Neonatal Circumcision Research Articles

Circumcision and Lifetime Risk of Urinary Tract Infection: A Systematic Review and Meta-Analysis

Urinary tract infection is common in infant males who are uncircumcised and can lead to renal parenchymal disease of the still growing pediatric kidney. Although the rate of urinary tract infection is highest in the first year of life, the cumulative incidence during the rest of the lifetime is under-recognized, but is expected to be nontrivial. Thus, any intervention that might prevent urinary tract infection would be expected to reduce suffering and medical costs. We conducted a meta-analysis of 22 studies examining the single risk factor of lack of circumcision, then determined the prevalence and relative risk of urinary tract infection in different age groups (0 to 1, 1 to 16 and older than 16 years). From these data we estimated the lifetime prevalence. For age 0 to 1 year the relative risk was 9.91 (95% CI 7.49-13.1), for age 1 to 16 years RR was 6.56 (95% CI 3.26-13.2) and for older than 16 years it was 3.41-fold (95% CI 0.916-12.7) higher in uncircumcised males. We then calculated that 32.1% (95% CI 15.6-49.8) of uncircumcised males experience a urinary tract infection in their lifetime compared with 8.8% (95% CI 4.15-13.2) of circumcised males (RR 3.65, 95% CI 1.15-11.8). The number needed to treat was 4.29 (95% CI 2.20-27.2). The single risk factor of lack of circumcision confers a 23.3% chance of urinary tract infection during the lifetime. This greatly exceeds the prevalence of circumcision complications (1.5%), which are mostly minor. The potential seriousness of urinary tract infection supports circumcision as a desirable preventive health intervention in infant males.

Routine neonatal circumcision for the prevention of urinary tract infections in infancy

Neonatal circumcision is a fairly common surgical procedure that may be carried out for medical reasons, one of them being prevention of urinary tract infections (UTI) in male infants. Circumcision could help in reducing the incidence of UTI by reducing periurethral bacterial colonization, which is accepted as a potential risk factor in UTI. Evidence is needed to inform the benefits or harm for the routine use of this intervention. To assess the effectiveness and safety of routine neonatal circumcision for the prevention of UTIs in infancy. We searched the Cochrane Neonatal Review Group Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We completed this search 30 June 2011. Randomised controlled trials and quasi-randomised controlled trials. Two review authors had planned to independently screen studies, extract data and assess risk of bias using standard Cochrane Collaboration methodologies. We did not identify any studies for inclusion in this review. We did not identify any relevant studies after a comprehensive search of the literature. We were unable to identify any randomised controlled trials on the use of routine neonatal circumcision for prevention of UTI in male infants. Until further evidence becomes available, clinicians should continue to base their decisions on position statements and recommendations and in conjunction with the opinions of the children's parents.

The ‘Beauty’ of Male Circumcision in Japan: Gender, Sexuality and the Male Body in a Medical Practice

This article introduces the construct of ‘the beauty of male circumcision’ to analyse male circumcision in Japan. Japanese men are largely circumcised at beauty and aesthetic clinics, neonatal circumcision has never been mandatory and no official records are provided, therefore the manuscript offers an iconographic and textual analysis of the information that Japanese men can access to decide whether they want to be circumcised. The analysis is grounded on four axes: medical knowledge, embodiment, gender and sexuality. Although male circumcision has been largely a preventative method against disease, in Japanese settings the surgery is sold as a means to regain control of the body and enhance self-confidence. The male body is seen as a commodity and male circumcision becomes a placebo that works on the psyche of men grappling with gender and sexual matters.

Glans amputation during routine neonatal circumcision: Mechanism of injury and strategy for prevention

ObjectiveGlans injury during circumcision is an uncommon yet potentially devastating complication. Its mechanism remains poorly understood. Herein we critically evaluate a case series and, based on common characteristics, hypothesize the mechanism of injury as well as means to prevent it. MethodsRetrospective review of circumcision-related glans amputation cases referred for evaluation and management, focusing on detection of common history and presentation patterns in order to evaluate possible underlying mechanisms. ResultsA neonatal elective circumcision was conducted using a Mogen clamp and an oblique injury to the ventro-lateral aspect of the glans was noted in 6 cases referred over a 5-year period, suggesting a similar trauma pattern. The urethra was consistently involved. The amputated segments were reattached as free composite grafts in 2/6 cases. Three patients underwent delayed glansplasty months after the trauma in an attempt to restore natural symmetry and cosmesis. In one case a buccal mucosa graft was employed to rebuild the ventral coronal sulcus. ConclusionsTrauma pattern suggests that the ventral glans is at high risk for injury by traction on incompletely released ventral preputial adhesions with subsequent glans entrapment. Practitioners performing neonatal circumcisions, particularly with a Mogen clamp, should exercise adequate release of ventral adhesions to prevent this complication.

Correcting Morris et al. with respect to anaesthesia for neonatal circumcision

Correcting <scp>M</scp>orris <i>et al</i>. with respect to anaesthesia for neonatal circumcision

Cuts, Claims and Cautionary Tales - An Overview of Circumcision

Allegations of poorly performed circumcisions may arise as negligence claims, civil claims or a professional (General Medical Council [GMC]) matter. This article explains the various types of circumcision, including those done for religious purposes, and attempts to provide an understanding of the issues relating to claims. The writer is a medicolegal expert (Accident &amp; Emergency Consultant) who trained in surgery and for over 25 years has performed neonatal circumcision for religious purposes (usually in the home), child circumcision and adult circumcision. He has provided reports for both claimant and defendants, in negligence claims, civil claims and GMC proceedings.

Male Neonatal Circumcision - A Review Article

Circumcision is the most common surgery performed worldwide and about 30% of men are circumcised, of whom 70% are Muslim. The majority of male neonates are circumcised based on religious and cultural practices. Neonatal circumcision has several advantages when compared to an older age group receiving the procedure. There is considerable controversy about circumcision neonatal or otherwise. The clinical benefits of circumcision include reducing the risk of urinary tract infection (UTI), sexually transmitted disease (STD), HIV infection, phimosis, balanitis and penile cancer. The most common complications of circumcision are infection, bleeding and failure to remove enough foreskin. These complications occur in less than 1% of all performed circumcisions.

Loss of anatomical landmarks with eutectic mixture of local anesthetic cream for neonatal male circumcision

We report two cases of newborns who developed marked local edema after application of a eutectic mixture of local anesthetic (EMLA) topical anesthetic cream for neonatal male circumcision (NMC). Although local edema and erythema are known potential side effects of EMLA cream, a common anesthetic used for NMC, the loss of landmarks precluding safe NMC has not previously been reported, and is described here. Although we cannot recommend an alternate local anesthetic for neonates with this reaction to EMLA, based on a review of the published data we think that serious systemic adverse events related to EMLA are extremely rare.

Costs and Effectiveness of Neonatal Male Circumcision

To evaluate the expected change in the prevalence of male circumcision (MC)-reduced infections and resulting health care costs associated with continued decreases in MC rates. During the past 20 years, MC rates have declined from 79% to 55%, alongside reduced insurance coverage. We used Markov-based Monte Carlo simulations to track men and women throughout their lifetimes as they experienced MC procedure-related events and MC-reduced infections and accumulated associated costs. One-way and probabilistic sensitivity analyses were used to evaluate the impact of uncertainty. United States. Birth cohort of men and women. Decreased MC rates (10% reflects the MC rate in Europe, where insurance coverage is limited). Lifetime direct medical cost (2011 US$) and prevalence of MC-reduced infections. Reducing the MC rate to 10% will increase lifetime health care costs by $407 per male and $43 per female. Net expenditure per annual birth cohort (including procedure and complication costs) is expected to increase by $505 million, reflecting an increase of $313 per forgone MC. Over 10 annual cohorts, net present value of additional costs would exceed $4.4 billion. Lifetime prevalence of human immunodeficiency virus infection among males is expected to increase by 12.2% (4843 cases), high- and low-risk human papillomavirus by 29.1% (57 124 cases), herpes simplex virus type 2 by 19.8% (124 767 cases), and infant urinary tract infections by 211.8% (26 876 cases). Among females, lifetime prevalence of bacterial vaginosis is expected to increase by 51.2% (538 865 cases), trichomoniasis by 51.2% (64 585 cases), high-risk human papillomavirus by 18.3% (33 148 cases), and low-risk human papillomavirus by 12.9% (25 837 cases). Increased prevalence of human immunodeficiency virus infection among males represents 78.9% of increased expenses. Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women.

Buried penis: An unrecognized risk factor in the development of invasive penile cancer.

One of the documented benefits of neonatal circumcision is protection against invasive penile cancer. To date there have been a handful of published cases of invasive penile cancer in men circumcised as neonates. We report a case of a 73-year-old man, with a history of neonatal circumcision with no evidence of previous human papillomavirus exposure, who developed a buried penis secondary to obesity. He was diagnosed with Grade 2, pT3N0 squamous cell carcinoma of the penis. This report suggests that buried penis may pose a risk factor for the development of penile cancer despite the protective effects of neonatal circumcision. Thus periodic examination of a buried penis is warranted even in patients with no risk factors for penile cancer. A review of the literature is provided.

Acceptability and Uptake of Neonatal Male Circumcision in Lusaka, Zambia

Neonatal male circumcision (NMC) is an uncommon procedure in Southern Africa, but is being scaled up in Zambia for long-term HIV prevention. We conducted a cross-sectional survey on NMC with a convenience sample of mothers of newborn boys at two public clinics in Lusaka. Following the survey, mothers received information on availability of NMC, and uptake of the service was tracked. Predictors of uptake were assessed using bivariate and multivariate logistic regression. Of the 1,249 eligible mothers approached, 1000 (80%) agreed to participate. Although 97% of surveyed mothers said they definitely or probably planned to have their newborn son circumcised, only 11% of participants brought their newborn sons for NMC. Significant predictors of uptake in adjusted models included: Older maternal age (AOR 3.77, 95% CI 1.48-9.63 for age 36 and above compared to mothers age 25 and below), having attended antenatal care at an NMC site (AOR 2.13, 95% CI 1.32-3.44), older paternal age (AOR 4.36, 95% CI 1.28-14.91 for age 26-35 compared to fathers age 25 and below), and the infant's father being circumcised (AOR 2.21, 95% CI 1.35-3.62). While acceptability studies in Southern Africa have suggested strong support for MC among parents for having their sons circumcised, this may not translate to high uptake of newly-introduced NMC services.

Circumcision in the United States: Where Are We?

Circumcision is one of the most common surgical procedures performed on males in the United States. Ethical considerations of the procedure have been considered for many years and, recently, research on the topic has shed more light on the debate. The purpose of this study was to review the history and emergence, current demographics, and practices of male circumcision, specifically, nonreligious, nonmedically indicated routine neonatal circumcision. A review of the current literature was conducted using PubMed and current practices from guidelines of major professional societies. Physicians should consider the various ethical concerns and provide the patient's guardians with unbiased counsel. There is a lack of evidence both in favor of and against recommending routine neonatal circumcisions in the United States. The question remains whether we should continue unwarranted male circumcisions, especially when the major tenet of medical ethics is "do no harm."

Routine neonatal circumcision: Opportunities for improving residency training

ObjectivesPrimary care physicians are the routine providers of neonatal circumcision, yet urologists commonly manage the complications. We previously identified a need for improved formalized training in neonatal circumcisions among ob-gyn residents. Here we extend the needs assessment to urology residents. MethodsFrom Nov 2008 to Nov 2009, ob-gyn and urology residents at our institution were given an online survey to assess comfort, education, and proficiency in pre-operative evaluation and performance of circumcisions. Results26/35 (74%) ob-gyn and 12/17 (65%) urology residents responded to the survey. 62% of ob-gyn and 33% of urology residents intended to perform neonatal circumcisions in practice. Both groups described having little formal training in neonatal circumcision. Ob-gyn residents felt more comfortable than urology residents in performing neonatal circumcisions [mean 5.9 vs. 4.3, p = 0.001; 1 (very uncomfortable) – 7 (very comfortable)], though urology residents' comfort level increased with resident year. Ob-gyn residents felt less comfortable than urology residents (mean 3.9 vs. 5.1, p = 0.031) evaluating if a newborn penis may undergo circumcision safely. Urology residents performed better than ob-gyn residents at identifying contraindications to routine circumcision from 10 scenarios (mean 63% vs. 42% p < 0.001). Both felt that an online module was a good alternative to practical experience. ConclusionsAt our institution, ob-gyn and urology residents have little formalized training in neonatal circumcision. While ob-gyn residents are comfortable performing circumcisions, they feel less comfortable evaluating the newborn penis and correctly managed fewer scenarios than did urology residents. This highlights the need for further curriculum development and formalized training.

Analysis of Decisional Conflict Among Parents Who Consent to Hypospadias Repair: Single Institution Prospective Study of 100 Couples

Although obtaining informed consent for distal hypospadias repair is common practice, little is known about the uncertainty or conflict between consenting parents faced with this decision. We systematically evaluated decisional conflict between parents who elected to have their child undergo hypospadias surgery. A total of 100 couples who were counseled about treatment options agreed to participate. Using a validated questionnaire, the Decisional Conflict Scale, we prospectively collected data on decisional conflict demographics, preference for circumcision, education level and prior knowledge about hypospadias. All parents elected surgical repair. Evidence of decisional conflict was encountered in 28% of participants (score less than 25 in 72%, 25 to 37.5 in 23.5%, greater than 37.5 in 4.5%). No statistically significant differences among parents were noted for total score (mean ± SD 16.1 ± 12 in mothers and 18.3 ± 12.6 in fathers) or subscales, except the informed subscale (mean ± SD 16.7 ± 14.3 in mothers and 21.1 ± 16.6 in fathers). Parental self-report of prior knowledge about hypospadias and preference for neonatal circumcision correlated with lower Decisional Conflict Scale scores (p = 0.02 and p <0.01, respectively). No statistical association was found between score and parental education level (p = 0.7) or expertise of the counselor (staff vs pediatric urology fellow, p = 0.4). These data describe the level of decisional conflict in couples agreeing to proceed with hypospadias repair, with no evidence of significant discrepancy between them. The novel description of factors related to decreased decisional conflict might help focus efforts aimed at minimizing difficulties encountered during the decision making process.

The new politics of male circumcision: HIV/AIDS, health law and social justice

This paper engages with a changing politics of male circumcision. It suggests that various shifts which have occurred in how the issue is debated challenge legal constructions of the practice as a private familial issue. Although circumcision rates have declined in those Western nations which have traditionally practised it, the procedure is now being promoted as a medicalised response to the HIV/AIDS pandemic in sub-Saharan Africa. Such initiatives propose a new biomedical rationale for the practice and have been difficult to confine to the African context or to adult bodies, prompting a resurgence of enthusiasm for neonatal male circumcision on the part of professional bodies in the USA and elsewhere. Although we have reservations about such public health policies, which we suggest downplay risks inherent in the procedure both for the individual and for the advancement of public health, we argue that such strategies have the potential to move debates about circumcision beyond the parameters of traditional ‘medical law’, with its focus on the doctor–patient nexus and the issue of who can validly consent to medical procedures. We suggest that, as with female genital cutting, male circumcision ought to be debated within a paradigm of social justice which gives adequate weighting to the interests of all affected parties (including women whose health may actually be compromised by the procedure) and which renders visible the socio-economic dimensions of the issue. In line with a social justice approach, we argue that public health initiatives must comply with international ethico-legal standards and be attentive to the emergence of an international human right to health. The shift in analytical frame that we propose has the potential not only to make us re-think our approach to the ethics and legality of male circumcision by challenging its construction as a familial decision but also to impact on the need for a broader conceptualisation of health law as rooted in social justice.

A comparison of two different doses of bupivacaine in caudal anesthesia for neonatal circumcision

A comparison of two different doses of bupivacaine in caudal anesthesia for neonatal circumcision

Circumcision of neonates and children without appropriate anaesthesia is unacceptable practice

Circumcision is painful surgery and appropriate intraoperative anaesthesia and postoperative analgesia is required. This is recognised in the policies of the Royal Australasian College of Physicians and the majority of Australian State Health Departments. Nevertheless, anecdotal evidence exists that neonatal circumcision continues to be performed in Australia with either no anaesthesia or with inadequate anaesthesia. This paper presents the evidence that neonatal circumcision is painful and reviews the available anaesthetic techniques. The authors conclude that general anaesthesia is arguably the most reliable way of ensuring adequate anaesthesia, although this may mean deferment of the procedure until the child is older. Local or regional anaesthesia for neonatal circumcision ideally requires a separate skilled anaesthetist (other than the proceduralist) to monitor the patient and intervene if the anaesthesia is inadequate. Topical anaesthesia with lignocaine-prilocaine cream is insufficient.

Attitudes and decision making about neonatal male circumcision in a Hispanic population in New York City.

To understand attitudes and decision making regarding neonatal male circumcision. Parents (n = 150) with a son 3 years old were interviewed regarding demographics, communication with a medical provider, attitudes, and process by which the neonatal circumcision decision was made. Thirty-three percent of sons were circumcised. In univariate analyses, choosing male circumcision was associated with parents being interviewed in English, the father being circumcised, positive attitudes, being informed of the advantages of circumcision, making a decision before birth, and being offered a choice. In the final model, parents who came from a culture and family that believed in circumcision and who believed that it was not too risky were more likely to circumcise their sons. Decisions regarding circumcision appear to be influenced by values, risk perceptions, and medical providers. Future research should address ways of ensuring that families have the opportunity to make an informed decision.

735 ELECTIVE CIRCUMCISION IN A MEDICAID POPULATION PARENTAL, PHYSICIAN, AND REGULATORY INSIGHT

You have accessJournal of UrologyPediatrics: Basic Research1 Apr 2012735 ELECTIVE CIRCUMCISION IN A MEDICAID POPULATION PARENTAL, PHYSICIAN, AND REGULATORY INSIGHT Austin Lutz, Christopher Small, Kurt Eeg, and Christopher Roth Austin LutzAustin Lutz New Orleans, LA More articles by this author , Christopher SmallChristopher Small New Orleans, LA More articles by this author , Kurt EegKurt Eeg New Orleans, LA More articles by this author , and Christopher RothChristopher Roth New Orleans, LA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.820AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Louisiana (LA) Medicaid stopped coverage of neonatal circumcisions in 2005. The aim of this study was to assess the current opinions of pediatricians, parents of boys seeking circumcision, and the Department of Health and Hospitals (DHH) regarding the outcomes of this policy change. METHODS The membership of the LA chapter of the American Academy of Pediatrics (AAP) was emailed a questionnaire regarding neonatal circumcision. Parents of boys referred to the urology clinic at Children's Hospital New Orleans for evaluation for circumcision werealso administered a survey. Personal communication with the DHH allowed for an assessment of the economic outcomes of this policy change. RESULTS 166 of the 581(29%) contacted pediatricians responded to the survey of which 58% have patient populations consisting of >60% Medicaid. The strongest responses in support of neonatal circumcision were ‘cultural, religious, and personal' (p< 0.05). 87% of pediatricians were familiar with AAP policy statement regarding neonatal circumcision. 3% were provided patient education materials by the DHH regarding the policy change. 44% and 60% of pediatricians have seen an increase in post-neonatal circumcisions secondary to medical indications and parental preference respectively. 62 of 73 (85%) of parents surveyed reported Medicaid as their primary insurance. The most common reason for not being circumcised as a newborn was lack of insurance coverage (49%). 48% reported being instructed on the care of the uncircumcised phallus of whom 78% were doing so correctly. When questioned about the importance of neonatal circumcision, parents most strongly answered to prevent urinary tract or skin infection and sexually transmitted disease. 90% of respondents stated that they would pursue circumcision of their son despite being told by the pediatrician that is not medically necessary. DHH data indicate that following the policy change there was a sharp decrease in the number of both elective and medically necessary circumcisions performed; however, the annual number of medically necessary circumcisions has steadily increased since that time. Cost savings for the State to date are estimated at $2.7 million. CONCLUSIONS Subjective data from pediatricians and objective data from the DHH demonstrate an increase in medically necessary circumcisions. Most parents seeking elective circumcision do so regardless of perceived medical need. Increased educational efforts towards parents and pediatricians alike may be needed to balance the medical and economical realities of elective circumcision. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e301-e302 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Austin Lutz New Orleans, LA More articles by this author Christopher Small New Orleans, LA More articles by this author Kurt Eeg New Orleans, LA More articles by this author Christopher Roth New Orleans, LA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

736 URINE DERIVED STEM CELLS WITH HIGH TELOMERASE ACTIVITY FOR CELL BASED THERAPY IN UROLOGY

You have accessJournal of UrologyPediatrics: Basic Research1 Apr 2012736 URINE DERIVED STEM CELLS WITH HIGH TELOMERASE ACTIVITY FOR CELL BASED THERAPY IN UROLOGY Yingai Shi, Guihua Liu, Bharadwaj Shantaram, Anthony Atala, and Yuanyuan Zhang Yingai ShiYingai Shi Winston Salem, NC More articles by this author , Guihua LiuGuihua Liu Winston Salem, NC More articles by this author , Bharadwaj ShantaramBharadwaj Shantaram Winston Salem, NC More articles by this author , Anthony AtalaAnthony Atala Winston Salem, NC More articles by this author , and Yuanyuan ZhangYuanyuan Zhang Winston Salem, NC More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.821AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Maintenance of telomere length by telomerase is an indicator of self-renewing cells, and telomerase is commonly expressed by embryonic stem cells and some types of mesenchymal stem cells (MSC). The purpose of this study was to evaluate whether telomerase activity can be detected in urine derived stem cells (USC) derived from donors of various ages, and to determine whether USC that express telomerase possess greater proliferative capacity than cells that do not express telomerase. If so, telomerase-expressing USCs could be optimized for use as a cell source for cell based therapy in urology. METHODS One hundred and fourteen USC clones were isolated from the urine of 10 donors (ages ranging from 20-50 years) and cultured. The telomerase activities of these USC and human bone marrow stromal cells (BMSC) were measured at p2, 7, and 11 using a TRAP-ELISA assay. The proliferative capacity of the USC was also assessed by producing a growth curve over 7 days and performing population doubling and doubling time analyses. Additionally, karyotypes of four different USC clones were determined at p5. Stem cell surface markers expressed by the USC clones were evaluated by flow cytometry. RESULTS Eighty out of 114 independent USC clones (70%) isolated from the urine of 10 donors of different ages displayed detectable levels of telomerase activity (TA+) at p2. Telomerase activity decreased gradually with culture passages. The cell growth curves showed that the TA+-cell clones grew more rapidly than the TA--cell clones. TA+-cell clones demonstrated more population doublings (PD) and shorter doubling times (DT) than TA--cell clones regardless of the age of the donor. The average PD was 60.30±5.1in TA+-USC compared to 37.6 ±2.9 that in TA--USC. The average DT was 26.9±2.0 h in TA+-USC compared to 35.9 ± 1.4 h in TA--USC. The TA+-cell clones reached p11 and maintained their original ′rice-grain like′morphology throughout all passages. However, the TA--cell clones began to display a larger, flattened morphology with cellular projections at p8 to 9. The karyotype of all USCs was normal and did not appear to depend on TA level. Both TA+-USC and TA--USC expressed stem cell markers, including CD44, CD90, CD73, CD105, and CD146. However, these cells did not express CD31, CD34, CD45, CD25, CD 117, or CD140b. CONCLUSIONS USC that expressed telomerase activity possessed higher proliferative capacities and could be maintained for a higher number of passages. This information further enhances our characterization of these cells and supports the potential clinical utility of these cells in regenerative medicine in urology. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e302 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yingai Shi Winston Salem, NC More articles by this author Guihua Liu Winston Salem, NC More articles by this author Bharadwaj Shantaram Winston Salem, NC More articles by this author Anthony Atala Winston Salem, NC More articles by this author Yuanyuan Zhang Winston Salem, NC More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...