Concomitant Augmentation Research Articles

Explantation with Concomitant Autologous Augmentation Mammoplasty Utilizing De-epithelialized Intercostal Perforator (IP) Flaps

Explantation with Concomitant Autologous Augmentation Mammoplasty Utilizing De-epithelialized Intercostal Perforator (IP) Flaps

Analysis of Changing Practice Trends in Anterior Cruciate Ligament Reconstruction: A Multicenter, Single-Institution Database Analysis

PurposeThis study sought to identify trends in anterior cruciate ligament (ACL) reconstruction (ACLR), including graft choice, femoral tunnel drilling, and augmentation techniques, and to assess how various surgeon factors impact these trends. MethodsA retrospective review of primary ACLR performed between 2014 and 2022 was performed using a multi-centered institutional database. Patient demographics, graft type, femoral drilling technique, use of extra-articular tenodesis, and use of suture augmentation were recorded from the medical record. Surgeon fellowship training (sports-trained versus non-sports-trained), experience (high: minimum 15 years in practice), and volume (high: minimum 15 ACLR per year) were used to stratify technique utilization. Z-test for proportions compared categorical variables. Pearson correlation analyses identified trends and assessed statistical significance, defined as a p-value less than 0.05. ResultsOur cohort consisted of 2,032 ACLR performed on 2,006 patients. The average patient age was 28.3 +/- 11.6 years, with more procedures performed on males (67.3%). The average surgeon experience was 19.7 +/- 11.4 years, with an average annual procedural volume of 4.0 +/- 5.4. Most surgeons were sports-trained (55, 64.7%), high experience (44, 57.1%), and low-volume (80, 94.1%). There were increasing annual proportion of ACLR performed by sports-trained (R=0.748, p=0.020) and low experience (R=0.940, p<0.001) surgeons. Autograft reconstructions were most often performed by sports-trained (71.2%), low experience (66.1%), and high-volume (76.9%) surgeons. There was an increasing proportion of autograft ACLR that utilized QT among sports-trained (R=0.739, p=0.023), high experience (R=0.768, p=0.016), and low-volume (R=0.785, p=0.012). Independent drilling (ID) techniques were used in an increasing proportion of ACLR performed by non-sports-trained (R=0.860, p=0.003) and high-volume surgeons (R=0.864, p=0.003). Augmentation of ACLR with concomitant suture augmentation (24, 1.2%) or extra-articular tenodesis (6, 0.3%) was rarely performed ConclusionIn our multi-centered institution, the QT autograft has been increasingly utilized in ACLR by sports-trained, low volume, and high experience surgeons, ID techniques have been increasingly utilized by non-sports-trained and high-volume surgeons Clinical RelevanceSurgeons must stay current with literature that affects their procedures to ensure that evidence-based medicine is being practiced.

Concomitant internal joint stabilizer augmentation with isometric lateral ulnar collateral ligament repair for unstable elbow dislocations: a surgical technique

Complex unstable elbow fracture dislocations can be a challenging pathology to treat for orthopedic surgeons. Historical treatment methods of persistent elbow instability after bony and ligamentous pathology have been addressed include prolonged immobilization, trans-articular pinning, and static or hinged external fixators. However, they can be associated with significant complications and unacceptable rates of unsatisfactory clinical outcomes. As a result, a movable internal fixator known as an internal joint stabilizer (IJS) was developed to help mitigate these complications. The IJS, when utilized, often is inserted at the origin of the lateral ulnar collateral ligament (LUCL). The rotating humeral pin of the IJS must be placed in the elbow’s center axis of rotation at the distal humerus to function properly. The competition for the same footprint makes concomitant anatomic repair of the LUCL challenging. This paper seeks to describe a surgical technique that allows for isometric humeral pin placement of the IJS without sacrificing the ability to restore the LUCL to its anatomic footprint by combining the LUCL suture anchor and IJS humeral pin sites.

Patients With Segond Fracture Demonstrate Similar Rates of Return to Sport and Psychological Readiness After Anterior Cruciate Ligament Reconstruction: A Matched Cohort Study at Minimum 2-Year Follow-Up

To compare clinical outcomes, rate of return to sports, and psychological readiness among patients undergoing anterior cruciate ligament reconstruction (ACLR) with and without concomitant Segond fracture. We retrospectively identified patients who underwent primary ACLR from January 2012 to December 2020 with minimum 2-year follow-up. Exclusion criteria were additional ligamentous injury, age <16 years, or a concomitant lateral augmentation procedure. Preoperative knee radiographs were reviewed to identify Segond fractures. Identified patients were matched 1:2 to controls by age/sex/body mass index/graft type. Charts were reviewed for pre- and postoperative knee stability. Surveys administered included preinjury sport participation and return status, Lysholm score, Tegner activity scale, and ACL-Return to Sport Index (ACL-RSI), a metric of psychological sport readiness. Multivariable logistic regression was conducted to identify predictors of return to sport. There were 120 patients who were included in the final analysis (40 Segond, 80 controls) at a mean follow-up of 5.7 ± 2.4 years. A total of 52.5% of patients received bone-patellar tendon-bone autograft. The overall rate of return to sport was 79.5% in the Segond group compared with an 83.8% rate of return in the control group (P= .569). In total, 48.7% of the Segond group and 56.8% of the control group returned to their preinjury level of sport (P= .415). Lysholm (89.6 ± 10.3 vs 85.4 ± 16.7, P= .296), Tegner (5.7 ± 1.8 vs 6.1 ± 2.2, P= .723), and ACL-RSI (62.2 ± 25.4 vs 56.6 ± 25.4, P= .578) scores were similar between Segond and control groups. There was a single graft failure in the Segond group 5 years' postoperatively. Increasing ACL-RSI score was significantly predictive of return to sport (P < .001). Patients who had an ACL tear and a concomitant Segond fracture who underwent isolated ACLR without lateral augmentation procedures had similar clinical outcomes and rates of return sport compared with a matched isolated ACLR control group at minimum 2-year follow-up. There was no significant difference in psychological readiness between groups as measured by the ACL-RSI. Level III, retrospective cohort study.

The cotton MYB33 gene is a hub gene regulating the trade-off between plant growth and defense in Verticillium dahliae infection

IntroductionSessile plants engage in trade-offs between growth and defense capacity in response to fluctuating environmental cues. MYB is an important transcription factor that plays many important roles in controlling plant growth and defense. However, the mechanism behind how it keeps a balance between these two physiological processes is still largely unknown. ObjectivesOur work focuses on the dissection of the molecular mechanism by which GhMYB33 regulates plant growth and defense. MethodsThe CRISPR/Cas9 technique was used to generate mutants for deciphering GhMYB33 functions. Yeast two-hybrid, luciferase complementary imaging, and co-immunoprecipitation assays were used to prove that proteins interact with each other. We used the electrophoretic mobility shift assay, yeast one-hybrid, and luciferase activity assays to analyze GhMYB33 acting as a promoter. A β-glucuronidase fusion reporter and 5′ RNA ligase mediated amplification of cDNA ends analysis showed that ghr-miR319c directedly cleaved the GhMYB33 mRNA. ResultsOverexpressing miR319c-resistant GhMYB33 (rGhMYB33) promoted plant growth, accompanied by a significant decline in resistance against Verticillium dahliae. Conversely, its knockout mutant, ghmyb33, demonstrated growth restriction and concomitant augmentation of V. dahliae resistance. GhMYB33 was found to couple with the DELLA protein GhGAI1 and bind to the specific cis-elements of GhSPL9 and GhDFR1 promoters, thereby modulating internode elongation and plant resistance in V. dahliae infection. The ghr-miR319c was discovered to target and suppress GhMYB33 expression. The overexpression of ghr-miR319c led to enhanced plant resistance and a simultaneous reduction in plant height. ConclusionOur findings demonstrate that GhMYB33 encodes a hub protein and controls the expression of GhSPL9 and GhDFR1, implicating a pivotal role for the miR319c-MYB33 module to regulate the trade-offs between plant growth and defense.

New Considerations in ACL Surgery: When Is Anatomic Reconstruction Not Enough?

➤ Clinicians should be careful to assess for associated injuries including anterolateral complex and medial meniscal ramp lesions or lateral meniscal posterior root tears.➤ Consideration of lateral extra-articular augmentation should be given for patients with >12° of posterior tibial slope.➤ Patients with preoperative knee hyperextension (>5°) or other nonmodifiable risk factors, including high-risk osseous geometry, may benefit from a concomitant anterolateral augmentation procedure to improve rotational stability.➤ Meniscal lesions should be addressed at the time of anterior cruciate ligament reconstruction with meniscal root or ramp repair.

Medial Crural Auto-rim Flap in Primary Open Rhinoplasty

Background: Aging significantly affects the nasal tip and columella; thus, weakening of fibroelastic attachments in the scroll area and intercrural suspensory ligaments results in tip ptosis, separation of the medial crural footplates, and expansion of the membranous septum.Aim: Thus, we focused on a new technique to maintain tip support without grafting and treat columellar-hanging deformity by folding in the caudal edge of the medial crura as a flap instead of trimming it in patients undergoing open aesthetic rhinoplasty.Patients and Methods: In this prospective-observational study, 37 patients were enrolled between July 2020 to January 2022 at Sulaimani Plastic, Burn and Reconstructive Surgery Hospital and Royal Private Hospital in Sulaimani, Republic of Iraq. After asking the age of the patients, all participants were appropriately prepared for the surgery and underwent primary open rhinoplasty for columellar hanging deformity correction.Results: We found that all enrolled patients were satisfied with their nasal shape except one patient who complained about the columellar region's appearance but without the need for revision. Also, the objective assessment of the nasal tip support showed good maintenance upon the follow-up time for patients despite the lack of cartilage graft in the tip area.Conclusion: In the medial crural auto-rim flap technique, the excess caudal medial crural cartilage could be used as a flap instead of trimming it despite concomitant tip support intercrural augmentation and correction of the columellar hanging deformity.

Increased circumferential deformation predicts cardiac events when left ventricular ejection fraction is normal

Abstract Background Recent research suggests that early left ventricular (LV) systolic dysfunction is characterized by compromised longitudinal function and a concomitant augmentation of circumferential deformation expressed as increased global circumferential strain (GCS). It is hypothesized that increased GCS could be used to identify people at higher risk of cardiovascular events when left ventricular ejection fraction (LVEF) is preserved. Purpose The present study aimed to investigate whether elevated GCS in individuals with preserved LVEF predicts major adverse cardiovascular events (MACE). Methods A total of 2,874 participants from the general population were included in this prospective cohort study. All participants had echocardiography performed and analyzed. Exclusion criteria were HF at baseline, non-sinus rhythm during echocardiography, and inadequate image quality for GCS assessment. Outcome was MACE including incident heart failure, myocardial infarction, and/or cardiovascular death. Absolute values of strain were used. To determine the optimal transition point of a potential effect modification, Cox regression models with different LVEF thresholds were created. The model with the optimal hazard ratio (HR) and P values of the interaction terms and Akaike information criterion was chosen. Results Mean age was 53±18 years and 60% were female. Mean LVEF and GCS were 57±6% and 21.6±4.0%, respectively. Median follow-up was 3.5 years [IQR: 2.6; 4.4] and a total of 92 (3.2%) developed MACE. A U-shaped relationship was observed between GCS and MACE. The lowest incidence rate was within the GCS range of 20 to 25% (Figure 1a). A significant interaction (P&amp;lt;0.001) between GCS and LVEF was observed regarding MACE. The optimal transition point for this effect modification was determined to be LVEF=50%. In multivariable Cox regressions (including conventional cardiovascular risk factors and global longitudinal strain (GLS)), increasing GCS was significantly associated with future MACE in participants with LVEF ≥50% (HR=1.09 [95% CI: 1.01; 1.17] per 1% increase, n=2420) while decreasing GCS were associated with a higher risk of MACE in individuals with abnormal LVEF (HR=1.16 [95% CI: 1.04; 1.29] per 1% decrease, n=289) (Figure 1b). A total of 50 (2.1%) developed the MACE amongst the participants with LVEF ≥50%. This group had significantly lower GLS (19.0±2.7% vs 19.9±2.0%, P=0.013) and ratio of peak early transmitral filling velocity to peak early diastolic tissue velocity (E/e') (10.7 [IQR: 7.9; 14.3] vs 6.5 [5.3; 8.4], P&amp;lt;0.001) compared to the participants that did not develop MACE with normal LVEF. Figure 2 illustrates a model of the development of GCS, LVEF, GLS, and E/e' as LV function declines. Conclusion In the general population, the prognostic value of GCS is modified by LVEF. In participants with normal LVEF, higher GCS was associated with increased risk of MACE, while the opposite was observed in participants with abnormal LVEF. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Copenhagen City Heart Study is funded by The Danish Heart FoundationThe Metropolitan Region of Denmark (public funding).

Disruption of tomato TGS machinery by ToLCNDV causes reprogramming of vascular tissue-specific TORNADO1 gene expression.

Vascular development-related TRN1 transcription is suppressed by cytosine methylation in fully developed leaves of tomato. ToLCNDV infection disrupts methylation machinery and reactivates TRN1 expression - likely causing abnormal leaf growth pattern. Leaf curl disease of tomato caused by tomato leaf curl New Delhi virus (ToLCNDV) inflicts huge economical loss. Disease symptoms resemble leaf developmental defects including abnormal vein architecture. Leaf vein patterning-relatedTORNADO1gene's (SlTRN1) transcript level is augmented in virus-infected leaves. To elucidate the molecular mechanism of the upregulation ofSlTRN1in vivo, we have deployedSlTRN1promoter-reporter transgenic tomato plants and investigated the gene's dynamic expression pattern in leaf growth stages and infection. Expression of the gene was delimited in the vascular tissues and suppressed in fully developed leaves. WRKY16 transcription factor readily activated SlTRN1 promoter in varied sized leaves and upon virus infection, while silencing of WRKY16 gene resulted in dampened promoter activity. Methylation-sensitive PCR analyses confirmed the accumulation of CHH methylation at multiple locations in theSlTRN1promoter in older leaves. However, ToLCNDV infection reverses the methylation status and restores expression level in the leaf vascular bundle. The virus dampens the level of key maintenance and de novo DNA methyltransferases SlDRM5, SlMET1, SlCMT2 with concomitant augmentation of two DNA demethylases, SlDML1 and SlDML2 levels inSlTRN1promoter-reporter transgenics. Transient overexpression of SlDML2 mimics the virus-induced hypomethylation state of theSlTRN1promoter in mature leaves, while silencing of SlDML2 lessens promoter activity. Furthermore, in line with the previous studies, we confirm the crucial role of viral suppressors of RNA silencing AC2 and AC4 proteins in promoting DNA demethylation and directing it to restore activated transcription ofSlTRN1. Unusually elevated expression of SlTRN1 may negatively impact normal growth of leaves.

PD24-08 ROBOT ASSISTED BLADDER NECK ARTIFICIAL URINARY SPHINCTER IMPLANTATION IN NEUROLOGICAL MALE PATIENTS: PRELIMINARY RESULTS

You have accessJournal of UrologyCME1 May 2022PD24-08 ROBOT ASSISTED BLADDER NECK ARTIFICIAL URINARY SPHINCTER IMPLANTATION IN NEUROLOGICAL MALE PATIENTS: PRELIMINARY RESULTS Benoit Peyronnet, Thibault Tricard, Thibaut Brierre, Juliette Hascoet, Thomas Prudhomme, Baptiste Poussot, Andrea Manunta, Evelyne Castel-Lacanal, Christian Saussine, and Xavier Gamé Benoit PeyronnetBenoit Peyronnet More articles by this author , Thibault TricardThibault Tricard More articles by this author , Thibaut BrierreThibaut Brierre More articles by this author , Juliette HascoetJuliette Hascoet More articles by this author , Thomas PrudhommeThomas Prudhomme More articles by this author , Baptiste PoussotBaptiste Poussot More articles by this author , Andrea ManuntaAndrea Manunta More articles by this author , Evelyne Castel-LacanalEvelyne Castel-Lacanal More articles by this author , Christian SaussineChristian Saussine More articles by this author , and Xavier GaméXavier Gamé More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002566.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In neurological male patients, implanting the artificial urinary sphincter (AUS) cuff at the bladder neck is an option aiming to decrease the risk of erosion. The robotic approach may decrease the morbidity of bladder neck AUS implantation but only scant evidence exist. The aim of this study was to report the preliminary results of robot-assisted bladder neck AUS implantation in male patients with neurogenic stress urinary incontinence (SUI) METHODS: The charts of all male patients with spina bifida (SB) or spinal cord injury (SCI) who underwent a primary robotic bladder neck AUS implantation at three academic centers between 2011 and 2020 were retrospectively reviewed. The procedure was performed with the Da-Vinci robot (Si and Xi) using a four arm transperitoneal approach. The primary endpoint was continence at 3 months and at the last follow-up categorized as: complete continence (0 pads), improved SUI, unchanged SUI, or worsened SUI. Patient characteristics, perioperative outcomes, and follow-up data were also collected. RESULTS: Eleven patients were included over the study period: 7 SCI and 4 SB. The median age was 40 years. One patient had a supra-trigonal cystectomy with concomitant robot-assisted augmentation cystoplasty. The median length of hospitalization was 4 days. There were 2 post-operative complications (33.3%): one Clavien 3 and one Clavien 4. After a median follow-up of 14 months, only one explantation was required (16.7%) due to early AUS infection in the patient who had a concomitant augmentation cystoplasty. Three patients underwent device revision at 4, 7 and 12 months respectively for pump repositioning (n=1) and early recurrence of SUI with cuff downsizing in the two later cases. At 3 months and at the last follow-up, four patients had recovered complete continence (36.4%), 6 patients had improvement in SUI (54.5%) and one patient had unchanged incontinence (9%). CONCLUSIONS: In this preliminary experience, robot-assisted bladder neck AUS implantation for neurogenic SUI yielded interesting results. The functional outcomes were satisfactory but the high rate of early revisions, already reported in the literature (Hervé, BMJ case report 2017), should prompt further evaluation in the upcoming years. Source of Funding: none © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e418 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Benoit Peyronnet More articles by this author Thibault Tricard More articles by this author Thibaut Brierre More articles by this author Juliette Hascoet More articles by this author Thomas Prudhomme More articles by this author Baptiste Poussot More articles by this author Andrea Manunta More articles by this author Evelyne Castel-Lacanal More articles by this author Christian Saussine More articles by this author Xavier Gamé More articles by this author Expand All Advertisement PDF DownloadLoading ...

CT-Guided Percutaneous Vertebroplasty for Vertebral Non-union Following Posterior Fixation: A Preliminary Retrospective Study

Traumatic thoracolumbar vertebral fractures are frequently treated with posterior fixation (PF) and vertebral augmentation. Sometimes, it is deemed too risky to offer vertebral augmentation under fluoroscopic guidance alone. Adjuvant CT/fluoroscopy-guided percutaneous vertebroplasty (PVP) could be offered in certain scenarios. The aim was to evaluate feasibility, safety and effectiveness of PVP in patients presenting with vertebral non-union (VNU) following PF performed without concomitant vertebral augmentation. All patients treated in our institution with PVP between July 2015 and July 2020 were retrospectively reviewed. Patients treated with CT/fluoroscopy-guided PVP under local anesthesia for symptomatic VNU following PF were selected. Three criteria were established to assess cement distribution, considering vertebral filling of: (1) fracture cleft, (2) anterior two-thirds of the vertebral body, (3) from superior to inferior endplates. Numeric pain rating scale (NPRS) assessing grade of discomfort (0 = no pain; 10 = worst pain) and complications were evaluated before and 1month after PVP. Ten patients were identified (mean age 53 ± 12y). Mean time between PF and PVP was 9.6 [2-35] months. Two patients required further cement injection with a second PVP. Eight patients had satisfactory vertebral filling according to the three criteria. Mean NPRS reduction was 2.7(-42%, p < 0.05). No significant complications occurred. Combined CT/fluoroscopy guidance seems a useful tool to perform PVP in VNU following PF, even in presence of orthopedic metalwork. Interventional radiologists may help in these scenarios, performing an adjuvant PVP under local anesthesia. In this small series, the procedure seems safe and effective and could be taken in consideration as alternative to revision surgery.

Aesthetic and functional restoration of the dental arch continuity in difficult cases of impacted teeth within the frontal segment.

Impacted teeth are a fairly common defect with the incidence ranging from 2.9 to 13.7%. Evaluation of the efficacy and safety of various treatment modalities in patients with impacted teeth within the frontal segment of the maxilla. The retrospective evaluation covered treatment outcomes in 81 patients with impacted teeth within the aesthetic segment. The subjects were divided into 3 groups. Patients with the impacted tooth uncovered and orthodontically repositioned in the arch were assigned to group 1. Group 2 consisted of patients with the impacted tooth qualified for extraction and the gap augmented and restored with an implant. Group 3 included subjects, who underwent en-bloc autotransplantation of the impacted tooth. In 38 group 1 subjects 47 teeth were uncovered with a mean efficacy of 58.1% (96.3% and 70% in patients below 18 yoa and adults, respectively). The excellent aesthetic treatment outcome was obtained in 75% and good in 25% of patients. In group 2 twenty-six adult subjects were treated with 100% efficacy. In 65.4% of patients, augmentation with a bone block was performed and in the remaining 34.6%, implantation and augmentation with bone granulate. In 88.3% subjects a satisfying treatment outcome was obtained. In group 3 eighteen teeth in a block were grafted with the efficacy of 88.9%. Excellent aesthetics was obtained in 56.25% of cases and good in 31.25%. Orthodontic repositioning of the impacted teeth in the arch in adult patients bears the risk of failure. Surgical treatment modalities in impacted teeth are effective and provide high aesthetics of the treatment outcome improved by prior orthodontic treatment of the concomitant malocclusion and augmentation of the vertical bone atrophy before implantation.

Super enhancer-mediated transcription of miR146a-5p drives M2 polarization during Leishmania donovani infection.

The outcome of Leishmania donovani infection depends upon the dynamic interchanges between M1 and M2 macrophages. Information of the involvement of microRNAs (miRNAs) and epigenetic modifiers in regulating macrophage plasticity during L. donovani infection is still elusive. Differential expression analysis of polarization-regulating miRNAs, revealed significant enrichment of miR146a-5p during Leishmania donovani infection. A sustained enrichment of miR146a-5p was observed in both infected bone marrow derived macrophages (BMDMs) and BALB/c mice organs. We found involvement of miR146a-5p in phagocytosis and survivability of parasites. Moreover, miR146a-5pgot enriched in interleukin 4- stimulated BMDMs, indicating its possible involvement in M2 polarization. Upon transfecting BMDMs with miRVANA anti-146a oligos, M2 markers (CCR7, YM-1, FIZZ-1, arginase-1, IL10 and IL4) and transcription factors (p-STAT6 and c/EBPβ) got depleted with concomitant augmentation of M1-polarizing transcription factors (p-STAT1, AP1 and IRF-1), miR146a target genes (TRAF6 and IRAK1), M1 cytokines (IL12 and TNFα), iNOS, nitric oxide, and nuclear translocation of phospho p-65 subunit. Neutralization of intracellular mature miR146a-5p pool in infected BALB/c mice lower organ parasite burden and expressions of M2 markers and IL10 with enrichment of M1 markers like iNOS and IL12. Additionally, we explored the novel role of super enhancer (SE), a cis-acting regulatory component, to enrich miR146a-5p expression during infection. Enhanced expression and nuclear retention of SE components like BET bromodomain 4 (BRD4) and p300 were found in infected BMDMs. Upon silencing BRD4, expressions of miR146a-5p and M2 markers were down regulated and TRAF6, IRAK1 and iNOS levels increased. STRING V.11 based predication and immune precipitation confirmed the strong interaction amongst BRD4, p300 and RNA pol II (RpbI). Chromatin immune precipitation studies suggested the recruitment of BRD4 at the enhancer loci of miR146a-5p gene during infection. Altogether, our findings revealed a novel role of BRD4/p300-depdendent super-enhancer in regulating miR146a expression during L. donovani infection which in turn mediates M2 polarization and immune-suppression.

Management and outcome in dehisced exstrophy with a simplified bladder re-closure and further reconstruction

The traditionally accepted method of bladder re closure in dehisced exstrophy involves osteotomy assisted pubic bone approximation (PBA). Continent voluntary voiding is achieved in a small proportion of children sometimes after many operative procedures. We propose a simple yet reliable method of repair of the dehisced bladder using Rectus abdominis muscle flap (RAM) instead of PBA to bridge the inter-pubic gap, followed by concomitant or subsequent bladder augmentation (BA). The aim of this study is to assess the outcome of dehisced exstrophy, using a RAM flap assisted redo closure (without PBA) with concomitant or subsequent further reconstruction. This is a retrospective analysis of children who presented with dehisced exstrophy after repair in other institutions and who have undergone redo repair using RAM flap in two tertiary care centers from 2001 to 2019. The outcome of the redo closure and subsequent or concomitant further reconstruction as regards dryness, stability of the upper tracts and resolution of vesico ureteric reflux (VUR) was studied. Fifty five children (34 boys) underwent redo exstrophy repair for dehisced exstrophy using the RAM flap. Epispadias repair was performed concomitantly in 31 boys. In 26 children (group1) of mean age 12 months further surgery was deferred while in 29 children (group 2) of mean age 69 months underwent concomitant BA. Nine group 1 children underwent BA subsequently. Ureteric reimplantation was done at the time of BA in 54 ureters, 40 into the bladder plate and rest into the bowel segment of BA. 22 ureters were not reimplanted. Bladder neck surgery including 18 bladder neck closure and Mitrofanoff port for Clean Intermittent catheterization (CIC) were done along with BA. The RAM assisted bladder closure was event free and none needed redo operation. 35/38 augmented children are dry on Mitrofanoff CIC and one unaugmented boy voids normally. The upper tracts remain stable on ultrasound and VUR has resolved in 67/76 ureters. At current follow up, after a mean period of 53 months eGFR was normal in all except 3 who had initially presented with severe hydro uretero nephrosis. We present a simple and reliable method of repair of dehisced exstrophy using RAM flap with the feasibility of concomitant BA. Dryness was achieved with stable upper tracts in 36/39 children, 27 of them with a single reconstructive attempt.

Correcting Nipple Inversion Simultaneously with Implant Augmentation of the Breast, Using “Pirelli” Technique

Background:Most techniques of isolated nipple inversion correction are well published. Simultaneous breast augmentation with nipple inversion correction is less often found in the literature. Previously, nipple inversion correction was thought to be performed as a staged procedure after other breast operations. We present a study of 19 patients and 34 breasts who had concomitant breast augmentation and nipple inversion correction treated with a “Pirelli” technique to assess the complication rates and the rate of recurrence of inversion.Methods:The Pirelli technique was used, involving division of lactiferous ducts and deep closure of breast tissue before closure. An external “Pirelli tire” was then applied and secured circumferentially around the nipple–areolar complex, which helped to maintain eversion of the nipple after 1 week. Patients were then followed up with specific postoperative instructions to ensure wound healing and maintenance of eversion.Results:Nineteen patients were included where 34 breasts were involved. Eighteen patients had primary breast implants. The recurrence rate was 5.9%, involving 2 patients who had unilateral recurrences. These patients were managed with the same technique and had no further recurrences. Two patients successfully breastfed at a median time of 10 years postoperatively.Conclusion:Simultaneous breast mammoplasty with nipple inversion correction using the Pirelli technique is safe with low complication rates and high long-term patient satisfaction.

Superomedial partial arytenoidectomy for voice improvement by correction of posterior glottic insufficiency

PurposeArytenoid resection is a well-known intervention to improve glottic airway. Superomedial partial arytenoidectomy (SPA) can also be used for voice improvement by correcting posterior glottic insufficiency in patients with an obstructing anteromedially prolapsed arytenoid. Posterior glottic insufficiency can be difficult to address and traditionally involves challenging arytenoid repositioning procedures. This study aimed to compare postoperative functional voice outcomes in patients who underwent SPA to pre-operative voice status. Second, consequences of concomitant injection augmentation in patients who underwent SPA were studied. Additionally, presenting the surgical technique.MethodsIn this retrospective cohort study, pre-operative and postoperative clinical data of patients who underwent SPA between 2004 and 2018 were analyzed. Both short- and long-term voice outcomes were assessed using Voice Handicap Index (VHI) and maximum phonation time (MPT). Pre- to postoperative assessment changes (delta: δ) were applied to multivariate analyses.ResultsA total of 105 patients were included, of which 91 had hemilaryngeal immobility, 25 had undergone previous phonosurgical procedures and 45 received concomitant injection augmentation. Patients who underwent SPA had significant improvement of VHI and MPT. In 81% of our population, laryngeal framework surgery was avoided. Multivariate analyses showed significantly improved short-term voice outcomes in patients who received injection augmentation concomitantly to SPA. Finally, δMPT was a significant predicting factor regarding additional procedures in patients who underwent SPA.ConclusionSPA is a safe and efficient procedure for voice improvement in patients with posterior glottic insufficiency due to an obstructing anteromedially prolapsed arytenoid. We recommend performing this procedure combined with injection augmentation.

Myocardial Adaptations to Competitive Swim Training

Swim training is performed in the prone or supine position and obligates water immersion, factors that may augment cardiac volume loading more than other endurance sports. At present, prospective data defining the cardiac responses to swim training are lacking. We therefore studied myocardial adaptations among competitive swimmers to establish a causal relationship between swim training and left ventricular (LV) remodeling. Collegiate swimmers were studied before and after a 90-d period of training intensification. Transthoracic echocardiography was used to examine LV structural and functional adaptations under resting conditions and during an acute LV afterload challenge generated by isometric handgrip testing (IHGT). A sedentary control population was identically studied with IHGT. In response to a discrete period of swim training intensification, athletes (n = 17, 47% female, 19 ± 0.4 yr old) experienced eccentric LV remodeling, characterized by proportionally more chamber dilation than wall thickening, with attendant enhancements of resting LV systolic (LV twist) and diastolic (early and late phase tissue velocities) function. Compared with baseline and controls, athletes posttraining demonstrated greater systolic twist impairment during IHGT. However, training-induced LV dilation coupled with gains in diastolic function offsets this acquired systolic susceptibility to acute afterload, resulting in the relative preservation of stroke volume during IHGT. Swim training, a sport characterized by unique cardiac loading conditions, stimulates eccentric LV remodeling with the concomitant augmentation of systolic twist and diastolic relaxation. This volume-mediated cardiac remodeling appears to result in greater systolic susceptibility to acute afterload challenge. Further work is required to establish how training-induced changes in function translate to human performance and whether these are accompanied by physiologic trade-offs with relevance to common forms of heart disease.

Itacolumite (Flexible Sandstone) From Kaliana, Charkhi Dadri District, Haryana, India

Abstract The objective of this study is to highlight main causes of flexibility in itacolumite from Kaliana Hills, Charkhi Dadri district, Haryana. Results of petrominerological studies, scanning electron microscopy (SEM), 3D analysis of SEM images, and quantitative micro fabric analysis reveal that the intergranular void spaces are significantly higher in more flexible specimen (mean 47.68 μm) relative to less flexible specimen (mean 14.32 μm, i.e., &amp;lt;3 times), whereas, non-flexible sandstones show negligible intergranular void spaces (4.97-6.40 μm). Therefore, it may be envisaged that the flexibility in Kaliana itacolumite is due to the presence of more intergranular void spaces. The chemical corrosion appears to be the main reason for the formation of more void spaces in between the constituent grains in the flexible sandstones. Leaching effect on the grains is evident on scanning electron microscopic (SEM) images. These solution channels and embayment might have removed the significant amount of cementing material and silica by dissolution and solution activity. Thus, obviously, the flexibility in the itacolumite was induced by solution activity, more the solution activity, more the void spaces and hence more resultant flexibility. Almost vertically dipping beds of sandstone would have facilitated capillary movement and solutioning leading to development of concomitant leaching induced porosity. Higher degree of flexibility in itacolumite specimen from quarry dump, compared to in-situ fresh itacolumite specimen, is apparently due to more exposure of former to surface processes like weathering, more solution activity and corrosion leading to more removal of cementing material and silica accompanied by concomitant augmentation of considerable intergranular void spaces (&amp;gt;3 times), relative to the latter. It is thus clear that relatively less flexibility in in-situ itacolumite is linked with its less solutioning relative to itacolumite from dump. Thermal shock resistance property of itacolumite can be used as a model material to process synthetic flexible ceramics by mixing phases with large differences of thermal expansion properties.

The fallow mitrofanoff

Treatment of severe congenital dysfunctional bladders often requires bladder drainage to maintain low bladder pressure, thus preserving renal function. Although clean intermittent catheterization is the ideal choice, this can be especially challenging in the younger pediatric population or in children with neurological impairment. Alternatives such as incontinent vesicostomy, long-term suprapubic catheterization, or button cystostomy exist, but these are rarely very long-term options. The objective of this study is to report the authors' experience with children who underwent a 'fallow' Mitrofanoff, meaning an appendicovesicostomy in which an indwelling catheter was placed for several months or years, allowing for bladder emptying several times a day, until the child was ready for clean intermittent catheterization (CIC). All patients who underwent a Mitrofanoff appendicovesicostomy with or without concomitant bladder augmentation, for whom there was a significant delay (≥6 months) between surgery and implementation of CIC, were reviewed. In all these cases, the child showed obvious opposition to CIC. An indwelling catheter was left in place, with a stopper allowing for bladder emptying 5-6 times a day as would happen with CIC. The catheter was changed once a week until CIC was implemented. Complications including febrile urinary tract infections (fUTIs) during the fallow period and complications including leakage or stenosis during the CIC period were noted. The series includes 10 patients (7 boys and 3 girls), aged a median 41±34 months (range: 23-144) at the time of the appendicovesicostomy (6 posterior urethral valves and 4 non-neurogenic neurogenic bladders). All underwent classic appendicovesicostomies. The delay before full implementation of CIC was a median 29.5±24 months (range: 6-72). During the fallow period, 3 patients presented fUTIs. The catheter was closed, allowing for bladder drainage 4-6 times a day. There were no episodes of leakage from the Mitrofanoff or stomal stenosisduring the fallow period or CIC period. Mean follow-up since the appendicovesicostomy is 66±33 months and since initiation of CIC is 26±26 months (range: 4-94). For children who require bladder drainage, an appendicovesicostomy can be performed even if CIC is not initiated immediatelyand be used as a suprapubic catheter or button cystostomy. When the child is ready, CIC can be initiated without need for further surgery and without risk for the conduit. The limitations of this study include its retrospective natureand the low number of patients. A Mitrofanoff appendicovesicostomy can be performed in a child requiring long-term bladder drainage and in whom classic CIC is not possible, even if CIC is not initiated immediately.

Venlafaxine and carvedilol ameliorate testicular impairment and disrupted spermatogenesis in rheumatoid arthritis by targeting AMPK/ERK and PI3K/AKT/mTOR pathways

Testicular impairment has been commonly described in long-standing rheumatoid arthritis (RA) patients. Since depression and cardiovascular disorders are the most disturbing co-morbidities of RA, investigating the efficacy of the anti-depressant venlafaxine or the beta-blocker carvedilol in RA-associated testicular dysfunction may add to their clinical utility for RA patients. Previously, both agents have demonstrated significant in vivo anti-oxidant and anti-inflammatory actions. In the current study, venlafaxine (50 mg/kg/day) and carvedilol (10 mg/kg/day) were orally administered to adjuvant arthritic rats for 20 days. Interestingly, venlafaxine and carvedilol effectively suppressed paw edema and mitigated the testicular histopathological aberrations and the disrupted spermatogenesis. Both drugs enhanced testicular steroidogenesis through upregulation of 3β-HSD, 17β-HSD and StAR gene expression with concomitant augmentation of serum testosterone. They also blunted the inflammatory burden via attenuation of myeloperoxidase, TNF-α and the protein expression of NF-κBp65 along with elevation of IL-10. They attenuated testicular oxidative perturbations via lowering lipid peroxides and nitric oxide and boosting glutathione levels. With regard to apoptosis, the two agents lowered the protein expression of caspase-3, cleaved caspase-3, cleaved PARP, Bax and p53, promoting germ cell survival. They also modulated the AMPK/ERK signaling via lowering of p-AMPK and upregulation of p-ERK1/2 along with PI3K/AKT/mTOR transduction by enhancing the PI3Kp110α, p-AKT and p-mTOR protein expression. Together, the present work demonstrates the beneficial effects of venlafaxine and carvedilol in RA testicular dysfunction and impaired spermatogenesis via modulation of AMPK/ERK and PI3K/AKT/mTOR signaling and intervention with the testicular oxidative stress, inflammation and apoptosis.