Pedicled chimeric superficial circumflex iliac artery perforator (SCIP) flap with external oblique fascia for vesicocutaneous bladder fistula repair: A case report and literature review on the utility of pedicled chimeric SCIP.

Following its initial description by Koshima in 2004, the superficial circumflex iliac artery perforator (SCIP) flap has become a ubiquitous and extremely useful flap in coverage of defects whereby bulkiness must be avoided. It also allows direct closure and concealment of the donor site. Its use as a free tissue transfer has been demonstrated by various surgeons globally. Nevertheless, there are few cases illustrating the utility of the pedicled SCIP flap in the reconstruction of lower abdominal defects. We present a case of a pedicled SCIP flap utilized as a chimeric flap incorporating external oblique muscle fascia on a deep branch along with the typical fasciocutaneous component based on the superficial branch to cover the suprapubic defect after vesicocutaneous fistula repair. We thereafter report on the literature of pedicled chimeric SCIP flap for locoregional reconstruction. A 26-year-old female was referred to the Plastic and Reconstructive Surgery unit after suffering a functional bladder outlet obstruction necessitating the creation of a urinary stoma. Subsequently, stoma obstruction occurred, and a suprapubic catheter was performed that was complicated by infection and resulted in the development of a vesicocutaneous fistula. Accordingly, the urological surgeons were planning surgical closure of the suprapubic vesicocutaneous defect, measuring 5 × 4 cm. A pedicled SCIP flap was designed to match the defect size; and raised as a chimeric flap with external oblique muscle fascia based on the deep branch, along with the fasciocutaneous component based on the superficial branch. The external oblique fascial component was used to secure the suture line of fistula repair, over which the fasciocutaneous component was inset, effectively double breasting the fistula repair and full thickness lower abdominal defect. The patient had an unremarkable postoperative recovery and has since been followed up in the outpatient setting without complication for the past 24 months. Robust coverage of the suprapubic defect was reliably achieved and no further fistulation has occurred. This case illustrates that a pedicled SCIP flap can be harvested as a chimeric flap and used to reliably cover defects in the infra-umbilical region.

Novel AI-based HRV analysis (NAIHA) in healthcare automation and related applications.

BACKGROUND: Heart rate variability (HRV) analysis computed on R-R interval series of ECG records with heavy burden of ectopic beats or non-sinus rhythm can significantly distort HRV parameters and hence clinically ineligible for HRV analysis. Yet, existing algorithmic methods of HRV analysis do not check such eligibility and require manual identification of eligible window (portion of ECG record) to ensure reliability. OBJECTIVE: We aimed to propose a robust algorithm with a sliding window feature to automate the identification of an eligible window, if available, which compute HRV parameters within that window obviating manual input. METHODS: The proposed algorithm classifies each window as either eligible or ineligible. With a window classified eligible, we stop sliding through the record, otherwise we move to the next window and repeat the eligibility identification process, until either an eligible window is found, or all windows are exhausted. RESULTS: When evaluated on random subset of 100 records from MIMIC-III waveform database, the proposed algorithm excluded every ineligible record, and missed only 1.25% of eligible ones. The HRV parameters computed using proposed method closely approximated the standard HRV analysis with Pearson correlation coefficients (ideally one) and fractions of variance unexplained (ideally zero) ranging from 96.3% to 99.8% and 0.34% to 7.43%, respectively. CONCLUSIONS: When translated into practice, proposed algorithm will reduce clinicians'' burden without compromising the accuracy of HRV analysis, potentially leading to its wider adoption.

Donor Site Changes in Bone Thickness, Volume, and Density Following Split Cranial Bone Graft Harvest.

The calvarium can provide large amount of good quality corticocancellous autogenous bone graft. Although many studies have highlighted the advantages of the split cranial bone graft, there is no published work available in the literature about the fate of donor site of the split cranial bone graft. The present study was undertaken to assess the donor site as regards to the thickness, volume, and the density of the residual bone over a period of 12 months in the postoperative period. A total of 30 patients in the age group of 15 to 43 years were studied from January 2015 to January 2016. Postoperative computer tomography scans were taken at 2 weeks, 6 months, and 1 year postoperative to measure the bone thickness, volume, and density at the donor site of the split cranial bone graft harvest. The bone thickness at the donor site showed progressive increase in the thickness over the period of study and the average increase in thickness was about 12.4% at the end of 1 year. The average increase in volume at the donor site was of 2.65% after 12 months. Similarly, the average bone density increased by 3.7% at the end of 1 year. This prospective study conclusively proves that the residual bone at the donor site of the split cranial bone graft harvest site continues to grow in thickness and density over a period of 1 year.

Pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) flap for perineo-scrotal reconstruction following Fournier's gangrene.

BACKGROUND: Fournier's gangrene is a form of necrotising fasciitis involving perineo-scrotal skin. It is treated with radical debridement, infection control and often leaves a large anatomical defect that is challenging to reconstruct. The anatomical location of the defect leads to faecal contamination, difficulties when mobilizing, and negative psychological impact. Traditional approaches for managing such defects have relied on either healing by secondary intention or skin grafting. There are few reported cases in the literature to cover such defects with a flap. METHODS: Pedicled Superficial Circumflex Iliac Artery Perforator (SCIP) flap reconstruction was performed in three patients who had perineo-scrotal defects following debridement for Fournier's gangrene. RESULTS: All flaps survived with no significant postoperative complications and good functional and aesthetic outcomes were achieved. The mean age of patient was 52 years and the largest defect measured 22 × 10 cm. CONCLUSION: The reconstruction of perineo-scrotal defects is difficult despite a range of reconstructive options. The pedicled SCIP flap offers many advantages over standard techniques. This flap is thin, pliable, and has a consistent anatomy. With continued experience, we feel that this flap could be considered the gold standard of treatment for such defects.

Nitrate supply regulates tissue calcium abundance and transcript level of Calcineurin B-like (CBL) gene family in wheat.

Calcium ion (Ca2+) is the most ubiquitous signalling molecule and is sensed by different classes of Ca2+ sensor proteins. Recent evidences underscore the role of calcium signalling in plant response to nitrogen/nitrate supply. Recently we found that under nitrate deficiency, a short-term supply of calcium could improve the plant biomass, nitrate assimilation, anthocyanin accumulation and expression of nitrate uptake and signalling genes. Long-term calcium supply, on the other hand, was not beneficial. Calcineurin B-like (CBL) proteins are one of the vital plant Ca2+ sensory protein family which is essential for stress perception and signaling. To understand the dynamics of CBL-mediated stress signalling in bread wheat, we identified CBL genes in bread wheat (Triticum aestivum) and its progenitors, namely Triticum dicoccoides, Triticum urartu and Aegilops tauschii with the aid of newly available whole-genome sequence. The expression of different CBLs and the changes in root Ca2+ localization in response to nitrate provision or deficiency were analysed. Expression of the CBLs were studied in two bread wheat genotypes with comparatively higher (B.T. Schomburgk, BTS) and lower (Gluyas early, GE) nitrate responsiveness and nitrogen use efficiency. High N promoted the expression of CBLs in seedling leaves while in roots the expression was promoted by N deficiency. At the 5 days after anthesis stage, nitrate starvation downregulated the expression of CBLs while nitrate supply enhanced the expression. At anthesis stage, expression of CBL6 was significantly promoted by HN in panicles of both the genotypes, the highest expression was recorded in BTS. Expression of CBL6 was significantly upregulated by short term nitrate treatment also suggesting its role in Primary nitrate response (PNR) in wheat. There was a significant down regulation of CBL6 expression post nitrate starvation, making it a probable regulator of nitrogen starvation response (NSR) as well. In seedling roots, the tissue localization of Ca2+ was increased both by high and low nitrate treatments, albeit at different magnitudes. Our results suggest that calcium signalling might be a major signalling pathway governing nitrogen responsiveness and CBL6 might be playing pivotal role in NSR and PNR in wheat.

Genome-Wide Identification and Expression Analysis of the Thioredoxin (Trx) Gene Family Reveals Its Role in Leaf Rust Resistance in Wheat (Triticum aestivum L.).

Bread wheat (Triticum aestivum L.; Ta) is the staple cereal crop for the majority of the world's population. Leaf rust disease caused by the obligate fungal pathogen, Puccinia triticina L., is a biotrophic pathogen causing significant economic yield damage. The alteration in the redox homeostasis of the cell caused by various kinds of reactive oxygen species (ROS) and reactive nitrogen species (RNS) in response to pathogenic infections is controlled by redox regulators. Thioredoxin (Trx) is one of the redox regulators with low molecular weight and is thermostable. Through a genome-wide approach, forty-two (42) wheat Trx genes (TaTrx) were identified across the wheat chromosome groups A, B, and D genomes containing 12, 16, and 14 Trx genes, respectively. Based on in silico expression analysis, 15 TaTrx genes were selected and utilized for further experimentation. These 15 genes were clustered into six groups by phylogenetic analysis. MicroRNA (miRNA) target analysis revealed eight different miRNA-targeted TaTrx genes. Protein-protein interaction (PPI) analysis showed TaTrx proteins interact with thioredoxin reductase, peroxiredoxin, and uncharacterized proteins. Expression profiles resulting from quantitative real-time PCR (qRT-PCR) revealed four TaTrx genes (TaTrx11-5A, TaTrx13-5B, TaTrx14-5D, and TaTrx15-3B) were significantly induced in response to leaf rust infection. Localization of ROS and its content estimation and an assay of antioxidant enzymes and expression analysis suggested that Trx have been involved in ROS homeostasis at span 24HAI-72HAI during the leaf rust resistance.

Genome Editing Targets for Improving Nutrient Use Efficiency and Nutrient Stress Adaptation.

In recent years, the development of RNA-guided genome editing (CRISPR-Cas9 technology) has revolutionized plant genome editing. Under nutrient deficiency conditions, different transcription factors and regulatory gene networks work together to maintain nutrient homeostasis. Improvement in the use efficiency of nitrogen (N), phosphorus (P) and potassium (K) is essential to ensure sustainable yield with enhanced quality and tolerance to stresses. This review outlines potential targets suitable for genome editing for understanding and improving nutrient use (NtUE) efficiency and nutrient stress tolerance. The different genome editing strategies for employing crucial negative and positive regulators are also described. Negative regulators of nutrient signalling are the potential targets for genome editing, that may improve nutrient uptake and stress signalling under resource-poor conditions. The promoter engineering by CRISPR/dead (d) Cas9 (dCas9) cytosine and adenine base editing and prime editing is a successful strategy to generate precise changes. CRISPR/dCas9 system also offers the added advantage of exploiting transcriptional activators/repressors for overexpression of genes of interest in a targeted manner. CRISPR activation (CRISPRa) and CRISPR interference (CRISPRi) are variants of CRISPR in which a dCas9 dependent transcription activation or interference is achieved. dCas9-SunTag system can be employed to engineer targeted gene activation and DNA methylation in plants. The development of nutrient use efficient plants through CRISPR-Cas technology will enhance the pace of genetic improvement for nutrient stress tolerance of crops and improve the sustainability of agriculture.

Ischaemic breast necrosis following coronary artery bypass grafting using left internal mammary artery: understanding the risks.

BACKGROUND: Coronary artery bypass grafting (CABG) is a common procedure performed commonly using left internal mammary artery (LIMA). We report a case of sternal wound dehiscence and breast necrosis following LIMA harvest in a 55-year-old obese lady with macromastia, diabetes mellitus, hypertension and end stage renal disease requiring dialysis. We also review the existing literature. METHODS: Publications were identified from Medline All, Web of Science Core Collection, Google Scholar and Cochrane Central Register of Controlled Trial between 1974 and 2 January 2020. We assessed patient co-morbidities, presentation time frame, quadrant of breast necrosis and reconstruction option utilized. RESULTS: There were 18 cases of breast necrosis reported post-CABG. The patients were aged 50 or over, morbidly obese and had large tubular breasts. Other risk factors included chronic renal insufficiency, diabetes and hypertension. The presentation was delayed with necrosis only evident 7 days or more after CABG. All the reported cases had necrosis at lower inner quadrant of the left breast with nipple-areola complex. CONCLUSION: Blood supply to the breast is segmental with considerable overlap, however, this overlap is reduced in large breasts. Patients with macromastia and multiple co-morbidities need preoperative imaging (computed tomography angiogram) to evaluate breast vascularity prior to CABG. Risk of breast necrosis needs to be explained during the informed consent. Surgical management of the hypermastia (breast reduction or amputation) may be a factor in facilitating the CABG procedure if indeed the LIMA is absolutely indicated considering the risks and benefits.

Patient satisfaction and acceptance of spherical equivalent spectacles correction wear in rural India.

PURPOSE: The aim of this study was to explore the possibilities of acceptance of a ready-to-dispense spherical equivalent (SE) of spherocylindrical (SC) correction spectacles in rural India. METHODS: Snellen visual acuity with SE power of refracted SC lenses was prospectively collected from all individuals visiting vision centers in Phase 1 (vision correction accuracy) of the study conducted in two South Indian districts. The satisfaction level was recorded by asking one standard question. The SE spectacles were dispensed in vision centers of one district in Phase 2 (SE acceptance) with a suggestion to return, if unsatisfied, for free exchange of spectacles within a month of dispensing. RESULTS: In Phase 1, 929 of 3529 patients were refracted and it was found that 320 patients and one eye of one patient (641 eyes) had astigmatism. The average age was 41 (±16; range: 7-84) years. There was no reduction of visual acuity in SE of 0.25 Dcyl (100% satisfaction) and progressive decrease in satisfaction to 43%, 26%, and 19% with SE correction of 0.50, 0.75, and 1.00 Dcyl, respectively. In Phase 2, 988 of 6168 patients needed refraction and 240 had astigmatism. A total of 103 patients (206 eyes) accepted SE equivalent spectacles. No client returned for the free exchange of spectacles. CONCLUSION: Dispensing SE power up to 1 Dcyl in ready - made spectacles could be considered in remote rural populations in resource-poor economic conditions.