Retrospective analysis of the perioperative outcome in living donor kidney transplantation with multiple renal arteries: does accessory vessel ligation affect the outcome?

PURPOSE: Accurate surgical reconstruction of arterial vascular supply is a crucial part of living kidney transplantation (LDKT). The presence of multiple renal arteries (MRA) in grafts can be challenging. In the present study, we investigated the impact of ligation versus anastomosis of small accessory graft arteries on the perioperative outcome. METHODS: Clinical and radiological outcomes of 51 patients with MRA out of a total of 308 patients who underwent LDKT with MRA between 2011 and 2020 were stratified in two groups and analyzed. In group 1 (20 patients), ligation of accessory arteries (ARAs) and group 2 (31 patients) anastomosis of ARAs was performed. RESULTS: Significant differences were observed in the anastomosis-, surgery-, and warm ischemia time (WIT) in favor of group 1. Students t-test showed comparable serum creatinine levels of 2.33 (± 1.75) to 1.68 (± 0.83) mg/dL in group 1 and 2.63 (± 2.47) to 1.50 (± 0.41) mg/dL in group 2, were seen from 1 week to 1 year after transplant. No increased rates of Delayed graft function (DGF), primary transplant dysfunction and transplant rejection were seen, but graft loss and revision rates were slightly higher when the ARAs were ligated. Analysis of Doppler sonography revealed that segmental perfusion deficits tend to regenerate during the clinical course. CONCLUSION: Ligation of smaller accessory renal arteries may not affect the outcome of living kidney transplantation, except for a minor increase in the reoperation rate. Segmental perfusion deficits of the graft seem to regenerate in most cases as seen in Doppler sonography.

Auditory vigilance task performance and cerebral hemodynamics: effects of spatial uncertainty.

The vigilance decrement, a temporal decline in detection performance, has been observed across multiple sensory modalities. Spatial uncertainty about the location of task-relevant stimuli has been demonstrated to increase the demands of vigilance and increase the severity of the vigilance decrement when attending to visual displays. The current study investigated whether spatial uncertainty also increases the severity of the vigilance decrement and task demands when an auditory display is used. Individuals monitored an auditory display to detect critical signals that were shorter in duration than non-target stimuli. These auditory stimuli were presented in either a consistent, predictable pattern that alternated sound presentation from left to right (spatial certainty) or an inconsistent, unpredictable pattern that randomly presented sounds from the left or right (spatial uncertainty). Cerebral blood flow velocity (CBFV) was measured to assess the neurophysiological demands of the task. A decline in performance and CBFV was observed in both the spatially certain and spatially uncertain conditions, suggesting that spatial auditory vigilance tasks are demanding and can result in a vigilance decrement. Spatial uncertainty resulted in a more severe vigilance decrement in correct detections compared to spatial certainty. Reduced right-hemispheric CBFV was also observed during spatial uncertainty compared to spatial certainty. Together, these results suggest that auditory spatial uncertainty hindered performance and required greater attentional demands compared to spatial certainty. These results concur with previous research showing the negative impact of spatial uncertainty in visual vigilance tasks, but the current results contrast recent research showing no effect of spatial uncertainty on tactile vigilance.

Sex-dependent impact of a short rest after lunch on hemodynamics as assessed by Doppler sonography.

PURPOSE: Taking a short rest after lunch suppresses increases in blood flow to the digestive organs and maintains blood flow to the brain in the afternoon, possibly providing beneficial effects in preventing post-prandial drowsiness. The present study investigated sex-dependent influences on changes in hemodynamics produced by taking a short rest after lunch. METHODS: Subjects comprised 20 healthy young adults (10 men, 10 women; mean age 21 ± 1 years). Doppler sonography was performed to measure blood flow in the superior mesenteric artery (SMA) and common carotid artery (CCA) before and after lunch every hour on each day, with and without a 15-min rest with eyes closed after lunch. Blood pressure and heart rate (HR) were also measured. RESULTS: For both men and women, peak systolic velocity (PSV) in the SMA was suppressed by taking a rest. PSV in the CCA in men was increased at 0.5 h after lunch in the resting condition but was decreased in the non-resting condition (median 109%, interquartile range [IQR] 102-120% vs. median 98%, IQR 90-107%; P = 0.037). No such differences were observed in women. Although post-prandial increases in HR were observed in women, a similar increase was only found for men in the resting condition. CONCLUSION: An increase in CCA blood flow was observed only in men. The present study suggests that a short rest after lunch could better promote the maintenance of blood flow to the brain in men than in women.

Close relationships between neck and upper-back stiffness and transverse cervical artery flow velocity.

PURPOSE: Neck and upper-back stiffness is encountered in daily life, with symptoms appearing as dullness or aches predominantly in the trapezius muscle (TM). Our previous study demonstrated that TM hardness as measured with a muscle hardness meter correlates well with transverse cervical artery (TCA) flow supplying the TM. Muscle hardness meters, however, cannot measure hardness in the TM alone. Meanwhile, recent advances in ultrasound elastography have enabled the evaluation of localized hardness in targeted tissues. The present study, therefore, aimed to clarify the relationship between TM hardness as measured by elastography and TCA hemodynamics as measured on Doppler sonography, with reference to daily symptoms of upper-back stiffness. METHODS: The study population comprised 66 healthy young adults (32 males, 34 females; mean age, 21 ± 1 years). Relationships were evaluated between TM hardness as a negative correlate of strain ratio from elastography and TCA hemodynamics on Doppler sonography. Hemodynamics in the TCA were evaluated according to the frequency of neck and upper-back stiffness. RESULTS: TM strain ratio correlated with peak systolic velocity (PSV) in the TCA (r = 0.273, p = 0.036), particularly in symptomatic subjects (r = 0.417, p = 0.022). PSV in the TCA decreased with increasing frequency of daily symptoms (p = 0.045). CONCLUSION: TCA hemodynamics correlated with muscle hardness when evaluating localized TM hardness. This relationship and low PSV in the TCA were evident in symptomatic subjects. These results suggest that PSV in the TCA is associated with neck and upper-back stiffness.

Quantification of steal flow on Doppler ultrasound in patients with arteriovenous graft for hemodialysis.

PURPOSE: Arteriovenous fistula (AVF) is the preferred treatment for long-term hemodialysis patients to allow reliable vascular access. Arteriovenous graft (AVG) is monitored using Doppler sonography to check a vessel's condition and predict complications such as steal syndrome. In this study, we developed an analysis algorithm and method to quantify steal syndrome using Doppler sonography. METHODS: Doppler sonography was used to determine the pattern of anterograde and retrograde flow. The ratio of blood volumes was calculated with a vision analysis software. First, performance of the developed algorithm was validated by comparing it with commercial Doppler sonography data. Doppler sonography was performed for an artificial vessel to analyze the steal flow. RESULTS: A total of 58 patients with steal flow were enrolled in this study. Of these patients, 23 did not have a difference in fingertip temperature between both sides. The median difference in temperature of 35 patients was 0.8°C (range, 0.3-1.9°C). The ratio of retrograde flow volume/antegrade flow volume in patients with the presence of temperature difference was significantly higher compared to that in patients without the temperature difference (p < .001). The ROC curve for the difference in flow volume had an AUC of 0.770. The optimal cutoff of difference in the flow volume between the two groups was 0.24 (sensitivity of 91.4 % and specificity of 52.2%). The flow volume difference was significantly positively correlated to temperature difference (r = 0.487, p < .003). CONCLUSION: Our algorithm could measure steal flow volume of a bidirectional waveform by antegrade arterial flow and retrograde reversal flow.

Deep-learning-based renal artery stenosis diagnosis via multimodal fusion.

PURPOSE: Diagnosing Renal artery stenosis (RAS) presents challenges. This research aimed to develop a deep learning model for the computer-aided diagnosis of RAS, utilizing multimodal fusion technology based on ultrasound scanning images, spectral waveforms, and clinical information. METHODS: A total of 1485 patients received renal artery ultrasonography from Peking Union Medical College Hospital were included and their color doppler sonography (CDS) images were classified according to anatomical site and left-right orientation. The RAS diagnosis was modeled as a process involving feature extraction and multimodal fusion. Three deep learning (DL) models (ResNeSt, ResNet, and XCiT) were trained on a multimodal dataset consisted of CDS images, spectrum waveform images, and individual basic information. Predicted performance of different models were compared with senior physician and evaluated on a test dataset (N = 117 patients) with renal artery angiography results. RESULTS: Sample sizes of training and validation datasets were 3292 and 169 respectively. On test data (N = 676 samples), predicted accuracies of three DL models were more than 80% and the ResNeSt achieved the accuracy 83.49% ± 0.45%, precision 81.89% ± 3.00%, and recall 76.97% ± 3.7%. There was no significant difference between the accuracy of ResNeSt and ResNet (82.84% ± 1.52%), and the ResNeSt was higher than the XCiT (80.71% ± 2.23%, p < 0.05). Compared to the gold standard, renal artery angiography, the accuracy of ResNest model was 78.25% ± 1.62%, which was inferior to the senior physician (90.09%). Besides, compared to the multimodal fusion model, the performance of single-modal model on spectrum waveform images was relatively lower. CONCLUSION: The DL multimodal fusion model shows promising results in assisting RAS diagnosis.

Fetal epicardial fat thickness and modified myocardial performance index in late-onset fetal growth restriction.

AIM: In our study, we aimed to investigate the value of fetal epicardial fat thickness (EFT) and modified myocardial performance index (mod-MPI) in fetal growth restriction (FGR) that develops after the 32nd week of gestation. MATERIALS AND METHODS: Fifty-six pregnant women who met the inclusion and exclusion criteria were included in the study and were divided into two groups: pregnancies diagnosed with FGR after the 32nd week of gestation (FGR group) and those without (control group). Demographic and obstetric histories, ultrasonographic and clinical characteristics, fetal EFT and mod-MPI values, and neonatal outcomes of the groups were recorded, and comparisons were made between the groups. Additionally, the diagnostic performance of fetal EFT value in late FGR was investigated. RESULTS: The FGR group had fetal EFT that was statistically significantly lower (1.11 ± 0.21 vs. 1.34 ± 0.23, p = 0.001). The FGR group had a significantly lower isovolumetric contraction time (ICT) (31.04 ± 6.88 vs. 35.14 ± 7.58, p = 0.048). The two groups' isovolumetric relaxation time (IRT), ejection time (ET), and mod-MPI values (p values 0.871, 0.55, and 0.750, respectively) were comparable. Receiver operating characteristic (ROC) analysis at a cutoff of 1.2 revealed 76.1% sensitivity and 74.2% specificity, respectively, for the diagnostic performance of the fetal EFT value in late-onset FGR. There was a positive predictive value (PPV) and negative predictive value (NPV) of 64.0% and 83.8%, respectively. CONCLUSION: We found that fetal EFT was significantly lower in FGR and may be useful in diagnosing FGR. However, we observed that mode-MPI did not change in FGR.

[Relationship Between Cerebrovascular Reactivity and Depression in Patients With End-Stage Renal Disease].

Objective To investigate the relationship between cerebrovascular reactivity (CVR) and emotional disorders in the patients undergoing continuous hemodialysis for end-stage renal disease (ESRD).Methods The clinical data of the ESRD patients undergoing continuous hemodialysis were collected.Anxiety and depression of the patients were assessed by the Hamilton anxiety scale (HAMA) and Beck depression inventory,respectively.The cerebral hemodynamic changes during the breath holding test were monitored by transcranial Doppler sonography,and the breath-holding index (BHI) was calculated.The BHI≥0.69 and BHI<0.69 indicate normal CVR and abnormal CVR,respectively.Binary Logistic regression was employed to analyze the factors affecting the depressive state of ESRD patients.Results The group with abnormal CVR exhibited higher total cholesterol level (P=0.010),low density lipoprotein level (P=0.006),and incidence of depression (P=0.012) than the group with normal CVR.Compared with the non-depression group,the depression group displayed prolonged disease course (P=0.039),reduced body mass index (P=0.048),elevated HAMA score (P=0.001),increased incidence of anxiety (P<0.001),decreased BHI (P=0.015),and increased incidence of abnormal CVR (P=0.012).Binary Logistic regression analysis indicated anxiety as a contributing factor (OR=22.915,95%CI=2.653-197.956,P=0.004) and abnormal CVR as a risk factor (OR=0.074,95%CI=0.008-0.730,P=0.026) for depression.Conclusion Impaired CVR could pose a risk for depression in the patients with ESRD.

Assessment of the treatment effectiveness of men with mild and medium degree of erectile dysfunction.

OBJECTIVE: . Aim: To assess the effectiveness of monotherapy and complex treatment of patients with erectile dysfunction depending on its severity. PATIENTS AND METHODS: Materials and Methods: Men with moderate and mild erectile dysfunction took part in the study, who, in turn, were divided into groups, depending on the treatment, with the evaluation of the results of the International Index of Erectile Function (MIEF-15), the state of cavernous hemodynamics and the function of the vascular endothelium before and after treatment. RESULTS: Results: In patients with an average degree of severity, who received complex treatment including a course of low-energy shock wave therapy, against the background of taking sildenafil and L-arginine, the best results were obtained in the quality of erection and increased cavernous blood flow, which positively affected satisfaction with sexual intercourse and overall satisfaction. It has also been proven that the function of the endothelium was improved in patients receiving L-arginine, due to which there was a probable decrease in endothelin-1. A probable improvement of erectile function was obtained in the group of patients with a mild degree who received L-arginine, and there was no statistical difference from the indicators in the group who received sildenafil, which was confirmed by the data of dopplerography. CONCLUSION: Conclusions: Patients with an average degree of erectile dysfunction require comprehensive treatment. The use of L-arginine can be an alternative to phosphodiesterase type 5 inhibitors in the treatment of mild erectile dysfunction.

Cerebrovascular reactivity after functional activation of the Brain using Photic Stimulation in Migraine and Tension Type Headache: a transcranial doppler Ultrasonography Study.

BACKGROUND: Previous studies in headache patients measured the cerebrovascular reactivity (CVR) in response to photic stimulation but they have yielded contradictory results. The purpose of study was to measure CVR of both migraine and chronic tension headache (TTH) patients in response to photic stimulation. METHODS: The study included 37 migraineurs and 24 chronic TTH patients compared with 50 age- and sex-matched healthy volunteers. Peak systolic, end diastolic, mean flow velocities and CVR (PSV, EDV, MFV, and CVR) were measured using TCD ultrasonography of the middle, anterior, posterior cerebral and vertebral arteries (MCA, ACA, PCA, and VA) before and after 100 s of 14 Hz photic stimulation. RESULTS: A three-way repeated measures ANOVA interaction with main factors of Vessels (MCA, ACA, PCA, VA), Time (pre-post photic) and Groups (migraine, TTH, and control group) revealed significant 3-way interactions for measures of PSV (P = 0.012) and MFV (P = 0.043). In the migraine patients there was significantly higher PSV, EDV, and MFV in the MCA, ACA, and PCA after photic stimulation compared with baseline. The CVR of the MCA was also significantly higher in migraineurs than controls. In the TTH group, there was significantly higher PSV, EDV, and MFV (P = 0.003, 0.012, 0.002 respectively) in the VA after photic stimulation than at baseline. The CVR was significantly higher in the VA of TTH patients than controls. CONCLUSION: Compared with controls after photic stimulation, the higher CVR of the MCA in migraineurs and of the VA in TTH patients could be used as diagnostic tool to differentiate between the two types of headaches.

Endometrial microstimulation effects on endometrial receptivity assessed by transvaginal color Doppler sonography.

OBJECTIVE: This study investigated the effect of endometrial microstimulation (EM) on endometrial receptivity using transvaginal color Doppler sonography (TVCDS). METHOD: Women of childbearing age who were preparing to conceive (n = 90) were randomly divided into the EM group (n = 30), who were examined by EM on days 3-5 of the menstrual cycle, and the control group (n = 60). TVCDS was conducted during the implantation window phase, and endometrial thickness, endometrial pattern, endometrial movement, blood flow type, and uterine and spiral arterial hemodynamic parameter measurements were made. The groups were compared to identify differences. RESULTS: Endometrial thickness (0.97 ± 0.18 cm and 0.95 ± 0.17 cm), endometrial movement (type 1: 46.7% and 51.7%; type 2: 30.0% and 28.3%; type 3: 6.7% and 5.0%; type 5: 16.7% and 15.0%), and hemodynamic parameters of the uterine (pulsatility index [PI]: 2.46 ± 0.50 and 2.41 ± 0.48; resistance index [RI]: 0.85 ± 0.05 and 0.84 ± 0.05) and spiral (PI: 1.11 ± 0.32 and 1.19 ± 0.33; RI: 0.48 ± 0.11 and 0.51 ± 0.08) arteries did not differ significantly between groups (P > 0.05). However, the endometrial pattern (a trilaminar pattern: 80.0% and 58.3%; P = 0.041) and blood flow type (type I: 16.7% and 43.3%; type II: 63.3% and 40.0%; type III 20.0% and 16.7%; P = 0.038) differed significantly between groups. CONCLUSION: Endometrial microstimulation did not alter endometrial pathological staging, endometrial thickness, or movement, nor did it affect uterine and spiral arterial blood flow parameters. However, it may be able to abrade abnormal endometrial tissue, optimizing the endometrial pattern. Endometrial microstimulation may support local spiral artery regeneration and increase endometrial blood supply in new cycles.

Possible effects of short rest after lunch on hemodynamics in the afternoon.

PURPOSE: Drowsiness is often experienced in the afternoon after lunch. Decreases in blood flow to the brain secondary to increases in blood flow to the digestive organs after food intake could represent an underlying cause. As various beneficial effects of short rests on mental activities have been reported, the present study investigated hemodynamics using Doppler sonography of the common carotid artery (CCA) and superior mesenteric artery (SMA) after lunch, comparing resting and non-resting cases. METHODS: Subjects comprised 24 healthy young adults (10 men, 14 women; mean age 22 ± 1 years). Sonography was performed to measure blood flow before and after lunch on each day, with and without a 15-min lying rest with eyes closed after lunch in each subject. RESULTS: The timing of the peak velocity-time integral in the SMA in resting cases was delayed to 1.5 h after lunch compared to 0.5 h in non-resting cases. Although end-diastolic velocity in the CCA decreased after lunch, this decrease was suppressed in resting cases compared to non-resting cases even 4.5 h after lunch (median 96%, interquartile range [IQR] 83-102% vs. median 87%, IQR 77-92%; P = 0.037). Mean velocity (MV) in the CCA maintained unchanged after lunch in resting cases (P = 0.318), whereas non-resting cases showed decreased MV after lunch (P < 0.001). CONCLUSION: These findings suggest that a short lying rest with eyes closed suppresses increases in blood flow to the digestive organ and maintains blood flow to the brain after lunch. These hemodynamic changes might help explain the benefits of afternoon rests.

Clinical improvement after cranioplasty and its relation to body position and cerebral hemodynamics.

Cranioplasty after decompressive craniectomy (DC) has been found to improve the neurological condition. The underlying mechanisms are still unknown. The aim of this study is to investigate the roles of the postural changes and atmospheric pressure (AP) in the brain hemodynamics and their relationship with clinical improvement. Seventy-eight patients were studied before and 72 h after cranioplasty with cervical and transcranial color Doppler ultrasound (TCCS) in the sitting and supine positions. Craniectomy size, shape, and force exerted by the AP (torque) were calculated. Neurological condition was assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Barthel index. Twenty-eight patients improved after cranioplasty. Their time elapsed from the DC was shorter (214 vs 324 days), preoperative Barthel was worse (54 vs 77), internal carotid artery (ICA) mean velocity of the defect side was lower while sitting (14.4 vs 20.9 cm/s), and torque over the craniectomy was greater (2480.3 vs 1464.3 N*cm). Multivariate binary logistic regression showed the consistency of these changes. TCCS findings were no longer present postoperatively. Lower ICA (defect side) velocity in the sitting position correlates significantly with clinical improvement. Greater torque exerted by the AP might explain different susceptibilities to postural changes, corrected by cranioplasty.

The Prevalence of Microembolic Signals in Transcranial Doppler Sonography With Bubble Test in Acute Ischemic Stroke.

OBJECTIVES: Transcranial Doppler ultrasound (TCD) is noninvasive and highly sensitive and specific for the diagnosis of patent foramen ovale (PFO). We evaluated the diagnostic implications of the TCD with a saline agitation test as a routine work-up for ischemic stroke patients. METHODS: A TCD bubble study was performed in all consecutive ischemic stroke patients as a routine work-up. We evaluated the prevalence of microembolic signals (MES) for each stroke etiology and the optimal number of MES for predicting the PFO-attributable stroke. RESULTS: Subjects (N = 499) with acute ischemic stroke were enrolled. A significant fraction of patients had MES during both normal respiration (5.7-44.4%) and the Valsalva maneuver (19.5-55.6%) across all stroke etiology categories. The optimal MES threshold for the diagnosis of PFO-attributable stroke confirmed by transesophageal echocardiography was 46 MES during the Valsalva maneuver (96% sensitivity and 95% specificity). Applying ≥46 MES during the Valsalva maneuver as a threshold effectively increased the ability to differentially diagnose PFO-attributable stroke from other etiologies. The number of MES during the Valsalva maneuver was negatively correlated with increasing age (r = -.108; P = .016). CONCLUSIONS: A significant fraction of patients had right to left shunt across all Trial of ORG 10172 in Acute Stroke Treatment etiologies. A threshold number of MES facilitated the differential diagnosis of PFO-attributable stroke from other etiologies, and the optimal threshold was 46 MES during the Valsalva maneuver.

Reproducibility of hemispheric lateralization over several days using functional transcranial Doppler sonography (fTCD): a pilot single-case study of word fluency.

Functional transcranial Doppler sonography (fTCD) is a time- and cost-effective, non-invasive approach to determining real time hemispheric lateralization and is well-suited for repetitive study designs comprising multiple days. To date, no study has examined the reproducibility of the direction and degree (strength) of lateralization during word fluency (WF) over multiple, consecutive sessions within a single person, although there are many studies of lateralization during language processing. Moreover, there is conflicting evidence as to whether there is a relationship between the degree of laterality and the word fluency performance. In this study, one right-handed male (aged 24 years) completed a total of seven examination sessions in the time span of 10 days. Each session comprised multiple phonological and semantic WF tasks. The maximum difference of relative cerebral blood flow velocity (CBFV) changes between the left and right middle cerebral artery (MCA) during WF was defined as the Lateralization Index (LI). The word-fluency performance and the LIs were used in a linear regression model to detect relative changes in the direction and degree of lateralization during repetitive WF tasks. The reproducibility of the direction of language-related lateralization is very stable over multiple sessions within this single person and the processed LIs were left-lateralized in every session for both WF tasks. In addition, performance during phonological WF could significantly predict the variability in the degree of lateralization. This result could not be confirmed for the semantic WF task. The results of this pilot study support the usage of fTCD as a reliable method for examining lateralization patterns, especially in longitudinal study designs. They also provide evidence for the notion that performance in WF tasks can be related to the degree of lateralization, at least intra-individually.

The value of color Doppler sonography in diagnosis and hemodynamic analysis of innominate artery occlusion.

The occlusion of the innominate artery caused a significant decrease in the distal end of the right subclavian artery and the right common carotid artery, internal carotid artery, and external carotid artery (ECA). Due to the different pressure and the abundant communicating arteries between the ECA and the bilateral vertebral artery (VA), different paths of blood steal in the anterior and posterior circulation occurred.

Dynamic contrast-enhanced MRI and Doppler sonography in patients with squamous cell carcinoma of head and neck treated with induction chemotherapy.

In view of the inherent limitations associated with performing dynamic contrast enhanced-magnetic resonance imaging (DCE-MRI) in clinical settings, current study was designed to provide a proof of principle that Doppler sonography and DCE-MRI derived perfusion parameters yield similar hemodynamic information from metastatic lymph nodes in squamous cell carcinomas of head and neck (HNSCCs). Strong positive correlations between volume fraction of plasma space in tissues (Vp ) and blood volume (r = 0.72, p = 0.02) and between Vp and %area perfused (r = 0.65, p = 0.04) were observed. Additionally, a moderate positive correlation trending towards significance was obtained between volume transfer constant (Ktrans ) and %area perfused (r = 0.49, p = 0.09).

Color Doppler Sonography Assisted Subcutaneous Mastectomy with Inferior Pedicled Nipple-Areola Complex in Female-to-Male Transsexuals: A Retrospective Cohort Analysis.

BACKGROUND: The surgical goals of gender reassignment surgery of the breast in female-to male transsexuals (FMT) is the aesthetic shaping of a male thoracic wall with minimal scarring, while preserving the sensitivity of the nipple-areola complex (NAC). For large and ptotic breasts, we perform a mastectomy over an inframammary access with inferior pedicled NAC under color Doppler visualization of the perforators. This paper presents the technique, including complications and assessment of quality of life, as part of a unicentric analysis. METHODS: This was a retrospective analysis of 23 patients (46 mastectomies) performed between September 2014 and September 2020. The complication rate and the number of corrective surgeries were recorded for quality assessment. A semiquantitative score was used to evaluate aesthetic outcome, nipple sensitivity, quality of life, and sexuality. RESULTS: A total of 46 mastectomies were performed in 23 patients. The patient survey showed high patient satisfaction. Loss of nipple sensitivity was observed after one mastectomy (2.17%). In 91.67% of cases, patients reported that their appearance reflected how they feel on the inside. In 75% of cases, patients reported feeling equal to other men. The overall complication rate was 10.87%. Shape correction due to persistent excess of volume was rare (2.17%, equivalent to one mastectomy). CONCLUSION: Subcutaneous mastectomy with inferior nipple pedicle can be performed with a high degree of safety and satisfaction in FMT. Color Doppler-guided visualization of the perforator vessels is helpful in allowing a thin pedicle preparation, thus reducing the need for secondary surgeries to optimize the shape. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Celiac Disease and Neurological Manifestations: From Gluten to Neuroinflammation.

Celiac disease (CD) is a complex multi-organ disease with a high prevalence of extra-intestinal involvement, including neurological and psychiatric manifestations, such as cerebellar ataxia, peripheral neuropathy, epilepsy, headache, cognitive impairment, and depression. However, the mechanisms behind the neurological involvement in CD remain controversial. Recent evidence shows these can be related to gluten-mediated pathogenesis, including antibody cross-reaction, deposition of immune-complex, direct neurotoxicity, and in severe cases, vitamins or nutrients deficiency. Here, we have summarized new evidence related to gut microbiota and the so-called "gut-liver-brain axis" involved in CD-related neurological manifestations. Additionally, there has yet to be an agreement on whether serological or neurophysiological findings can effectively early diagnose and properly monitor CD-associated neurological involvement; notably, most of them can revert to normal with a rigorous gluten-free diet. Moving from a molecular level to a symptom-based approach, clinical, serological, and neurophysiology data might help to disentangle the many-faceted interactions between the gut and brain in CD. Eventually, the identification of multimodal biomarkers might help diagnose, monitor, and improve the quality of life of patients with "neuroCD".

Cerebroplacental doppler ratio and perinatal outcome in late-onset foetal growth restriction.

The purpose of this study was to determine whether gestational age-specific levels of the cerebroplacental ratio (CPR) as a third-trimester ultrasound marker has benefits in the prediction of perinatal morbidity and mortality on foetuses with late-onset foetal growth restriction (FGR). A retrospective study of singleton pregnancies diagnosed with late-onset FGR was performed. Of 407 pregnancies meeting our inclusion criteria, 313 had normal (Group 1) and 94 had abnormal CPR (Group 2). Both groups were similar in age, gestational age at diagnosis, body mass index and parity. There was a significant association between the presence of oligohydramnios and abnormal CPR. Mean gestational age at delivery and mean neonatal birth weight were significantly lower in Group 2. Neonatal intensive care unit admission, foetal distress, low 5-minute Apgar score <7, and low cord pH < 7.1 rates were significantly higher in Group 2. There was one neonatal death in both groups. Multivariable regression analysis demonstrated that, in the prediction of APO, there was a significant contribution from neonatal birth weight <10th percentile, CPR <5th percentile and oligohydramniosis. Our findings revealed that CPR value less than 5th centile can be used as a predictor of APO in late-onset FGR.IMPACT STATEMENTWhat is already known on this subject? Low cerebroplacetal ratio (CPR) is a marker of failure to reach the growth potential regardless of foetal weight.What do the results of this study add? The CPR can be used as an adequate predictor of adverse perinatal outcome in pregnancies with late-onset foetal growth restriction.What are the implications of these findings for clinical practice and/or further research? Routine calculation and report of CPR during basic ultrasound examination may help to identify foetuses with FR with a higher risk of adverse perinatal outcome. Future prospective studies on pregnancies with FGR with oligohydroamnios or normal amniotic fluid volume should focus on determining CPR threshold.