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Study objectiveRecent studies have shown that dexmedetomidine can be safely used in peripheral nerve blocks and spinal anesthesia. Epidural administration of dexmedetomidine produces analgesia and sedation, prolongs motor and sensory block time, extends postoperative analgesia, and reduces the need for rescue analgesia. This investigation seeks to identify the median effective concentration (EC50) of ropivacaine for epidural motor blockade, and assess how incorporating varying doses of dexmedetomidine impacts this EC50 value.DesignProspective, double-blind, up-down sequential allocation study.SettingOperating room, post-anesthesia care unit, and general ward.InterventionsOne hundred and fifty patients were allocated into five groups in a randomized, double-blinded manner as follows: NR (normal saline combined with ropivacaine) group, RD0.25 (0.25 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.5 (0.5 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.75 (0.75 μg/kg dexmedetomidine combined with ropivacaine) group, RD1.0 (1.0 μg/kg dexmedetomidine combined with ropivacaine) group. The concentration of epidural ropivacaine for the first patient in each group was 0.5%. Following administration, the patients were immediately placed in a supine position for observation, and the lower limb motor block was assessed every 5 min using the modified Bromage score within 30 min after drug administration. According to the sequential method, the concentration of ropivacaine in the next patient was adjusted according to the reaction of the previous patient: effective motor block was defined as the modified Bromage score > 0 within 30 min after epidural administration. If the modified Bromage score of the previous patient was >0 within 30 min after drug administration, the concentration of ropivacaine in the next patient was decreased by 1 gradient. Conversely, if the score did not exceed 0, the concentration of ropivacaine in the next patient was increased by 1 gradient. The up-down sequential allocation method and probit regression were used to calculate the EC50 of epidural ropivacaine.MeasurementsAdverse events, hemodynamic changes, demographic data and clinical characteristics.Main resultsThe EC50 of epidural ropivacaine required to achieve motor block was 0.677% (95% CI, 0.622–0.743%) in the NR group, 0.624% (95% CI, 0.550–0.728%) in the RD0.25 group, 0.549% (95% CI, 0.456–0.660%) in the RD0.5 group, 0.463% (95% CI, 0.408–0.527%) in the RD0.75 group, and 0.435% (95% CI, 0.390–0.447%) in the RD1.0 group. The EC50 of the NR group and the RD0.25 group were significantly higher than that of the RD0.75 and the RD1.0 groups, and the EC50 of the RD0.5 group was significantly higher than that of the RD1.0 group.ConclusionThe EC50 of epidural ropivacaine required to achieve motor block was 0.677% in the NR group, 0.624% in the RD0.25 group, 0.549% in the RD0.5 group, 0.463% in the RD0.75 group, and 0.435% in the RD1.0 group. Dexmedetomidine as an adjuvant for ropivacaine dose-dependently reduce the EC50 of epidural ropivacaine for motor block and shorten the onset time of epidural ropivacaine block. The optimal dose of dexmedetomidine combined with ropivacaine for epidural anesthesia was 0.5 μg/kg.

Rehmannia chingii is an important medicinal plant with immense value in scientific research. However, its mitochondrial genome (mitogenome) has not yet been characterized. Herein, based on whole-genome Illumina short reads and PacBio HiFi reads, we obtained the complete mitogenome of R. chingii through a de novo assembly strategy. We carried out comparative genomic analyses and found that, in comparison with the plastid genome (plastome) showing a high degree of structural conservation, the R. chingii mitogenome structure is relatively complex, showing an intricate ring structure with 16 connections, owing to five repetitive sequences. The R. chingii mitogenome was 783,161 bp with a GC content of 44.8% and contained 77 genes, comprising 47 protein-coding genes (CDS), 27 tRNA genes, and 3 rRNA genes. We counted 579 RNA editing events in 47 CDS and 12,828 codons in all CDSs of the R. chingii mitogenome. Furthermore, 24 unique sequence transfer fragments were found between the mitogenome and plastome, comprising 8 mitogenome CDS genes and 16 plastome CDS genes, corresponding to 2.39% of the R. chingii mitogenome. Mitogenomes had shorter but more collinear regions, evidenced by a comparison of the organelles of non-parasitic R. chingii, hemiparasitic Pedicularis chinensis, and holoparasitic Aeginetia indica in the Orobanchaceae family. Moreover, from non-parasitic to holoparasitic species, the genome size in the mitogenomes of Orobanchaceae species did not decrease gradually. Instead, the smallest mitogenome was found in the hemiparasitic species P. chinensis, with a size of 225,612 bp. The findings fill the gap in the mitogenome research of the medicinal plant R. chingii, promote the progress of the organelle genome research of the Orobanchaceae family, and provide clues for molecular breeding.

Abstract Background Malalignment is a common event during the intramedullary nailing (IMN) of distal tibia fractures (DTFs). Although it is reported that the semi-extended IMN techniques such as suprapatellar (SP) and parapatellar (PP) approaches may be superior in preventing malalignment, the application of these techniques is concerning owing to the intra-articular involvement. We thus developed an extra-articular semi-extended infrapatellar (SEIP) approach which utilizes the infrapatellar (IP) space while maintaining the knee in a semi-extended position. However, there are no studies on the safety and efficacy of SEIP in treating DTFs. Therefore, in this study, the SEIP technique was examined, particularly in terms of the potential alignment improvement of DTFs, and this technique was compared with the traditional hyperflexed infrapatellar (HFIP) procedure. Materials and methods This randomized clinical trial (RCT) compared IMN malalignment while correcting extraarticular and nondisplaced intra-articular DTFs between April 2018 and June 2021 using the HFIP and SEIP techniques at a level I trauma center in China. The study participants were clinically and radiographically examined for at least 12 months of follow-ups. Intraoperative fluoroscopy time, operation time, blood loss, hospitalization duration, functional ankle score, and complications were assessed as well. Results Among the 88 recruited participants, 45 (51%) underwent traditional HFIP IMN and 43 (49%) underwent SEIP IMN. Malalignment occurred in 9 patients (20.0%) from the HFIP cohort and in 2 patients (4.7%) from the SEIP cohort (P value = 0.030). In addition, the SEIP IMN technique significantly reduced the intraoperative fluoroscopy time, operation time, and improved the postoperative ankle function compared to the HFIP IMN technique. However, the intraoperative blood loss, hospitalization duration, infection, delay union, and nonunion remained the same between the two cohorts. Conclusions In summary, we demonstrated that the SEIP IMN provides markedly enhanced alignment of extraarticular and nondisplaced intra-articular DTFs compared to the traditional HFIP IMN procedure. The described technique represents an effective option for IMN of DTFs. Level of evidence Level 2. Trial registration The Chinese Clinical Trial Registry, ChiCTR2100043673. Registered 26 February 2021, retrospectively registered, http://www.chictr.org.cn/showprojen.aspx?proj=122263

Thalictrum is a phylogenetically and economically important genus in the family Ranunculaceae, but is also regarded as one of the most challengingly difficult in plants for resolving the taxonomical and phylogenetical relationships of constituent taxa within this genus. Here, we sequenced the complete plastid genomes of two Thalictrum species using Illumina sequencing technology via de novo assembly. The two Thalictrum plastomes exhibited circular and typical quadripartite structure that was rather conserved in overall structure and the synteny of gene order. By updating the previously reported plastome annotation of other nine Thalictrum species, we found that the expansion or contraction of the inverted repeat region affect the boundary of the single-copy regions in Thalictrum plastome. We identified eight highly variable noncoding regions—infA-rps8, ccsA-ndhD, trnSUGA-psbZ, trnHGUG-psbA, rpl16-rps3, ndhG-ndhI, ndhD-psaC, and ndhJ-ndhK—that can be further used for molecular identification, phylogenetic, and phylogeographic in different species. Selective pressure and codon usage bias of all the plastid coding genes were also analyzed for the 11 species. Phylogenetic relationships showed Thalictrum is monophyly and divided into two major clades based on 11 Thalictrum plastomes. The availability of these plastomes offers valuable genetic information for accurate identification of species and taxonomy, phylogenetic resolution, and evolutionary studies of Thalictrum, and should assist with exploration and utilization of Thalictrum plants.

Chloroplasts are critical to plant survival and adaptive evolution. The comparison of chloroplast genomes could provide insight into the adaptive evolution of closely related species. To identify potential adaptive evolution in the chloroplast genomes of four montane Zingiberaceae taxa (Cautleya, Roscoea, Rhynchanthus, and Pommereschea) that inhabit distinct habitats in the mountains of Yunnan, China, the nucleotide sequences of 13 complete chloroplast genomes, including five newly sequenced species, were characterized and compared. The five newly sequenced chloroplast genomes (162,878–163,831 bp) possessed typical quadripartite structures, which included a large single copy (LSC) region, a small single copy (SSC) region, and a pair of inverted repeat regions (IRa and IRb), and even though the structure was highly conserved among the 13 taxa, one of the rps19 genes was absent in Cautleya, possibly due to expansion of the LSC region. Positive selection of rpoA and ycf2 suggests that these montane species have experienced adaptive evolution to habitats with different sunlight intensities and that adaptation related to the chloroplast genome has played an important role in the evolution of Zingiberaceae taxa.

Abstract. Background. Human infections with zoonotic coronaviruses (CoVs), including severe acute respiratory syndrome (SARS)-CoV and Middle East respiratory syndrome (MERS)-CoV, have raised great public health concern globally. Here, we report a novel bat-origin CoV causing severe and fatal pneumonia in humans. Methods. We collected clinical data and bronchoalveolar lavage (BAL) specimens from five patients with severe pneumonia from Wuhan Jinyintan Hospital, Hubei province, China. Nucleic acids of the BAL were extracted and subjected to next-generation sequencing. Virus isolation was carried out, and maximum-likelihood phylogenetic trees were constructed. Results. Five patients hospitalized from December 18 to December 29, 2019 presented with fever, cough, and dyspnea accompanied by complications of acute respiratory distress syndrome. Chest radiography revealed diffuse opacities and consolidation. One of these patients died. Sequence results revealed the presence of a previously unknown β-CoV strain in all five patients, with 99.8% to 99.9% nucleotide identities among the isolates. These isolates showed 79.0% nucleotide identity with the sequence of SARS-CoV (GenBank NC_004718) and 51.8% identity with the sequence of MERS-CoV (GenBank NC_019843). The virus is phylogenetically closest to a bat SARS-like CoV (SL-ZC45, GenBank MG772933) with 87.6% to 87.7% nucleotide identity, but is in a separate clade. Moreover, these viruses have a single intact open reading frame gene 8, as a further indicator of bat-origin CoVs. However, the amino acid sequence of the tentative receptor-binding domain resembles that of SARS-CoV, indicating that these viruses might use the same receptor. Conclusion. A novel bat-borne CoV was identified that is associated with severe and fatal respiratory disease in humans.

Objective: Asymmetrical cortical vein sign (ACVS) shown on susceptibility-weighted imaging (SWI) can reflect regional hypoperfusion. We investigated if ACVS could predict the cerebral collateral circulation (CC) as assessed by digital subtraction angiography (DSA) in acute ischemic stroke patients with ipsilateral severe stenosis/occlusion of the anterior circulation.Methods: Clinical data and imaging data of 62 acute ischemic stroke patients with ipsilateral severe stenosis or occlusion of the anterior circulation confirmed by DSA were collected retrospectively. Participants underwent magnetic resonance imaging, including an SWI sequence. ACVS was defined as more and/or larger venous signals in the cerebral cortex of one side of SWI than that in the contralateral side. ACVS was measured using the Alberta Stroke Program Early Computed Tomography score based on SWI. The grading of the cerebral CC was judged using DSA.Results: Of the 62 patients, 30 patients (48.4%) had moderate-to-severe ACVS. According to DSA assessment, 19 patients (30.6%) had a good CC (grade 3–4), and 43 (69.4%) patients had a poor-to-moderate CC (grade 0–2). Among the 30 patients with moderate-to-severe ACVS, only three (10%) patients had a good CC, and 27 (90%) patients had a poor-to-moderate CC; among the 32 patients with none or mild ACVS, 16 (50%) of them had a good CC, and the other 50% had a moderate-to-severe CC. We constructed two logistic regression models with ACVS grading and none or mild ACVS entered into the models, respectively, together with age and large-artery occlusion. In model 1, no ACVS (compared with severe ACVS; OR = 40.329, 95%CI = 2.817–577.422, P = 0.006), mild ACVS (compared with severe ACVS; OR = 17.186, 1.735–170.224, 0.015) and large-artery occlusion (OR = 45.645, 4.603–452.592, 0.001) correlated with a good CC. In model 2, none or mild ACVS (OR = 36.848, 95%CI = 5.516–246.171, P < 0.001) was significantly associated with a good CC as judged by DSA, adjusted by age and large-artery occlusion.Conclusions: Cortical venous changes in SWI may be a useful indicator for the cerebral CC as confirmed by DSA.

The high-frequency signal injection-type maximum torque per ampere (MTPA) algorithm is usually employed to control the operation of interior permanent magnet synchronous motors (IPMSMs). The MTPA algorithm exhibits good dynamic performance and anti-interference ability. However, due to the injection of a high-frequency current signal, problems such as torque ripple and additional loss are encountered. Therefore, in this paper, a virtual signal injection control (VSIC) method that does not require actual injection is proposed for solving the aforementioned problems while yielding good performance. However, in the control process of the proposed method, the d-axis inductance parameter affects the accuracy of the torque information, resulting in errors in the system. To solve this problem, an online identification algorithm of model reference adaptive systems (MRAS) based on the Popov super stability theory as the basis for the design of the adaptive law is proposed in this paper. The d-axis inductance parameter of the motor is obtained in real-time and then introduced into the control system by using the VSIC method. Finally, VSIC-type MTPA control based on inductance identification is realized. The proposed algorithm does not depend on the design parameters of the motor and exhibits good dynamic response and anti-interference performance.

Abstract Background The use of the suprapatellar approach for intramedullary nailing has recently become popular for the treatment of tibial fractures. This study aimed to investigate the effectiveness of using the Chinese Aircraft-shaped Sleeve (CASS) system on the clinical outcomes of tibial intermedullary nailing using a suprapatellar approach for the treatment of tibial fractures in a cohort of adult Chinese patients. Methods Magnetic resonance images (MRI) of the knee joints of 212 healthy adults with normal lower limb function from May 2011 to May 2015 were obtained from a level I Chinese regional trauma centre. Sixty inpatients at the same trauma centre who underwent treatment for tibial shaft fractures from June 2015 to June 2018 were enrolled. Tibial intramedullary nailing fixation of tibial shaft fractures via the suprapatellar approach was performed with either a CASS system or a conventional sleeve. The measurements of patellofemoral joint anatomy, the surgical time, the assessments of the patellofemoral joint cartilage conditions, and information of residual debris based on arthroscopic analysis were subsequently collected. Results The mean patellar angle (PA), sulcus angle (SA), sulcus width (SW) and sulcus depth (SD) were 135.40 ± 6.20°, 142.37 ± 5.33°, 33.37 ± 2.73 mm, and 4.29 ± 0.63 mm, respectively. The surgical time until entry reaming commencement and the irrigation time were significantly lower in the CASS group (P

Abstract Introduction Very few studies have investigated the specific relationship between neutrophil‐to‐lymphocyte ratio (NLR) and the short‐term outcomes of patients suffering from mild acute ischemic stroke (AIS) and receiving intravenous thrombolysis (IVT). This study aimed to investigate whether a high NLR is associated with a poor short‐term outcome in patients with mild AIS after IVT. Methods We retrospectively analyzed data that were prospectively acquired from patients with AIS treated with IVT. Mild AIS was defined as a National Institutes of Health Stroke Scale (NIHSS) score ≤ 7 on admission. The NLR was based on a blood test performed prior to IVT and was classified as ‘high’ when exceeding the 75th percentile. Follow‐ups were performed at discharge and 3 months after onset. A poor outcome was defined as a modified Rankin scale (mRS) ≥3. Results A total of 192 patients were included in this study. The median NLR was 3.0 (interquartile range [IQR]: 2.0–3.9). Fifty‐one patients (26.6%) had a high NLR (≥3.9) on admission. Forty‐one patients (21.4%) had a poor outcome at discharge, while 34 patients (17.7%) had a poor outcome at 3 months. Patients with a poor outcome at discharge, and at 3 months after onset, were more likely to have a high NLR at discharge (42.9% vs. 21.9%; p = .005) and at 3 months (44.1% vs. 22.8%; p = .011), compared with those with a better outcome. After adjustment for NIHSS score on admission, ipsilateral severe intracranial large artery occlusion, and atrial fibrillation, logistic regression analyses revealed that a high NLR was a significant predictor of poor outcome at discharge and at 3 months after onset. Conclusions A high NLR on admission could be a useful marker for predicting poor short‐term outcome in patients with mild AIS following IVT.

Abstract Objective The aim of this prospective cohort study was to determine the incidence and neuroimaging risk factors associated with Babinski sign following acute ischemic stroke, as well as its relationship with the functional outcome of patients. Methods A total of 351 patients were enrolled in the study within 7 days of acute ischemic stroke. The Babinski sign along with other upper motor neuron signs were examined upon admission and between days 1 and 3 and days 5 and 7 after admission. Neuroimaging parameters included site and volume of infarction and white matter lesions. All patients were followed up at 3 months. Functional outcome was assessed with the Lawton Activities of Daily Living scale and modified Rankin Scale. Results Babinski sign was observed in 115 of 351 (32.8%) patients in the acute ischemic stroke. These patients had higher National Institutes of Health Stroke Scale (NIHSS) scores at admission and higher rates of atrial fibrillation and cardioembolism; higher frequencies of frontal, temporal, and limbic lobes and basal ganglia infarcts; and larger infarct volume. Higher NIHSS score and basal ganglia infarct were significant predictors of the presence of Babinski sign. After adjusting for confounds, the presence of Babinski sign did not predict poor functional outcome. Conclusion The incidence of Babinski sign was 32.8% in the acute ischemic stroke. Severe infarction and basal ganglia infarct were independent predictors of Babinski sign. Although Babinski sign is common in acute ischemic stroke patients, it does not predict poor functional outcome 3 months later.

A subspace tracking technique has drawn a lot of attentions due to its wide applications. The main objective of this approach is to estimate signal or noise subspace basis for the sample covariance matrix. In this paper, we focus on providing a fast, stable, and adaptive subspace tracking algorithm that is implemented with low computational complexity. An alternative realization of the fast approximate power iteration (FAPI) method, termed modified FAPI (MFAPI), is also presented. Rather than solving an inverse square root of a matrix employed in the FAPI, the MFAPI applies the matrix product directly to ensure the orthonormality of the subspace basis matrix at each recursion. This approach yields a simpler derivation and is numerically stable while maintaining a similar computational complexity as compared with that of the FAPI. Furthermore, we present a detailed mathematical proof of the numerical stability of our proposed algorithm. Computer simulation results indicate that the MFAPI outperforms many classical subspace tracking algorithms, particularly at the transient-state step.

Trapa bispinosa Roxb. is an annual aquatic herb with great significance of medicinal, edible and economic value. Here, we reported the complete chloroplast genome sequence of Trapa bispinosa and conducted preliminary investigation of its phylogenetic relationship with other related species. As the result showed, the whole chloroplast genome size was 155,556 bp consisting of four adjoining regions, i.e., a large/small single copy (LSC, 88,506 bp/SSC, 18,274 bp) region and two inverted repeat (IRs, 24,388 bp) regions. Among 112 identified unique genes were 78 protein coding genes, 30 transfer RNA (tRNA) genes, and four ribosomal RNA (rRNA) genes. Trapa spp. were precisely clustered as a monophyly, and simultaneously, the closest relation between Trapa bispinosa and Trapa natans were strongly supported in the maximum likelihood analysis.

Lagerstroemia villosa is a kind of ornamental tree with surprising potential for applying in the landscape. We characterized the complete chloroplast genome of this scarce species and analyzed its phylogeny within Lythraceae. The result showed that the genome possessed a typical quadripartite structure, in more detail, a lager single-copy region (LSC, 88,702bp), a small single-copy region (SSC, 18,255bp), and a pair of inverted repeat regions (IRa and IRb, 26,906 bp). 78 protein-coding genes, four ribosomal RNA (rRNA) genes, and 30 transfer RNA (tRNA) genes were detected. Phylogenetic analysis based on maximum likelihood (ML) supported the closest relationship between L. villosa and Lagerstroemia limii plus Lagerstroemia subcostata.

Pomegranate (Punica granatum L.) is of great significance both as a fruit tree and an ornamental plant. Hereon, we sequenced and characterized the complete chloroplast genome of Punica granatum ‘Nana’ and performed phylogenetic analysis concerning related species. It turned out that the length of chloroplast genome sequence reached 158,639 bp and exhibited a four-conjoined structure, i.e., a large single copy region (LSC, 89,022 bp), a small single copy region (SSC, 18,685 bp) and twain inverted repeat regions (IRa and IRb, 25,466 bp). 112 unique genes were identified, consisting of 78 protein-coding genes, four ribosomal RNA (rRNA) genes and 30 transfer RNA (tRNA) genes. The result of phylogenetic analysis based on Neighbor-joining (NJ) method was consistent with that of Bayesian inference (BI), which strongly supported that Punica granatum ‘Nana’ was close to its original species Punica granatum and they together had a close relationship with Heimia myrtifolia within Lythraceae.

Cuphea hyssopifolia is a small evergreen shrub of great economic and medicinal values. However, there are few studies on the ecological and genetic characteristics of this species. Chloroplast genomic analysis has been shown to resolve phylogenetic relationships. Here, we sequenced the complete chloroplast (cp) genome of C. hyssopifolia, which is the first complete cp genome reported in the genus Cuphea. The size of the whole cp genome is 158,821 bp, exhibiting the large (LSC, 89,064 bp) and small (SSC, 18,373 bp) single-copy regions and a pair of inverted repeats (IRs, 25,692 bp). The genome contained 111 unique genes, including 78 protein coding genes, 29 transfer RNAs (tRNA), and four ribosomal RNAs (rRNA). Neighbour-joining (NJ) phylogenetic analysis based on 43 genomes showed that C. hyssopifolia was closer to Heimia myrtifolia than Lagerstroemia species in the Lythraceae family.

More than 50% of Chinese mangroves were lost between 1950 and 2000 to habitat destruction, prompting an urge for conservation. To assess the importance of the protected Maowei Gulf mangrove estuary for fish population assemblage in the Beibu Gulf (China), we studied species composition and abundance of juvenile fish (including larvae) from July 2012 to June 2013. A total of 11 691 specimens were collected, which belonged to 24 species and 15 families. Six perciform species constituted 93% of the total sample. Pseudogobius javanicus (53.29%) was the dominant species from August to November, Omobranchus elegans (28.49%) from April to July, non-identified species in December and January, and Liza carinata in February and March. A number of commercially important fish species were also identified. Abundance was the highest in summer/early autumn (max 162.4 in Sep), and lowest in winter/early spring (Mar = 4.5). Diversity (H') and richness (Dma) indices (both max. in May: 1.67 and 1.95 respectively) were generally positively correlated with tide and temperature, and negatively with salinity. Seasonal variations play a more important role in the fish assemblage structure than tidal rhythm, with differences particularly pronounced between colder and warmer months. Despite the prominent seasonal differences in abiotic factors, this study indicates that Maowei mangroves provide habitat and food for juvenile fish throughout the year and thus are indispensable for the fish diversity in the Beibu Gulf.

To pool reliable evidences for the optimum anterior transposition technique in the treatment of cubital tunnel syndrome by comparing the clinical efficacy of subcutaneous and submuscular anterior ulnar nerve transposition.A comprehensive search was conducted in PubMed MEDLINE, Cochrane Library, EMBASE, Web of Science, OVID AMED, EBSCO and potentially relevant surgical archives. Risk of bias of each included studies was evaluated according to Cochrane Handbook for Systematic Reviews of Interventions. The risk ratio (RR) and 95% confidence intervals (CI) were calculated for the clinical improvement in function compared to baseline. Heterogeneity was assessed across studies, and subgroup analysis was also performed based on the study type and follow-up duration.Three studies with a total of 352 participants were identified, and the clinically relevant improvement was used as the primary outcomes. Our meta-analysis revealed that no significant difference was observed between two comparison groups in terms of postoperative clinical improvement in those studies (RR 1.04, 95% CI 0.86 to 1.25, P = 0.72). Meanwhile, subgroup analyses by study type and follow-up duration revealed the consistent results with the overall estimate. Additionally, the pre- and postoperative motor nerve conduction velocities were reported in two studies with a total of 326 patients, but we could not perform a meta-analysis because of the lack of concrete numerical value in one study. The quality of evidence for clinical improvement was 'low' or 'moderate' on the basis of GRADE approach.Based on small numbers of studies with relatively poor methodological quality, the limited evidence is insufficient to identify the optimum anterior transposition technique in the treatment of cubital tunnel syndrome. The results of the present study suggest that anterior subcutaneous and submuscular transposition might be equally effective in patients with ulnar neuropathy at the elbow. Therefore, more high-quality randomized controlled trials with standardized clinical improvement metrics are required to further clarify this topic and to provide reproducible pre- and postoperative objective outcomes.

The Qinghai-Tibetan Plateau (QTP) and its southern and southeastern mountain ranges, Himalaya-Hengduan Mountains (HHM), are one of the most extensive habitats for alpine plants in the world. How ferns occurring in QTP and HHM changed their distribution ranges in response to Quaternary climatic oscillations remains almost unknown.We employed sequences of two chloroplast DNA regions, rps4-trnS and trnL-trnF, to reconstruct phylogeography of the Sino-Himalayan fern Lepisorus clathratus, occurring mainly in the QTP and HHM. Individuals of this species have either dehiscent or indehiscent sporangia with the latter evolved from the plesiomorphic dehiscent forms. Based on a range-wide sampling, we detected 27 cpDNA haplotypes that were divided into five groups by network analyses. Populations in the Hengduan Mountains possess the highest genetic diversity, while a single haplogroup is detected across the north-central region. A distinct phylogeographical subdivision was detected between the Hengduan Mountains and north-central region by AMOVA analysis. The haplogroup distribution pattern, coalescence and AMOVA analysis suggest that a long term survival area (refugia) of the species was located in the Hengduan Mountains during glaciations, with probable range expansions into north-central regions during interglacial periods. Populations with indehiscent sporangium can carry private haplotypes and are inclined to maintain genetic homogeneity. One group with indehiscent sporangia most likely survived in situ on the QTP during glaciations.This study for the first time sheds light on the response of alpine ferns in the QTP and HHM to the Quaternary climatic oscillations.