 h. The rats were acclimated to the conditions for 1 week. The rats were then randomly categorized into six groups. For 4 weeks, the rats were orally administered drinking water , and SHRs were orally administered ECE  or DK . At the end of the four-week study period, blood pressure of all rats was measured by using a noninvasive tail-cuff CODA system  [Male SHRs  ,35. Afteg for 15 min at 4 °C. The aqueous phase was collected, placed in cleaned tubes, mixed with 0.5 mL of isopropanol, and centrifuged at the same conditions. The supernatant was discarded, leaving only the RNA pellet that was then washed with 70% ethanol and dissolved in 50 µL of diethyl pyrocarbonate-treated water. The isolated RNA was synthesized with cDNA using a Prime Script 1st strand cDNA Synthesis Kit according to the manufacturer’s instructions .The rat intestine and aorta were homogenized in ice using a disposable pestle in 1 mL of RNisol , and homogenates were added to 0.2 mL of chloroform, mixed, and centrifuged at 12,000× TM software [Quantitative real-time polymerase chain reaction (qRT-PCR) was performed using cDNA synthesis by the CFX384 TouchTM Real-Time PCR detection system. Two hundred nanograms of cDNA, 5 μL of SYBR premix , 0.4 μM forward and reverse primers  [Staining with PAS was used to determine the intestinal mucosa with goblet cells in absorptive columnar epithelium. Deparaffined intestine tissue sections were stained with using the PAS staining kit . The intestinal tissue slides were oxidized in 1% periodic acid solution  for 5 min, rinsed in distilled water, and placed in Schiff reagent  for 20 min at room temperature. Nuclei were stained with Harris’ hematoxylin , and the slides were cover-slipped using a mounting medium and observed under an optical microscope . The number of PAS-positive goblet cells per μmMD, USA) . MorphomH&E staining was used for determining the intestinal pathologic changes including villi length and tunica muscularis thickness. The intestinal tissue slides were incubated with hematoxylin  for 1 min, rinsed in distilled water for 10 min, and placed in eosin Y solution  for 1 min at room temperature. Nuclei were detected with blue color and cytoplasm was detected with light pink, and the completed slides observed under an optical microscope . The villi length and tunica muscularis thickness were measured by ImageJ  . Histolog for 10 min and the supernatant was transferred to a new tube. The transparent serum specimens obtained were stored in a freezer at −80 °C.To measure the serum IL-17A and IL-10 levels, 1 mL of blood was centrifuged and incubated in serum separator tubes  for 30 min. Samples were then centrifuged at 2000× The 96-well microplates were coated with anti-IL-17A and anti-IL-10 antibodies diluted in 100 nM carbonate and bicarbonate mixed buffer, adjusted to pH 9.6, and incubated overnight at 4 °C. The microplates were then washed with PBS containing 0.1% Triton X-100 (TPBS). The remaining protein-binding sites were then blocked using 5% skim milk for 6 h at room temperature . After w+ ratio  in the aorta of each group were determined using the appropriate kit, in accordance with the manufacturer’s instructions. Nitrate/nitrite levels  and NADP/NADPHNonparametric tests were performed in this study. The Kruskal–Wallis test was used to determine the significance of differences among the WKY/water, SHR/water, and SHR/ECE150 groups. If significant difference was confirmed by Kruskal–Wallis, multiple comparison was performed with the Mann–Whitney U test. Results were presented as mean ± SD, and statistical significance was accepted as follows: *, versus WKY/water; $, versus SHR/water; and #, versus SHR/ECE150. Statistical analysis was performed using SPSS version 22 .The mRNA expression level of a Th17 cell marker (RORγt) in the intestine of SHRs was higher than that in WKY rats, but it was decreased following treatment with either ECE or DK A. The deThe expression level of IL-17A in the intestine of SHRs was significantly higher than that in WKY rats C,D. It wThe expression level of zonula occludens-1 (ZO-1), a tight junction protein of the gut barrier, was evaluated to confirm gut barrier integrity A,B. The The number of goblet cells in the PAS-stained intestine was decreased in SHRs compared with that in WKY rats C,D. It wThe thickness of tunica muscularis was increased in SHRs compared with that in WKY rats E,F. It wThe increasing effect was most prominent in the 100 and 150 mg/kg ECE treatment. The mRNA expression level of SGK1 in the intestine of SHRs was significantly increased, which was in turn significantly decreased following the administration of 100 and 150 mg/kg ECE and DK H. The deThe serum level of IL-17A in SHRs was significantly higher than that in WKY rats. This level was decreased following the administration of either ECE or DK). The decreasing effect was most prominent in the 150 mg/kg ECE treatment . The serum level of IL-10 in SHRs was significantly lower than that in WKY rats, but it was significantly increased following the administration of either ECE or DK. The increasing effect was most prominent in the 150 mg/kg ECE treatment .The mRNA expression of RORγt (a marker of Th17) in the aorta of SHRs was increased compared with that in WKY rats A. HoweveThe expression level of IL-17A in the aorta of SHRs was significantly increased compared with that in WKY rats C,D. It wThe expression levels of ACT and TRAF6, which are essential factors for IL-17A to initiate the upregulation of NF-κB, was significantly higher in the aorta of SHRs than in WKY rats A,B. It wThe expression level of NF-κB in the aorta of SHRs was significantly higher than that in WKY rats C. It wasThe expression levels of C/EBPβ and C/EBPδ in the aorta of SHRs were significantly higher than that in WKY rats D,E. It wThe expression levels of IL-6 in the aorta of SHRs were significantly higher than that in WKY rats F. It wasThe ratio of peNOS/eNOS expression in the aorta of SHRs was significantly lower than that in WKY rats . It was + ratio in the aorta of SHRs was significantly higher than that in WKY rats (The nitrate/nitrite level in the aorta of SHRs was significantly higher than that in WKY rats C. It wasWKY rats D. It wasThe systolic blood pressure (BP) of SHRs was significantly higher than that of WKY rats E. It wasEndothelial cells, which make a lining of blood vessels, have prothrombotic, proinflammatory, and proconstrictive actions . EndotheMany studies have shown that gut epithelial cell barriers are associated with endothelial cell dysfunction, which is a major pathophysiological factor underlying hypertension . RecentlWe evaluated intestinal barrier impairment by measuring the number of goblet cells, thickness of tunica muscularis, and length of villi. It was reported that these changes of intestinal impairment were shown in SHR . Our stuSHR is the most widely used animal model for essential hypertension, which the incidence is up to 95% in human hypertension . In addiThus, we thought SHR was the proper animal model to evaluate the effect of ECE and DK on endothelial cell dysfunction in hypertension. In addition, the results of our study showed that the expression of Th17 cell/Treg and IL-17A in the intestine of SHR was different from WKY. It suggested that SHR might be the proper model to evaluate the attenuation effect of ECE or DK in the intestine by modulating Th17 cell/Treg balance. In our study, ECE or DK showed to be preserved the intestinal barrier in SHR. We also evaluated expression of ZO-1 and occludin in the intestine of SHR. The expression level of ZO-1 and occludin in the intestine of SHRs was significantly decreased compared with that in WKY rats, and it was increased following the administration of ECE or DK. It is known that increased gut permeability is accompanied by decreasing gut junctional proteins in an angiotensin II-induced hypertension animal model . PrehypeThe administration of ECE or DK significantly decreased the expression level of a marker of Th17 cells and increased the expression of a marker of Treg cells in the intestine of SHRs. The expression level of IL-17A in the intestine of SHRs was also decreased following the administration of ECE or DK. Meanwhile, the expression level of IL-10 in the intestine of SHRs was significantly increased by ECE or DK treatment. It seems that ECE or DK restored the Treg/Th17 balance in the intestine of SHR, decreased the expression of IL-17A, and increased the expression of IL-10.It is known that SGK1 involves changes of Th17/Treg balance . SGK1 inIn our study, the number of Th17 cells was increased in the aorta of SHRs, but was significantly decreased by either ECE or DK. Moreover, the number of Treg cells was decreased in the aorta of SHRs, but was significantly increased by either ECE or DK. The expression level of IL-17A was increased in the aorta of SHRs, whereas the expression of IL-10 was decreased. These two changes were reversed following the administration of ECE or DK. We also evaluated the IL-17A/NF-κB/IL-6 pathway, which induced endothelial cell dysfunction. IL-6 is considered a biomarker in the development of atherosclerosis and progression of inflammation in atherosclerotic vessels ,67. IL-6The binding of IL-17A to IL-17RA requires ACT and TRAF6 to activate NF-κB . NF-κB aThe peNOS/eNOS ratio in the aorta of SHRs was decreased, but it was increased by ECE or DK treatments. The nitrate/nitrite ratio in the aorta of SHRs was increased, but it decreased following ECE or DK. NADPH oxidase activity was increased in the aorta of SHRs, which was decreased by ECE or DK treatment. It appeared that ECE or DK attenuated endothelial cell dysfunction in SHR. The systolic BP, diastolic BP, and mean BP of SHR were decreased by administration of either ECE or DK. It seems that the attenuating effect of ECE or DK on endothelial cell dysfunction lead to decrease BP. Phlorotannins from ECE contains DK, 2,7-phloroglucinol-6,6-bieckol (PHB), pyrogallol-phloroglucinol-6,6-bieckol (PPB), and phlorofucofuroeckol-A (PFFA) ,73,74. IECE contained 2% DK ; thus, 1Gut health, especially the balance of Treg/Th17 cells, is important for avoiding endothelial cell dysfunction, which is a major pathophysiological factor underlying various cardiovascular diseases including hypertension and atherosclerosis. Our study suggested that ECE or DK could modulate the Treg/Th17 balance in both intestine and aorta, and decrease endothelial cell dysfunction by decreasing the activity of the IL-17A/NF-κB/IL-6 pathway. The results suggested that DK could be potentially used as a therapeutic agent for endothelial dysfunction by modulating gut health.


The combination of breast conserving surgery (BCS) with plastic surgery techniques has provided a useful surgical tool matching the radicality of the oncological excision with the preservation of breast cosmesis. Even though BCS represents a good option for surgical treatment of tumors located in these quadrants, wide excisions often necessitate breast reshaping in order to avoid nipple areola complex (NAC) displacement and skin retraction. We present a new surgical technique to repair upper-outer quadrants’ defects following breast cancer excision using dermo-glandular flaps and an axillary adipo-fascial flap.During the period from January 2014 to December 2015, 168 patients with an upper-outer quadrant’s breast cancer have been treated in our Department. 83 women have been treated with the described oncoplastic technique and immediate contra-lateral symmetrisation and 85 women underwent standard BCS. We present surgical, oncological and cosmetic outcomes comparing our results with standard BCS.At a mean follow-up of 27 months loco-regional recurrences in the two groups were comparable. Short-term complication rates were comparable between the two groups. Re-intervention rates for positive margins were significantly higher in the standard BCS group. The overall satisfaction with cosmetic outcome both assessed by the patient and the surgeon was significantly higher in the oncoplastic group.The proposed oncoplastic technique represents a safe and effective solution for reshaping that follows upper-outer breast cancer wide excision, achieving comparable complication rates, lower re-intervention rates for positive margins and better cosmetic results when compared with standard BCS. The upper-outer quadrant of the breast is the most common location for breast cancer. Conventional Breast Conserving Surgery (BCS) is nowadays the standard surgical approach for the treatment of breast cancer located in the upper outer quadrants.Although BCS followed by radiotherapy presents comparable survival rates with patients treated with mastectomy, it may hesitate in breast deformity in 20–30% of cases , 2. FurtThe possible distortion of breast shape and the following poor cosmetic result lead surgeons to develop different surgical techniques in order to overcome the aestethic discomfort for the patient . The so-We present a new surgical technique to repair upper-outer quadrants’ defects following breast cancer excision using dermo-glandular flaps and an axillary adipo-fascial flap. We present surgical and oncological outcomes comparing our results with standard BCS for the treatment of breast cancer located in the upper-outer quadrants.We retrospectively collected from our database all the women who underwent upper-outer quandrantectomies in our Department in the period from January 2014 to December 2015.Women with a diagnosis of both invasive or in situ breast cancer, affected by both unifocal or multifocal lesions located at the level of the upper-outer quadrant have been enrolled in the study.We divided our cohort of patients in two groups according with the surgical technique used to excise the breast cancer. The first group included 83 women who underwent our innovative oncoplastic technique and immediate contra-lateral breast symmeytrisation. The second group included 85 women who underwent a standard upper-outer BCS.Women who previously underwent breast or axillary surgery or chest radiotherapy have been excluded. Patients with clinical pre-operative or histological intra-operative evidence of axillary lymph node involvement have been excluded as well, such as patients presenting skin involvement of the cancer, local recurrence, distant metastases or genetic mutations.This study was approved by our institutional review board  and appropriate informed consent was obtained from all patients for the surgical procedures performed in the present study and for personal images use and publication.Ultrasound examination, mammography, MRI and subsequent vacuum-assisted breast biopsy have been performed for all patients. All patients underwent a multidisciplinary approach, involving medical and surgical oncologists, plastic surgeons, breast radiologists, and radiation oncologists. In order to perform breast conserving surgery, we localized the lesions the day before surgery using Tc99m-MAA ; the sentinel lymph node was localized preoperatively by injecting Tc99m-nanocoll.Positive margins were defined as presence of cancer cells at less than 1 mm from the specimen’s margin.Post-operative radiotherapy (50 Gy on the breast) was administered in each case.We assessed short-term post-operative complications (occurring less than 30 days after surgery), re-operations for positive margins of resection, local recurrences and cosmetic outcome (both patient-reported and surgeon-reported).In the study group patients were marked the day before surgery with a vertical or inverted-T Wise pattern approach according to the balance between the expected tumor excision dimension and breast volume.Antibiotic prophylactic therapy was administered to all patients according to hospital protocols.The patient was placed in supine position with the arms abducted to 90 degrees and fixed on arm boards.A two team approach was always planned in order to reduce operation room time and decrease the surgical stress for patients.With a blade number 10 the incision was performed and all the skin within the preoperative markings was removed. Subsequently the skin over the tumor was undermined leaving a flap thickness of 3–4 mm. A wide tumor resection through the glandular tissue reaching the pectoralis major muscle fascia was performed.Intra-operative frozen sections or radiographic examinations  of the specimen were performed in order to proceed to immediate re-excision if necessary.Surgical clips were placed in the tumor bed following the tumor resection.The sentinel lymph node biopsy was performed through the same skin incision.Subsequent total skin undermining was performed in the medial and inferior quadrants of the breast to completely detach the gland from the skin.An infero-lateral glandular flap was advanced upward, rotated and fixed with a 2/0 absorbable monofilament suture to an adipo-fascial flap mobilized from the axilla.Then the residual glandular tissue of the upper portion of the breast could be approximated to the described flap and the nipple-areola complex was fixed in the desired position Figs.  and 2.FiWhen necessary, suction drains were positioned and then the suture was completed.Contra-lateral symmetrization mammoplasty was always performed simultaneously.Antibiotic therapy had been administered to all patients until drain’s removal.In the control group patients underwent a standard upper-outer quadrantectomy. Sentinel Lymph node biopsy was performed through the same surgical incision.p value of 0.05 or less was considered statistically significant. All the analyses were performed using SPSS 22 software package .Variables were analysed using the chi-square test. A During the period from January 2014 to December 2015, 168 patients with an upper-outer quadrant’s breast cancer have been treated in our Department.Eighty-three women have been treated with the described oncoplastic technique and immediate contra-lateral symmetrisation (study group) and 85 women underwent standard BCS (control group).Patients’ Median age was 57.5 years (range 39–76) for the study group and 58.3 years (range 38–79) for the control group, median Body Mass Index (BMI) was 24.5 kg/cm2 (range 20.2–32.6) for the study group and 25.1 kg/cm2 (range 20.5–33.1) for the control group. The two groups were comparable for baseline characteristics and comorbidities. Patients’ comorbidities are presented in Table p = 0.03). All patients with positive surgical margins have been re-operated in both groups.Surgical margins of resection were positive in 2 cases (2.4%) in the study group and in 9 cases (10.6%) in the control group (Mean time of follow-up was 27 months (range 16–39). During this period one patient (1.2%) has been re-operated for a local recurrence both in the study group and in the control group. Both patients presenting with a local recurrence were affected by Intermediate Grade (G2) Ductal Carcinoma In Situ (DCIS), completely excised at primary surgery with more than 5 mm free margin, and recurred as pT1N0 Invasive Ductal Carcinoma (IDC) at a follow-up of 25 months (in the study group) and 20 months (in the control group). Both patients underwent skin sparing mastectomy and breast reconstruction with tissue expander positioning.p = 0.79); hormonal therapy was provided to 57 patients (68.7%) in the study group and 60 patients (70.6%) in the control group (p = 0.68); Trastuzumab was provided to 13 patients (15.7%) in the study group and 14 patients (16.5%) in the control group. Oncological characteristics  of both groups were comparable and are presented in Table All patients included in the study received post-operative radiotherapy. Adjuvant chemotherapy was administered to 23 patients (27.7%) in the study group and 26 patients (30.6%) in the control group (p = 0.50). In the study group we experienced 4 wound dehiscences, 4 fat or glandular necrosis, 2 seroma formation, 2 hematoma, 4 marginal skin necrosis, 2 partial NAC necrosis.We experienced a total of 18 (21.7%) short-term post-operative complications in the study group and 15 (17.6%) in the control group (p = 0.67), fat or glandular necrosis (p = 0.67), seroma formation (p = 0.67), hematoma (p = 0.67), marginal skin necrosis (p = 0.38), partial NAC necrosis (p = 0.56).In the control group we experienced 3 wound dehiscences, 3 fat or glandular necrosis, 3 seroma formation, 3 hematoma, 2 marginal skin necrosis, 1 partial NAC necrosis. Complication rates were comparable: wound dehiscence ; the overall satisfaction with cosmetic outcome assessed by the surgeon was considered excellent in 48 cases (57.8%) in the study group and in 35 cases (41.2%) in the control group (p < 0.0001)  in the study group, while in 32 cases (36.6%) in the control group (Breast Conserving Surgery (BCS) followed by radiotherapy has become the standard surgical approach for early stage breast cancer –15.When adequate surgical margins are obtained local recurrence rates have been documented to range from 3.5 to 6.5% at 10-year follow-up , 17. TheUpper-outer quadrantectomies can be easily performed with standard BCS but breast deformity and NAC displacement may follow this procedure. Different oncoplastic approaches have been proposed during the years trying to overcome these complications. Small-sized breasts with early breast cancer can be effectively treated by Benelli mastoplasty: glandular rotation flaps combine good cosmetic results with satisfactory resections . When wiWe aim to propose a reliable technique both respecting oncological radicality and preserving a pleasant breast contour. The large skin undermining and the breast reshaping performed using our technique do not determine NAC dislocations and irregular breast shapes.Fitoussi and colleagues stated that the huge undermining could lead to increased rates of seroma, fat necrosis, bleeding and the NAC transposition may cause partial or total necrosis . Other aFurthermore from an oncological point of view, we confirmed other data reported in literature evidencing that the oncoplastic approach reduces the number of re-operations for positive or close margins , 28.We did not experience any delay for adjuvant therapies, either radio or chemotherapy, caused by a longer time of wound healing.Some author suggest to postpone contra-lateral breast symmetrization after radiotherapy because of the risk of volume modification in the radiotreated breast . We agreOur study presents the limitation of being retrospective and a longer follow-up could further confirm the oncological safety of the proposed surgical approach .The proposed oncoplastic technique represents a safe and effective solution for reshaping that follows upper-outer breast cancer wide excision, achieving comparable complication rates, lower re-intervention rates for positive margins and better cosmetic results when compared with standard BCS.


FIP1L1-PDGFRA gene fusion and bone marrow analysis confirmed a diagnosis of chronic eosinophilic leukemia. The patient was treated with daily imatinib and prednisone and he was symptom-free at a four-week follow-up examination.We report the case of a 40-year-old man with no significant past medical history who had been hospitalized multiple times over the course of one year with recurring cough, dyspnea, pruritic rash, and variable degrees of eosinophilia. He was variably diagnosed with asthma and pneumonia. After his last hospitalization with severe symptoms, the patient was referred for pulmonary evaluation where hypereosinophilia (HE) led to a hematologic workup. Fluorescence in situ hybridization revealed the  Asthma and atopy can sometimes present as HE, although an AEC ≥5.0 × 109 cells/L in these cases would be rare [Peripheral blood eosinophilia, defined as an absolute eosinophil count (AEC) of > 0.5 to 1.0 × 10entities . Hypereo be rare . Rapid d be rare  and coulWe report the case of a man with HE who was hospitalized numerous times before being diagnosed with chronic eosinophilic leukemia and whose symptoms significantly improved upon initiation of therapy.A 40-year-old man had recurrent hospitalizations with cough, pleuritic chest pain, and a relapsing and remitting pruritic papular rash associated with variable levels of eosinophilia. His symptoms were variously attributed to asthma and pneumonia, although he had no history of asthma. He was hospitalized more than six times over one year and was repeatedly treated with steroids and antibiotics. Additionally, he had undergone multiple non-invasive and invasive testing, including several computed tomograms and cardiac imaging.During the last hospitalization, the patient’s symptoms were particularly severe, with cough leading to a syncopal episode and hemoptysis with a rise in cardiac biomarkers. He was transferred to our institution for further pulmonary evaluation. Upon arrival, he presented with pleuritic chest pain, dry cough, anorexia, and diffuse pruritic rash. His vital signs were unremarkable except for tachycardia with a heart rate of 103 beats per minute. Physical examination revealed a chronically ill-appearing man in moderate distress. Scattered erythematous papules that were in various stages of healing were noted on his extremities, some having central ulceration and crusting Figure . ResultsDaily imatinib 400 mg was initiated and prednisone was continued due to concern for cardiac involvement despite normal trans-thoracic echocardiogram. Within one day of imatinib initiation, the patient’s eosinophilia normalized and he was discharged home in stable condition. At the follow-up examination four weeks later, all his symptoms had resolved. He reached both hematologic, cytogenetic, and molecular remission within three months of treatment. Prednisone was tapered off and his imatinib dose was decreased to 100 mg daily.HE can be primary , secondary to other etiologies, or idiopathic . Once seClonal eosinophilia is most frequently associated with chronic myeloid neoplasms. Chronic eosinophilic leukemia is a rare chronic myeloproliferative disease resulting from clonal proliferation of eosinophil precursors. The 2008 World Health Organization classification of tumors of hematopoietic and lymphoid tissues introduced a new category of myeloid and lymphoid neoplasms characterized by eosinophilia and abnormalities in the PDGFRA, PDGFRB or FGFR1 genes . The FIPThe presence of dysplastic eosinophils may suggest clonal eosinophilia, and elevated serum tryptase and vitamin B12 levels have been observed with myeloid neoplasms, particularly in those with PDGFRA or PDGFRB fusion genes . ClinicaDermatologic manifestations from PDGFRA-associated hypereosinophilic syndrome are common and can include dermatitis and urticaria. Lymphomatoid papulosis with erythematous papulonodular lesions is a recurrent skin eruption, which can become necrotic. It has histopathologic features resembling lymphoma , and aboPatients with documented rearrangements or mutations involving PDGFRA should be treated with imatinib mesylate (100-400 mg by mouth daily). The response to imatinib is rapid (within days), and complete hematologic and molecular remission is almost universal . In our HE can be indicative of chronic eosinophilic leukemia, a rare hematologic malignancy, which can often be mistaken for more common conditions such as asthma, pneumonia, allergies, cardiac disease, and others. While chronic eosinophilic leukemia can be treatable, end-organ failure and severe outcomes will ensue if left untreated. Therefore, physicians should be wary of anchoring bias, where uncommon causes of common presentations are not considered, such as occurred in our patient with HE.


Heterodontus francisci) are nocturnally active, non-obligate ram ventilating sharks in rocky reef habitats that play an important ecological role in regulating invertebrate communities. We predicted horn sharks would use an area restricted search (ARS) movement strategy to locate dense resource patches while minimizing energetic costs of travel and nighttime activity. As ectotherms, we predicted environmental temperature would play a significant role in driving movement and activity patterns.California horn sharks  as a proxy for energy expenditure. Behavior within a patch was characterized into three activity patterns: resting, episodic burst activity, and moderate, consistent activity.After resting in daytime shelters, individuals travelled to multiple reefs throughout the night, traversing through depths of 2–112 m and temperatures of 10.0–23.8 °C. All sharks exhibited area restricted search patch use and arrived at their first patch approximately 3.4 ± 2.2 h (mean ± SD) after sunset. Sharks exhibited moderate, consistent activity in 54% of the patches used, episodic burst activity in 33%, and few (13%) were identified as resting at night. ODBA peaked while sharks were swimming through relatively deeper (~ 30 m), colder channels when traversing from one patch to the next. There was no consistent pattern between ODBA and temperature.We provide one of the largest fine-scale, high-resolution paired data sets for an elasmobranch movement ecology study. Horn sharks exhibited ARS movement patterns for various activity patterns. Individuals likely travel to reefs known to have profitable and predictable patches, potentially tolerating less suitable environmental temperatures. We demonstrate how gathering high-resolution information on the movement decisions of a community resident enhances knowledge of community structure and overall ecosystem function. Mobile animals across all taxa make daily movement decisions to optimize daily energetic requirements. Since animals often live in environments that experience heterogeneous conditions with patchily distributed resources, they may modify their daily movements and behaviors in response to prey availability, environmental conditions, and their exposure to predation risk –4. ThereARS has been demonstrated across a wide range of taxa of varying body sizes including insects , 13, birMarine predators, such as coastal elasmobranchs , exhibit a wide variety of movement patterns and behavioral strategies in order to maximize fitness over several spatial  and temporal  scales –24. Non-10) of an ectotherm will determine the extent of how dynamic thermal conditions may allow them to remain in their current environment or cause them to move and seek out more suitable thermal conditions [As ectotherms, water temperature is known to be a key abiotic factor that influences elasmobranch physiology and movement patterns –31. The nditions , 32–34. nditions . Alternanditions –38. Thernditions , 32, 38.Measuring animal movements in a marine environment is typically done with acoustic or satellite telemetry –42. AlthHeterodontus francisci) were used as a model species to represent non-obligate ram ventilating elasmobranchs. California horn sharks (herein “horn sharks”) are small (< 1 m), nocturnally active, and relatively abundant residents in temperate Northeast Pacific rocky reef kelp beds [In the present study, California horn sharks  were continuously actively tracked using acoustic telemetry at Santa Catalina Island, California : 40 mm × 28 mm × 17 mm, 19.5 g in air, 5.2 g in seawater; or TechnoSmArt (n = 12) Axy-Depth: 12 mm × 31 mm × 11 mm, 6.5 g in air)  (ESRI). Modelling and statistical analyses were done in R (vers. 3.5.2) . For most analyses, data were analyzed in 24 h diel cycles, separated into daytime and nighttime periods using the king day .adehabitatHR package [lme4 package in R [p-values, we used the Anova function in the car package with Type II Wald Chi-square tests [For spatial movement analyses, geo-positions derived from active tracking were filtered to only include detections of highest positional accuracy . To estimate two-dimensional (2D) activity space for each individual, Brownian bridge kernel utilization distributions (BBKUDs) were calculated in R with the  package . By usin package . The BBK package . Daytimeage in R , 63 werere tests , 65.adehabitatLT package in R [max) to be 20 to ensure all possible segments would be accounted. The ideal number of segments for each sharks’ trajectory (Kopt) was determined by choosing the last value of K for which the second derivative D(k) of the standardized contrast function was greater than the threshold of S = 0.75 [opt varied from 2 to 7 segments across nighttime periods. Each Lavielle segment that indicated ARS was then imported into ArcGIS where they were visually assessed and minimum convex polygons (MCPs) were used to calculate the 2D area of the patch. Linear distances (km) travelled to and from a patch were measured in ArcGIS using 1) the centroid of the daytime resting shelter (obtained from the daytime 50% BBKUD) to the centroid of the ARS patch, 2) centroids in between ARS patches , and 3) the distance from the centroid of the last ARS patch used to the next morning’s daytime shelter site. LME models were used to statistically test if there was a significant relationship between the time spent in a patch (response) and the area of a patch, distance travelled to get to a patch, or activity within a patch . We conducted three separate LME models to determine how each predictor alone influenced time spent within a patch. Time spent in a patch (response) was the total time (min) spent within each patch and was calculated from the start and end times of patch use from the FPT analysis. To account for temporal autocorrelation associated with time spent, we included the number of patches per individual per night as another predictor in each model. Individual was included as a random effect, and p-values were obtained with the Anova function from the car package with Type II Wald Chi-square tests [To identify the scale and location of potential patches via area restricted search (ARS) patterns, a first passage time (FPT) analysis was performed using the age in R . The FPTage in R , 14, 15.age in R . We onlyage in R . For theage in R  to identage in R , 68. We re tests , 65. To re tests .+) or every 25 Hz (Technosmart AxyDepth). All acceleration data were processed in IgorPro  and analyses were conducted using Ethographer [ADLs recorded tri-axial acceleration data at 25 Hz and temperature and depth every 1 Hz , a spectrum analysis was generated using a continuous wavelet transformation with the Morlet wavelet function using the sway axis to quantify the periodicity and intensity of the acceleration signals , 74 Add. A periothan one , 26. Usithan one . Binary k-means analysis were used to estimate and classify activity patterns within ARS patches. Using the FPT analysis above  times of patch use were acquired and used to find related periods of activity. For each identified patch, binary activity values were used to estimate the percent of time spent resting within a patch to first classify patches as resting (95% majority) or active. ODBA and depth within a patch were then visually assessed in IgorPro to further classify patch activity patterns. Resting patches were confirmed by observing low ODBA values (< 0.2 g) and no discernible changes in depth throughout the entire duration of patch activity. Active patches were identified by comparatively higher ODBA values (> 0.5 g), indicating periods of swimming tail beats or bursts of activity. From these assessments , we identified three classifications of patch activity patterns including 1) resting , 2) episodic burst activity , and 3) active . Resting patches were removed from further patch statistical analyses because we could not confidently determine whether the shark was truly using a patch  yet spending a majority of the time motionless, or if the shark was instead inattentively refuging in a shelter.In addition, binary activity values from the mgcv package in R [mgcv package to ensure proper fit [To determine diel and environmental drivers in nighttime activity patterns (ODBA), we used general additive mixed models (GAMMs) using the age in R . GAMMs wage in R , 72, 79.oper fit , 79.n = 8), Isthmus Reef , Bird Rock , and Campgrounds  , females spent 88.1 ± 1.3% of the day resting and 48.9 ± 3.1% of the night resting. Similarly, males spent 93.3 ± 2.2% of the day resting and 55.02 ± 3.47% of the night resting. We chose to not remove any acceleration data as most of our statistical analyses were performed on nighttime periods only. However, it is important to note the tagging day often had periods of increased ODBA  compared to subsequent daytime periods after the tagging day . This increase in activity on the day of tagging was likely due to individuals being unaccustomed to the tag package. Since sharks were tagged during the morning, we assumed that by sunset, individuals had become accustomed to the tag package and nighttime activity was unaffected. This was further confirmed by no differences in activity patterns during the nights for individuals tagged for 48 h .Sharks rested in depths 0.2–35 m 15 ± 1.4 m) during the day. As a shark remained resting in a shelter during the day, ambient water temperatures changed  approximately 3.3 ± 0.3 °C around them and ranged from 11.0–23.0 °C (18.1 ± 2.3 °C). In contrast, sharks experienced a mean temperature range of approximately 7.4 ± 0.4 °C while traveling throughout the night. In addition, during the night, sharks travelled through depths ranging from 1 to 112 m (19 ± 15 m) and through temperatures from 10.0–23.8 °C  and 0.00006–0.0096 km2  and 0.00005–0.025 km2 .Daytime BBKUDs ranged between 0.00028–0.0699 kmn = 17 sharks). Based on the results of the k-means binary activity values and the visual confirmation of ODBA, five patches (13%) were removed from further statistical analyses. Two additional patches were removed because their spatial characteristics were not consistent with our definition of a patch, leaving a total of 31 patches (n = 16 sharks) for further analysis  and the linear distance travelled to get to a patch ranged from 21 to 1747 m (450 ± 484 m). For most (79%) nighttime periods, a single patch was used, and only a few nights (21%) showed individuals used multiple patches (max: 3 patches per night).A total of 38 patches were identified from the 27 nighttime periods analyzed , or the activity (% spent resting) in a patch   , approximately 3.5 ± 2.4 h after sunset. Once an individual had found a patch, it spent 0.2–7.5 h (2.3 ± 2.0 h) in the patch. Individuals that used more than one patch throughout the night spent 2.0 ± 1.3 h travelling in between patches. All individuals left their last patch 3.5 ± 2.6 h before sunrise, at approximately 04:03  to then travel to their next daytime resting location. All sharks travelled from a final patch to a daytime resting shelter, so final patches were never the same as the final resting location. There was no significant relationship between the time spent in a patch and the distance travelled to get to a patch  was 0.182 km2. Therefore, the resulting area overlap of patch space to core activity space was 0.072 km2, which amounted to an 84.7% overlap  was IR   peaked around 21:00 and 03:30  Fig. a, which 01) Fig. a, b. AddThis study combined high-resolution spatial movement and acceleration data to understand the fine-scale movement and activity patterns of a non-obligate ram ventilating elasmobranch. There was high individual variation across movement paths, regardless of where or when individuals were tagged, yet nocturnal activity and search modes  were consistent across individuals. All individuals rested in a shelter from sunrise to sunset, then departed their shelters at sunset in search of a resource patch. Acceleration data revealed that all individuals arrived and departed patches at similar times, regardless of size, sex, tagging location, or patch reef. Additionally, nighttime activity (ODBA) was strongly correlated  to patch arrival and departure times, demonstrating bimodal peaks in activity representing the energetic costs of traversing through the relatively deeper (~ 30 m), cooler channels in between reefs. Once individuals were in a patch, there was an overall reduction in ODBA, likely because periods of inactivity were interspersed with periods of activity  and due to travel speeds decreasing within a patch , 19.Thalossoica antarctica). They found the petrels would use a hierarchical search strategy and move their large-scale search areas in response to seasonally varying densities and the spatial dynamics of Antarctic krill (Euphausia superba).While it is unclear from our results what exactly was influencing the timing of patch behaviors, our activity classification within a patch  allows us to hypothesize what behaviors are potentially driving horn shark movement patterns. Moderate activity within a patch may be indicative of prey or shelter searching, and episodic burst activity may be indicative of foraging or predator evasions, both of which could be energetically costly behaviors for these demersal sharks . TherefoMirounga leonina) first use prior knowledge of predictable areas to drive large-scale movements, then secondarily use ARS to focus their search once in a profitable area [Visually, there was some overlap in ARS patches among individuals indicating an overlap of ‘search effort’, which may indicate areas where foraging success was greatest . We founble area . Additioble area . Most ofble area . Howeverble area , 52.The overlapping search effort of the patches occurred on a few key reefs, suggesting those reefs are potentially profitable habitat and ‘activity hotspots’ , 42. It Carcharhinus limbatus), were using less productive habitats to avoid predators. Therefore, determining the ultimate motivation behind ARS behaviors, although difficult, is critical to correctly interpreting movement path structures.Although we hypothesize foraging efforts and patchy prey distributions are the likely drivers of patch use, other behaviors could have equally resulted in the observed ARS movement paths. For instance, while patches characterized as episodic burst activity (48% of active patches) may have been indicative of successful foraging attempts, predator evasions could have also produced the ODBA signatures observed in these patches . Horn shPristis pristis) increase activity during crepuscular and nocturnal periods, regardless of thermal environment [Carcharhinus amblyrhynchos) had an insignificant effect on routine metabolic rates (RMRs) at the diel scale, and instead diel changes in RMRs were driven by swim speeds [Surprisingly, our work found no correlation between ODBA and water temperature for these ectothermic elasmobranchs. While average nighttime activity was highest when individuals were traveling in relatively deeper, cooler channels in between reefs, it was not apparent from these results that horn sharks were purposely seeking an energetic advantage of moving through cooler water to minimize activity costs , 102. Siironment . While sironment . Additiom speeds .10 (2.01), demonstrating that they are relatively thermally insensitive. This may explain why we saw no clear pattern between activity and temperature, yet we did see clear patterns in diel activity. However, it is important to note Luongo and Lowe [Luongo and Lowe  determinand Lowe  additionand Lowe , 35. FurThis study provides one of the largest fine-scale, high-resolution paired data sets available for an elasmobranchmovement ecology study. We demonstrate that horn sharks exhibited ARS movement patterns and displayed various activity patterns within ARS patches. Our work found that horn shark movements and activity patterns are not reliant upon environmental temperature, indicating they may instead focus their movements by traveling to reefs known to have profitable and predictable patches. As nocturnal, hard prey  specialists known to be annual residents in rocky reef communities, horn sharks may be ecologically important regulators of lower trophic level invertebrates, potentially responsible for regulating kelp bed community structure , 104–107Additional file 1. Acceleration summaries for actively tracked California horn sharks (Heterodontus francisci). Mean values for ODBA , temperature (°C), and depth (m) for each 24 h period for each California horn shark tracked.Additional file 2. Example of k-means cluster analysis. Example of how k-means clusters were derived from the acceleration ethogram in IgorPro using Ethographer . Clusters were then used to quantify if California horn sharks were resting or active.Additional file 3. Diel comparisons of Brownian bridge kernel utilization distributions (BBKUDs). Diel comparisons of Brownian bridge kernel utilization distributions (BBKUDs) for California horn sharks for both 95% (daily) and 50% (core) activity spaces estimates.