Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants.

BACKGROUND: Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES: To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS: An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS: Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION: Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

Effect of Bovine Lactoferrin Treatment on Iron Homeostasis and Gene Expression Changes in Multiple Organ Dysfunctions During Wound Healing Process in Rats.

BACKGROUND: Injury systemically disrupts the homeostatic balance and can cause organ failure. LF mediates both iron-dependent and iron-independent mechanisms, and the role of LF in regulating iron homeostasis is vital in terms of metabolism. OBJECTIVES: In this study, we evaluated the organ-level effect and gene expression change of bLf in the cutaneous repair process. MATERIALS AND METHODS: An excisional full-thickness skin defect (FTSD) wound model was created in male Sprague Dawley rats (180-250 g) (n = 48) fed a high-fat diet (HFD) and the PHGPx, SLC7A11 and SLC40A1 genes and iron metabolism were evaluated. The animals were randomly divided into 6 groups: 1- Control, 2- bLf (200 mg/kg/day, oral), 3- FTSD (12 mm in diameter, dorsal), 4- HFD + bLf, 5- HFD + FTSD, 6- HFD + FTSD + bLf. Histologically, iron accumulation was demonstrated by Prussian blue staining in the liver, kidney, and intestinal tissues. Gene expression analysis was performed with qPCR. RESULTS: Histologically, iron accumulation was demonstrated by Prussian blue staining in the liver, kidney, and intestinal tissues. Prussian blue reactions were detected in the kidney. PHPGx and SLC7A11 genes in kidney and liver tissue were statistically significant (P < 0.05) except for the SLC40A1 gene (P > 0.05). Expression changes of the three genes were not statistically significant in analyses of rat intestinal tissue (P = 0.057). CONCLUSION: In the organ-level ferroptotic damage mechanism triggered by wound formation. BLf controls the expression of three genes and manages iron deposition in these three tissues. In addition, it suppressed the increase in iron that would drive the cell to ferroptosis and anemia caused by inflammation, thereby eliminating iron deposition in the tissues.

Investigation into effects of tocilizumab and epoetin beta in rats with experimental sciatic nerve injury model.

OBJECTIVE: To investigate the effects of tocilizumab (TCZ), epoetin beta (EPO), and their combination on nerve regeneration in a sciatic nerve injury model. MATERIALS AND METHOD: Male Sprague-Dawley rats were divided into (-) negative control, sham, TCZ, EPO ((+) positive control), and TCZ+EPO groups. The TCZ group received TCZ (8 mg/kg intraperitoneal) immediately after surgery. On day 14th, the EPO group received EPO (5000 IU/kg, intraperitoneal); the TCZ+EPO group received TCZ (8 mg/kg, intraperitoneal), EPO (5000 IU/kg, intraperitoneal), and TCZ (8 mg/kg, intraperitoneal) post-surgery. Motor and sensory functions were assessed pre and post-surgery. Lipid peroxidation and oxidative stress parameters were evaluated biochemically in the serum, and sciatic nerve tissue was evaluated histopathologically using haematoxylin-Eosin and Masson trichrome staining. CONCLUSIONS: TCZ and EPO decreased nerve injury effects by increasing motor and sensory conduction velocities of the sciatic nerve. Biochemically, TCZ and EPO significantly increased Superoxide Dismutase, Catalase, and Glutathione peroxidase 4 levels while decreasing Lipid Peroxidation levels (p=0.001). Histopathologically, neuronal degeneration following nerve injury was decreased in the groups receiving TCZ and EPO (p=0.001). EPO and TCZ attenuate the adverse effects of nerve injury. However, the TCZ+EPO treatment favoured biochemical activities over tissue and functional activities. This has been confirmed functionally, biochemically, and histopathologically.

Monte Carlo calculated photon interaction coefficients for several body tissues.

Absorption of energy in body tissues because of radiation interactions may induce harmful outcomes such as cancer and hereditary effects due to a variety of damages in the integrity and activity of the cells. This study presents Monte Carlo calculated $\boldsymbol{\mu} /\boldsymbol{\rho}$, ${\boldsymbol{\mu}}_{\boldsymbol{en}}/\boldsymbol{\rho}$ and ${\boldsymbol{\mu}}_{\boldsymbol{tr}}/\boldsymbol{\rho}$ values of some common tissues and organs found in the human body (namely, adipose tissue, blood, bone-cortical, brain-grey/white matter, breast tissue, eye lens, lung tissue, muscle-skeletal, ovary, soft tissue and testes) as well as water for comparison purposes. The simulation model involves a monoenergetic point source producing a pencil beam where, depending on the parameter under study, particle flux, energy flux or absorbed dose from photon interactions are scored in the range of 10 keV to 20 MeV energy. The simulations were performed using the Monte Carlo package MCNP6.1 and provided $\boldsymbol{\mu} /\boldsymbol{\rho}$, ${\boldsymbol{\mu}}_{\boldsymbol{en}}/\boldsymbol{\rho}$ and ${\boldsymbol{\mu}}_{\boldsymbol{tr}}/\boldsymbol{\rho}$ values. The data produced in this study were compared with theoretical photon attenuation data from the XMUDAT database and demonstrated good agreement. The results, which are based on a simple model geometry and pure elemental compositions, indicate that this approach can be applied to evaluate $\boldsymbol{\mu} /\boldsymbol{\rho}$, ${\boldsymbol{\mu}}_{\boldsymbol{en}}/\boldsymbol{\rho}$ and ${\boldsymbol{\mu}}_{\boldsymbol{tr}}/\boldsymbol{\rho}$ in a broad energy range for any element, compound or mixture.

PTZ-kindled rat model; evaluation of seizure, hippocampal EGR-1, and Rev-erbα gene regulation, behavioral analysis, and antioxidant capacity of Gum Arabic.

BACKGROUND: Epilepsy is a neurological disease characterized by recurrent seizures, hyperexcitable neurons and various behavioral comorbidities. The electrical charge during seizures depletes the antioxidant defense mechanism in the epileptic brain and increases the oxidative burden. Natural antioxidant compounds are potential therapeutics in the treatment of two major pathologies of epilepsy with their anticonvulsant and anxiolytic effects and can modulate these targets. Gum Arabic is one of the natural plant polysaccharides that is non-toxic and biodegradable. METHODS AND RESULTS: A total of 30 Wistar albino male rats (8-12 weeks, 350-500 g), were randomly divided into 5 groups with 6 animals in each group: 1-Control, 2-Sham (Phosphate buffer saline (PBS)), 3-PTZ, 4-Gum Arabic, 5-PTZ + Gum Arabic. PTZ was administered i.p at 35 mg/kg/day for 11 days. After 48 h, the injection was completed with 75 mg/kg PTZ. Locomotor activity, immobilization, rearing, grooming, eating, and drinking behaviors were recorded with the LABORAS behavior system for 30 min after kindling. Animals were treated with Gum Arabic (2 mg/kg/day, oral gavage) for 10 days. At the end of the period, animal behavior was recorded again. Then the hippocampus tissues were removed. Oxidative parameters (TAS and TOS), early growth response 1 (EGR1) and nuclear receptor subfamily 1 group D member 1 (Rev-erbα) gene expressions and behaviors were analyzed. CONCLUSION: Gum Arabic increased TAS levels (P = 0.000), decreased TOS levels (P = 0.000), and thus exhibited antioxidant properties by reducing oxidative stress burden. EGR1, which was upregulated in the seizure group, was downregulated after treatment (P = 0.000), and Rev-erbα was downregulated in seizure and upregulated after treatment (P = 0.000). Gum arabic may be an antiepileptic and anxiolytic therapeutic in improving epileptic seizures by reducing oxidative stress burden through EGR1 and Rev-erbα.0.

Evaluation of mucin-1, nuclear factor κB, and hemoglobin A1c levels in obese and non-obese individuals

SUMMARY OBJECTIVE: Obesity is a chronic multisystem disease associated with increased morbidity and mortality. Obesity, which is a complex, multifactorial, and heterogeneous condition, is thought to result from the interaction of environmental, physiological, and genetic factors. In this study, the relationship between serum levels of hemoglobin A1c, mucin-1, and nuclear factor κB in obese and healthy cohorts was evaluated along with biochemical and gene expressions and with demographic and clinical covariates, and their effects on obesity were evaluated. METHODS: This case-control study included a total of 80 individuals, 40 healthy controls and 40 obesity patients, consisting of female and male aged between 18 and 63 years. Hemoglobin A1c, mucin-1, and nuclear factor κB levels were determined by ELISA in serum samples obtained from patients. In addition, aspartate aminotransferase, alanine transaminase, low density lipoprotein, and glucose values were measured. The gene expressions of the same markers were analyzed by quantitative real-time polymerase chain reaction, and their regulation status was defined. RESULTS: Serum levels of hemoglobin A1c, mucin-1, and nuclear factor κB were found to be high in obese individuals (p<0.05). The gene expression of these serum markers was found to be upregulated. Of the anthropometric measurements, waist circumference and body mass index were correlated with both serum markers and gene expressions (p<0.05). CONCLUSION: In addition to the known association of hemoglobin A1c and nuclear factor κB with obesity, serum levels of mucin-1 as well as upregulation of genes point to its modifier effect on obesity. These parameters can be the powerful markers in the diagnosis of obesity.

[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / "Wahl der Lappenplastik zur Phalloplastik ­ was ist zeitgemäßer Standard" ­ Konsensus-Bericht der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

A personalized Monte Carlo study of tumor and critical organ doses for trans-arterial radioembolization patients.

Trans-arterial radioembolization (TARE) is an intra-arterial treatment method for liver malignancies. In this procedure, the therapeutic tumor dose is significant for predicting the treatment effectiveness while the dose absorbed in an organ at risk provides an understanding of its tolerance to radiation. This study proposes a Monte Carlo (MC) approach for determining absorbed organ doses for patients undergoing TARE treatment. The technique is based on the use of a voxel-based partial body model generated for each patient from his/her anatomical image data to represent the critical body structures more realistically. These structures are first segmented from image slices to create an image block which is then incorporated into a radiation transport package (MCNP6.2) to perform MC simulations. When used along with the parameters specific to a patient's treatment, such as lung-shunt factor, tumor-to-normal liver ratio, fractional uptakes, and administered activity, this approach allowed more accurate simulation of radiation interactions and hence provided absorbed doses specific to a TARE patient. The MC method also calculated the absorbed doses in organs or tissues that were close to target tissues for which the Medical Internal Radiation Dose Committee (MIRD) formalism makes no predictions. MIRD calculations were found to overestimate the absorbed doses by as much as 11% in lungs, 5% in liver, and 20% in tumor volumes. This raises concerns about the treatment's efficacy when estimating the correct activity to be administered to a patient. When each patient simulation was repeated with a90Y source spectrum to reflect the distribution of varying beta energies, the liver and the lungs were observed to receive relatively lower doses than those obtained with monoenergetic beta particles. Thus, it can be stated that the approach adopted in this study offers a more precise model of the patient's critical tissues and serves as a personalized dosimetric tool for TARE treatment planning.

Histopathological efficacy of tacrolimus in an experimental head trauma study.

BACKGROUND: This study aimed to investigate the protective effect of tacrolimus (FK506), an immunosuppressive agent, on secondary brain damage in rats with experimental head trauma. METHODS: 40 Sprague-Dawley rats, aged 10-12 weeks and weighing 250-350 g, were used without gender selection. The subjects that were divided into five groups of 8 rats per group (sham control, negative control, positive control, vehicle control, and treatment) were sacrificed 1 month after head trauma was induced under appropriate conditions, their brains were then removed en bloc and evaluated histopathologically. Secondary brain injury was evaluated with the immunoreactive score (IRS) after Glial Fibrillary Acid Protein staining of gliosis that would occur in brain tissue. RESULTS: The evaluation of the histopathological IRS values of all groups showed significant statistical differences between all groups. The pairwise group comparison revealed the highest increase in IRS value in the treatment group (p<0.05), with no statistical significance despite the increase in the negative control, positive control, and vehicle control groups. The sham group had the lowest rate of severe histopathological reaction score. CONCLUSION: It was observed that the group treated with FK506 had a statistically significant increase in gliosis in the traumatic area compared to the other control groups. This shows that FK506 cannot prevent and even increase gliosis by a mechanism that has not yet been clarified. In conclusion, it is obvious that the FK506 immunosuppressive agent does not reduce post-traumatic brain injury; on the contrary, it increases gliosis.

[Body Contouring after Massive Weight Loss: A Road Map]. / Wiederherstellungsoperationen (WHO's): Eine Übersicht - Straffungsoperationen nach massivem Gewichtsverlust.

Body contouring procedures are the consequent and final step for patients after massive weight loss. These surgical procedures are mainly indicated for functional reasons resulting from extensive excess skin flaps. The current overview serves as an introduction to body contouring strategies without any claim to comprehensiveness. In the following, we describe the general and specific aspects of the respective body contouring procedures. These are in accordance with the guidelines published by the Association of Scientific Medical Societies in Germany (AWMF). This includes principle anatomical functional features, detailed general and specific aspects of a comprehensive history with the respective physical examination. We also describe the documentation and fundamentals of the application for required assumption of costs for hospital care. The main section deals with the principles of the most frequent lifting operations, such as abdominoplasty, brachioplasty, mastopexy, thigh lift etc. We describe the specific aspects of the specific body regions as well as different surgical techniques, with step-by-step instructions and with pre-, intra- and postoperative pictures.

The Great Saphenous Vein-An Underrated Recipient Vein in Free Flap Plasty for Lower Extremity Reconstruction: A Retrospective Monocenter Study.

Background Reconstruction of large soft tissue defects of the lower extremity often requires the use of free flaps. The main limiting factor and potential for complications lie in the selection of proper donor and recipient vessels for microvascular anastomosis. While the superficial veins of the lower leg are easier to dissect, they are thought to be more vulnerable to trauma and lead to a higher complication rate when using them instead of the deep accompanying veins as recipient vessels. No clear evidence exists that proves this concept. Methods We retrospectively studied the outcomes of 97 patients who underwent free flap plasty to reconstruct predominantly traumatic defects of the lower extremity at our institute. The most used flap was the gracilis muscle flap. We divided the population into three groups based on the recipient veins that were used for microvascular anastomosis and compared their outcomes. The primary outcome was the major complication rate. Results Overall flap survivability was 93.81%. The complication rates were not higher when using the great saphenous vein as a recipient vessel when comparing to utilizing the deep concomitant veins alone or the great saphenous vein in combination to the concomitant veins. Conclusions In free flap surgery of the lower extremity, the selection of the recipient veins should not be restricted to the deep accompanying veins of the main vessels. The superficial veins, especially the great saphenous vein, offer an underrated option when performing free flap reconstruction.

Role of Betatrophin and Inflammation Markers in Type 2 Diabetes Mellitus, Prediabetes and Metabolic Syndrome.

OBJECTIVE: To determine the association of betatrophin and inflammation factors in metabolic diseases such as diabetes, impaired fasting glucose, impaired glucose tolerance and metabolic syndrome. STUDY DESIGN: A cross-sectional, analytical study. PLACE AND DURATION OF STUDY: Firat University Medical School between April 2017 and December 2020. METHODOLOGY: The study included 20 patients with type 2 diabetes mellitus, 20 patients with impaired fasting glucose (IFG), 20 patients with impaired glucose tolerance (IGT), 20 patients with metabolic syndrome (MetS), and a control group consisting of 20 healthy individuals. Anthropometric, fasting serum biochemical data were collected. Circulating betatrophin, and inflammation markers were measured by enzyme-linked immunosorbent assay (ELISA). The association of betatrophin, TNF-alpha, and IL-6 levels between groups were performed with One-way ANOVA and post-hoc Tukey HSD test. RESULTS: Significantly higher levels of circulating betatrophin were observed in IFG, IGT, And MetS groups compared to healthy controls (p=0.017). There were significantly difference TNF-α levels in IFG, IGT, and MetS groups compared to healthy controls (p<0.001). The levels of IL-6 were significantly higher in MetS group than healthy controls (p=0.007). CONCLUSION: The circulating betatrophin and TNF-α levels were increased in MetS, IFG and IGT. IL-6 was decreased in MetS compared to the healty controls. Further studies are needed to elucidate the role of betatrophin and inflammatory parameters in the development of T2DM and prediabetic syndromes, whether betatrophin could have clinical applications in the development of new antidiabetic agents. Key Words: Betatrophin, IL-6, TNF-alpha, Metabolic syndrome, Insulin resistance, Diabetes mellitus type 2.

Multimodal evaluation of donor site morbidity in transgender individuals after phalloplasty with a free radial forearm flap: a case-control study.

BACKGROUND: In phalloplasty, there is a lack of standardized follow-up examinations of motor function and strength after harvesting oversized radial forearm free flaps (RFFF). METHODS: We evaluated the donor site of 20 transmen after phalloplasty, using a multimodal, standardized approach, assessing the following parameters: opposition of the thumb, composite range of motion of the finger joints, grip strength, mobility of the wrist, lesion of the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the sensation of pain, and cold intolerance. The contralateral, nonoperated forearm was used as a control. RESULTS: No impairment of the mobility of the thumb (Kapandji score median 10, range 5-10) or fingers (all fingers at both sides pulp-to-palm 0 cm, nail-to-table 0 cm) were detected. Grip strength (median 36,3kg, p=0.629) and wrist extension (62.5°vs.70°, p=0.357), flexion (70°vs.70°, p=0.535), pronation (90°vs.90°), supination (90°vs.90°), radial (30°vs.30°, p=0.195), and ulnar deviation (40°vs.50°, p=0.125) did not statistically differ between donor and control hand. Injury of the dorsal branch of the ulnar nerve was uncommon (0% hypoesthesia, 10% positive Tinel's sign). We did not observe any persistent pain of the donor forearm (NRS median 0, range 0-9). We did observe irritation of the superficial branch of the radial nerve (hypoesthesia 40%, neuroma 45%). CONCLUSION: The harvest of an oversized RFFF for phalloplasty does not cause any significant difference in motor function or strength between the donor and nonoperated hand. A potential risk of injuring the radial nerve branch is to be avoided. An aesthetic impairment could be addressed in future studies.

Candida albicans Osteochondromyelitis after Gastroesophageal Surgery: Two Case Reports.

Candida osteochondromyelitis is a rare complication after thoracoabdominal surgery. We herein report two such cases after uncomplicated thoracoabdominal surgery, who presented with chronic postsurgical site infection and fistula. CT scans showed fistulas reaching the costochondral areas of the fifth rib. Inflammatory parameters were not elevated. Both patients were treated successfully after the initiation of systemic antimycotic treatment and surgical debridement. We conclude that C. albicans infections should always be considered in cases of chronic postoperative surgical site infections after thoracoabdominal surgery. Additional risk factors do not need to be present. Appropriate therapy consists of the application of systemic antimycotics and surgical debridement.

National guidelines on the management of venous thromboembolism: Joint guideline of the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society.

These evidence-based guidelines from the Turkish Society of Cardiovascular Surgery, National Society of Vascular and Endovascular Surgery, and Phlebology Society intend to support clinicians in best decisions regarding the treatment of venous thromboembolism (VTE). The Editor was selected by the three national societies and was tasked with the recruitment of the recognized panel. All financial support was solely derived from the sponsoring societies without the direct involvement of industry or other external stakeholders. The panel prioritized clinical questions and outcomes according to their importance for clinicians in terms of VTE. The panel agreed on 42 recommendations under 15 headings for the diagnosis, initial management, secondary prevention of VTE, and treatment of recurrent VTE events. Important recommendations included the use of ultrasonography, preference for home treatment over hospital treatment for uncomplicated VTE, preference for direct oral anticoagulants (DOACs) over vitamin K antagonists for primary treatment of cancer and non-cancer-related VTE, extended or indefinite anticoagulation with DOACs in selected high-risk patients. Early catheter-directed thrombectomy was recommended in only young symptomatic patients with a diagnosis of fresh iliofemoral deep vein thrombosis.

The protective effect of Ferula elaeochytris on age-related erectile dysfunction.

ETHNOPHARMACOLOGICAL RELEVANCE: Ferula elaeochytris Korovin (FE) is a perennial medicinal plant of Apiaceae family. Ferula elaeochytris Korovin, known as 'Çaksir' in Anatolia, is widely used as an aphrodisiac as well as antioxidant, anti-inflammatory, and anti-diabetic. AIM OF THE STUDY: Erectile dysfunction (ED) is a serious public health problem that has a high prevalence and negatively affects the quality of life in elderly men. In the treatment and prophylaxis of many diseases, because of widely increasing use of plant extracts as therapeutic agents, preclinical studies related to plant extracts are becoming more important by the day. In this study, we aimed to investigate the protective effect of Ferula elaeochytris Korovin (FE) root extract on age-related ED. MATERIALS AND METHODS: Seventy-two male Wistar albino rats were equally divided into four groups: 4-month aged rats (Y), 24-month aged rats (AG), and FE-administered (20 and 40 mg/kg/day; oral gavage; over 8 weeks) 24-month aged rats (AG + FE). The measurements included: changes in smooth muscle cells and collagen fibrils, tumor necrosis factor alpha (TNF-α), penile neuronal nitric oxide synthase (nNOS) and endothelial nitric oxide synthase (eNOS) expression, serum testosterone concentrations (ST), neurogenic- and endothelial-dependent relaxations of the corpus cavernosum (CC), intracavernosal pressure/mean arterial pressure (ICP/MAP), area under the curve (total ICP), total antioxidant status (TAS), and total oxidant status (TOS) on corpus cavernosal tissue. RESULTS: These results have an important role in the development of ED. ICP/MAP, total ICP, eNOS/nNOS expressions and ST levels increased in AG+40 mg FE group compared to the AG group, whereas TNF-α levels decreased and oxidative and antioxidant parameters balanced. CONCLUSIONS: Our findings show that FE may have a useful effect on decelerating the development of age-related ED.

Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap.

BACKGROUND: Constructing a sensitive phallus is a key objective in sex affirmation surgery, but still there is a major lack of evidence in outcome analysis of postoperative sensibility of the newly constructed body part. AIM: To evaluate the innervation and sensibility of a forearm free-flap neophallus with nerve coaptation by a broad-spectrum follow-up. METHODS: The phallic sensibility of 20 transgender individuals who underwent phalloplasty with a free radial forearm flap was evaluated by a standardized multimodal approach, examining 5 main sensory modalities. Measurements were performed in defined areas at the phallus and at the unoperated forearm as a control area. Additionally, all patients were asked to complete a questionnaire about their subjective quality of life and ability to orgasm. OUTCOME: This study evaluated the following parameters: perception of pressure (Semmes-Weinstein monofilaments) and vibration (C64 Hz tuning fork), static two-point discrimination, sharp-blunt and hot-cold discrimination at the phallus and the forearm, sum score of calculated life satisfaction, and ability to orgasm. RESULTS: Most of the patients (n = 14) were able to perceive 2 or more sensory modalities tested at the newly constructed phallus. 2 patients did not develop any sensibility. Interestingly, the median values for vibration perception were similar for the phallus and the unoperated forearm. Pressure sensibility was present at the phallus, but less than at the forearm. Moreover, sharp-blunt sensibility was present in 11 patients. In contrast, clear cold-warm discrimination could not be achieved, although the majority of patients detected the cold stimulus. A two-point discrimination of up to 23 mm could not be detected in either body part. 15 patients experienced orgasms without difficulty after 23 months (n = 20 after 54 months). CLINICAL IMPLICATIONS: We observed successful recovery of sensibility at the phalli for the majority of patients, including the preservation of orgasm. STRENGTHS & LIMITATIONS: Our institution is one of the few centers regularly performing phalloplasties in transgender patients, especially preferring the technique of Gottlieb and Levine. This study contributes to the few studies that perform sensory testing at the phallus and is unique in its kind in that it uses a multimodal approach. A limitation of this study is the limited number of cases and the limited validity of vibratory testing. CONCLUSION: Confirming a promising tactile sensibility after phalloplasty with a neurovascular radial forearm flap, the next step would be to identify whether this reinnervation effectively develops due to nerve coaptation or spontaneous sprouting. Küenzlen L, Nasim S, van Neerven S, et al. Multimodal Evaluation of Functional Nerve Regeneration in Transgender Individuals After Phalloplasty With a Free Radial Forearm Flap. J Sex Med 2020;17:1012-1024.

Current surgical approaches in Takayasu's arteritis: a single-centre experience.

OBJECTIVES: We investigated cardiovascular surgical interventions in a group of patients with Takayasu's arteritis (TAK) diagnosed and followed by a single centre. METHODS: . Twenty patients with TAK (5 males, 15 females, mean current age: 38.1±10.7) who were operated for a broad spectrum of cardiovascular diseases ranging from coronary heart disease to coeliac stenosis or aneurysm between July 2008 and April 2016 were studied. One patient underwent operation related to aneurysm of ascending aorta and aortic insufficiency, 2 patients had operations for both coronary arteries originating from aortic arch, 6 patients for only arteries originating from aortic arch, 1 patient for both carotid and infra-inguinal artery, 5 patients for aorta-iliac or femoral revascularisation, 5 patients for renal artery and/or coeliac or superior mesenteric artery revascularisations. Three of these interventions were endarterectomy and patch plasty. RESULTS: The mean time between diagnosis and surgical intervention was 6.1±3.1 years (range: 3 months-12 years). A total of 4/32 (12.5%) grafts were occluded during the follow up period of mean 39.2±24.6 months. Secondary interventions like cross-femoral, or graft to superficial femoral artery bypasses were needed in 2 patients who underwent aorta-bifemoral bypasses to keep patency. There was no operative mortality. We did not observe any anastomotic aneurysm. One patient died due to graft infection 3 months after the operation. Stroke occurred in 2 patients who underwent re-vascularisations of the arteries originating from aortic arch. CONCLUSIONS: In our series, we have a relatively good midterm patency rates in patients with TAK and did not observe any anastomotic pseudoaneurysm. Stroke developed in 2 patients and mortality occurred in one patient due to the graft infection 3 months after the operation. In patients with limited carotid or aorta-iliac stenosis, chance for endarterectomy should be evaluated. Well-controlled disease activity with intensive medical treatment and multi-disciplinary approach could be associated with a favourable long-term outcome.

Mastectomy in female-to-male transgender patients: A single-center 24-year retrospective analysis.

BACKGROUND: Mastectomy in male transgender patients is an important (and often the first) step toward physical manhood. At our department, mastectomies in transgender patients have been performed for several decades. METHODS: Recorded data were collected and analyzed for all male transgender patients undergoing mastectomy over a period of 24 years at our department. RESULTS: In total, 268 gender-reassigning mastectomies were performed. Several different mastectomy techniques (areolar incision, n=172; sub-mammary incision, n=96) were used according to patients' habitus and breast features. Corresponding to algorithms presented in the current literature, certain breast qualities were matched with a particular mastectomy technique. Overall, small breasts with marginal ptosis and good skin elasticity allowed small areolar incisions as a method of access for glandular removal. In contrast, large breasts and those with heavy ptosis or poor skin elasticity often required larger incisions for breast amputation. The secondary correction rate (38%) was high for gender reassignment mastectomy, as is also reflected by data in the current literature. Secondary correction frequently involved revision of chest wall recontouring, suggesting inadequate removal of the mammary tissue, as well as scar revision, which may reflect intense traction during wound healing (36%). Secondary corrections were performed more often after using small areolar incision techniques (48%) than after using large sub-mammary incisions (21%). CONCLUSIONS: Choosing the suitable mastectomy technique for each patient requires careful individual evaluation of breast features such as size, degree of ptosis, and skin elasticity in order to maximize patient satisfaction and minimize secondary revisions.

Fibroadhesive scarring of grafted collagen scaffolds interferes with implant-host neural tissue integration and bridging in experimental spinal cord injury.

Severe traumatic spinal cord injury (SCI) results in a devastating and permanent loss of function, and is currently an incurable condition. It is generally accepted that future intervention strategies will require combinational approaches, including bioengineered scaffolds, to support axon growth across tissue scarring and cystic cavitation. Previously, we demonstrated that implantation of a microporous type-I collagen scaffold into an experimental model of SCI was capable of supporting functional recovery in the absence of extensive implant-host neural tissue integration. Here, we demonstrate the reactive host cellular responses that may be detrimental to neural tissue integration after implantation of collagen scaffolds into unilateral resection injuries of the adult rat spinal cord. Immunohistochemistry demonstrated scattered fibroblast-like cell infiltration throughout the scaffolds as well as the presence of variable layers of densely packed cells, the fine processes of which extended along the graft-host interface. Few reactive astroglial or regenerating axonal profiles could be seen traversing this layer. Such encapsulation-type behaviour around bioengineered scaffolds impedes the integration of host neural tissues and reduces the intended bridging role of the implant. Characterization of the cellular and molecular mechanisms underpinning this behaviour will be pivotal in the future design of collagen-based bridging scaffolds intended for regenerative medicine.