Significant Vision Recovery from Filler-Induced Complete Blindness with Combined Intra-Arterial Injection of Hyaluronidase and Thrombolytic Agents.

With the increase of cosmetic injectable hyaluronic acid (HA), there have been more cases with serious complications, including skin necrosis, blindness, and cerebral embolism. Patients who have recovered from HA filler-induced total vision loss are extremely rare. We report a case of a 27-year-old female who developed severe ocular pain on the right side and total vision loss following a 1.0 ml HA filler injection in the nasal dorsum. She arrived at our hospital 4 hours later. Her visual acuity was no light perception (NLP), and she exhibited eyelid ptosis, ophthalmoplegia, and frontal and nasal ecchymosis. She was promptly treated with subcutaneous and retrobulbar hyaluronidase injections, as well as intra-arterial 1500 IU hyaluronidase injections into the right ophthalmic artery with DSA assistance. Her vision improved from NLP to counting fingers at 1.0 meters. Unfortunately, 13 hours later, she felt an intense headache, and her vision again decreased to NLP. We immediately performed an injection of 1500 IU hyaluronidase combined with 8 mg alteplase for intra-arterial thrombolysis (IAT) into the right ophthalmic artery. Her vision improved immediately afterward. After 3 months, her visual acuity had significantly recovered from NLP (admission vision status) to 20/50 (Snellen chart with glasses). Similarly, skin, conjunctival, eye movement, and ptosis symptoms completely recovered. This case demonstrates that reversal of complete blindness due to embolism of the ophthalmic and central retinal arteries could be accomplished through multidisciplinary therapies, especially IAT using fibrinolytic agents combined with hyaluronidase followed by an anticoagulant regimen.Level of evidence VThis 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Comparison Of Endoscopic Transaxillary And Peri-areolar Approaches In Breast Augmentation With Smooth Implants.

INTRODUCTION: The most common surgical approaches for breast augmentation in Asia have traditionally been peri-areolar and transaxillary. In recent years, transaxillary approach has become increasingly popular with the use of endoscopic methods, which result in safer and better outcomes. In the literature, there are no comparison studies of endoscopic transaxillary and peri-areolar approaches. METHODS: This prospective study compared the outcomes of 275 women undergoing primary breast augmentation (endoscopic transaxillary n=205, peri-areolar n=70). All procedures were performed by a single surgeon using smooth round silicone implants and dual-plane pockets from April 2013 to March 2016. Every patient was monitored for a minimum of 4 years for minor and major complications. RESULTS: Types and percentage of patients experiencing minor complications among transaxillary and peri-areolar patients were localized fluid collection in the wound (1% transaxillary, 7.1% peri-areolar), hypertrophic scarring or keloids (1% transaxillary, 8.6% peri-areolar), and areolar and nipple deformity (0% transaxillary, 8.6% peri-areolar). Major complications were postoperative bleeding (0% transaxillary, 2.9% peri-areolar) and capsular contracture, Baker Group III or IV (1% transaxillary, 5.7% peri-areolar). CONCLUSIONS: Endoscopic transaxillary breast augmentation had better outcomes, with lower rates of complications than the peri-areolar approach. Reviewing the literature, our study is the first direct comparison of peri-areolar and endoscopic transaxillary incisions using smooth implants. With the risk of anaplastic large cell lymphoma associated with certain macrotexture implants, endoscopic transaxillary approach using smooth implants is the safer technique and very good alternative choice for Asian women who do not want any scarring on their breasts. 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.

Reducing the Cost of Implementing Filters in LoRa Devices.

This paper presents two methods to optimize LoRa (Low-Power Long-Range) devices so that implementing multiplier-less pulse shaping filters is more economical. Basic chirp waveforms can be generated more efficiently using the method of chirp segmentation so that only a quarter of the samples needs to be stored in the ROM. Quantization can also be applied to the basic chirp samples in order to reduce the number of unique input values to the filter, which in turn reduces the size of the lookup table for multiplier-less filter implementation. Various tests were performed on a simulated LoRa system in order to evaluate the impact of the quantization error on the system performance. By examining the occupied bandwidth, fast Fourier transform used for symbol demodulation, and bit-error rates, it is shown that even performing a high level of quantization does not cause significant performance degradation. Therefore, the memory requirements of LoRa devices can be significantly reduced by using the methods of chirp segmentation and quantization so as to improve the feasibility of implementing multiplier-less filters in LoRa devices.

Superficial temporal artery branching pattern in single stage auricular reconstruction: A novel classification.

INTRODUCTION: The two most severe complications of single-stage, porous polyethene microtia reconstruction are flap necrosis/framework exposure and frontal nerve paralysis. To reduce these risks, require a temporoparietal fascia (TPF) flap that includes both the parietal and frontal branches of the superficial temporal artery (STA) while sparing the nerve. We propose a classification that helps minimize said complications. MATERIAL AND METHODS: Fifty-five TPF flaps of 54 microtia patients who underwent single-stage auricular reconstruction from May 2018 to July 2021 were studied. Flaps were harvested using endoscopic techniques. The parietal and frontal branch characteristics and measurements were obtained using a microscope/endoscope. RESULTS: The frontal artery might have 1 to 4 branches. If they were close to Pitanguy's line (≤5 mm), there would be a high risk of nerve damage. Parietal (P) and frontal (F) artery diameters <0.5 mm were risk factors for partial flap necrosis. Based on this observation, we proposed 0.5 mm as the diameter threshold to determine whether an arterial branch is hypoplasia or sufficient. From this study, a new classification of STA branching pattern was proposed with five types: PF1 (23.6 %), PF2 (43.6 %), pF1 (3.6 %), pF2 (12.8 %), and Pf (16.4 %); where P/F indicates sufficient branches, p/f indicates absent or hypoplasia ones, and the number indicates single or multiple frontal artery branching. CONCLUSION: The risk of flap necrosis and frontal nerve damage is due to abnormalities of the frontal artery of the STA in the TPF flap. Understanding the anatomical classification with clear visualization during flap harvest ensures a successful outcome.

Anatomical variant of the superficial temporal artery in temporoparietal fascia flap for microtia reconstruction.

BACKGROUND: Single-stage microtia auricular reconstruction is becoming more relevant. The determining factor is a temporoparietal fascia flap (TPF) with both branches of the superficial temporal artery (STA). There are not many studies regarding vascular branching in people with microtia. METHODS: We conducted an anatomical study on the TPF flap harvested during single-stage endoscopic-assisted microtia auricular reconstruction from May 2018 to July 2021. We observed the flaps under endoscopic and surgical microscopes to determine several variables (vascular size, number of frontal/parietal branches, distance from the branching location to the estimated external ear canal, distance from the frontal artery to projected course of facial nerve's frontal branch, etc.). RESULTS: The study included 55 flaps from 54 patients. Of the 55 flaps, 50 (90.9%) had a parietal branch, and all 55 (100%) had a frontal branch with a mean diameter of 0.98 and 0.91 mm, respectively. Regarding the frontal artery, 1.8%, 25.5%, 50.9%, 16.35% and 5.45% had 0-4 traverse frontal branch(es), respectively. The mean distance from the frontal artery to the estimated course of the frontal nerve was 10.56 mm. Parietal artery absence is more likely in patients with severe hemifacial microsomia or STA trunk go under the auricular cartilage remnants (p < 0.05). Either frontal or parietal artery absence or small diameter can cause necrosis. Frontal arteries travelling near the frontal nerve may result in post-operative nerve palsy. CONCLUSIONS: Microtia auricular reconstructive surgery is always a big challenge for plastic surgeons. Anatomical variants are common. A detailed anatomical description of the STA, with the help of microsurgery and endoscopy, allows arterial-based flap designing and harvest, which tremendously improves surgical success rate by diminishing flap necrosis and nerve damage. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Development and validation of a 6-plex Luminex-based assay for measuring human serum antibodies to group B streptococcus capsular polysaccharides.

Six serotypes (Ia, Ib, II, III, IV, and V) cause nearly all group B streptococcal (GBS) disease globally. Capsular polysaccharide (CPS) conjugate vaccines aim to prevent GBS disease, however, licensure of a vaccine would depend on a standardized serological assay for measuring anti-CPS IgG responses. A multiplex direct Luminex-based immunoassay (dLIA) has been developed to simultaneously measure the concentration of serum IgG specific for the six prevalent GBS CPS serotypes. Assay validation was performed using serum samples obtained from human subjects vaccinated with an investigational 6-valent GBS CPS conjugate vaccine. Results for the assay are expressed as IgG concentrations (µg/mL) using a human serum reference standard composed of pooled sera from vaccinated subjects. The lower limits of quantitation (LLOQ) for all serotypes covered in the 6-plex GBS IgG dLIA fell within the range of 0.002-0.022 µg/mL IgG. Taken together, the 6-plex GBS IgG dLIA platform is specific for the six GBS serotypes included in Pfizer's investigational vaccine, has a wide dilution adjusted assay range, and is precise (<18.5% relative standard deviation) for all serotypes, and, therefore, is suitable for quantitatively measuring vaccine-induced or naturally acquired serotype-specific anti-CPS IgG responses against GBS.

Axonal endoplasmic reticulum tubules control local translation via P180/RRBP1-mediated ribosome interactions.

Local mRNA translation in axons is critical for the spatiotemporal regulation of the axonal proteome. A wide variety of mRNAs are localized and translated in axons; however, how protein synthesis is regulated at specific subcellular sites in axons remains unclear. Here, we establish that the axonal endoplasmic reticulum (ER) supports axonal translation in developing rat hippocampal cultured neurons. Axonal ER tubule disruption impairs local translation and ribosome distribution. Using nanoscale resolution imaging, we find that ribosomes make frequent contacts with axonal ER tubules in a translation-dependent manner and are influenced by specific extrinsic cues. We identify P180/RRBP1 as an axonally distributed ribosome receptor that regulates local translation and binds to mRNAs enriched for axonal membrane proteins. Importantly, the impairment of axonal ER-ribosome interactions causes defects in axon morphology. Our results establish a role for the axonal ER in dynamically localizing mRNA translation, which is important for proper neuron development.

Calibration of a serum reference standard for Group B streptococcal polysaccharide conjugate vaccine development using surface plasmon resonance.

Group B streptococcus (GBS) is a leading cause of neonatal morbidity and mortality worldwide. Development of a maternal vaccine to protect newborns through placentally transferred antibody is considered feasible based on the well-established relationship between anti-GBS capsular polysaccharide (CPS) IgG levels at birth and reduced risk of neonatal invasive GBS. An accurately calibrated serum reference standard that can be used to measure anti-CPS concentrations is critical for estimation of protective antibody levels across serotypes and potential vaccine performance. For this, precise weight-based measurement of anti-CPS IgG in sera is required. Here, we report an improved approach for determining serum anti-CPS IgG levels using surface plasmon resonance with monoclonal antibody standards, coupled with a direct Luminex-based immunoassay. This technique was used to quantify serotype-specific anti-CPS IgG levels in a human serum reference pool derived from subjects immunized with an investigational six-valent GBS glycoconjugate vaccine.

MOXAIC: A classification of major maxillofacial wounds, concerning 310 cases.

INTRODUCTION: Although classification for facial fractures have been extensively described in the literature, corresponding systems for major maxillofacial wounds (MMW) are few. We would like to present MOXAIC: a new classification system for MMW. MATERIAL AND METHODS: A retrospective study of 310 patients with MMW who underwent emergency operation between January 2005 and December 2016. MMW was defined as a facial wound longer than 10 cm, which includes damage to the craniofacial bone or other important facial structures such as the carotid arteries, facial nerves, parotid gland, Stensen's duct, or the eye. All the patients were followed at least 36 months. RESULT: Based on the shape of the wound, the severity, and the mechanism of injury we were able to classify the MMW into five types: O, X, A, I, C. For each wound type we then looked at the treatment required and the outcome, objectively classified as good, satisfactory, or poor, concerning anatomical correction, aesthetics, and function. + Type OCircumferential wound: 81.6% result good. + Type X-Oblique wound: only 48.1% good, despite initial multidisciplinary approach. + Type A-Transverse facial wound: 78.1% good. + Type I-Direct wound: Immediate airway management and hemorrhage control are important. 48.8% good. + Type CCut wound: 88.1% good. The above classification was named MOXAIC which is a mnemonic of 'Maxillofacial' and the five wound types: O, X, A, I, C. CONCLUSION: This classification is highly reproducible, easy to use, and allows quick treatment work up and prognosis. However, this classification requires further specialist review and study.

Moving the ER tip by tip.

Endoplasmic reticulum (ER) and microtubule (MT) interactions have been observed in different cell types. However, how these interactions are regulated remains unknown. In this issue of Developmental Cell, Nourbakhsh et al. show that an ER-localized kinase, TAOK2, catalyzes the dynamic tethering of the ER tip to the MT tip.

The microsurgical replantation of seven complete scalp avulsions: is one artery sufficient?

BACKGROUND: Total scalp avulsion is a rare and devastating event. Microsurgical replantation is the sole method to achieve an ideal cosmetic outcome. In the literature, most studies have reviewed limited sample sizes. Most authors report better outcomes when a greater number of microvascular anastomoses are used. This strategy remains controversial, as some authors have suggested that one artery may be sufficient. METHODS: From 2005 to 2008, seven patients who sustained scalp avulsion underwent microsurgical replantation. All of the vascular anastomoses were made with a branch of the superficial temporal artery. We did not use vein grafts. The ischaemia time was 4-16 h. RESULTS: In six cases, a single artery and one to two veins were anastomosed; in another case, two arteries and three veins were anastomosed. Six of the seven scalp replantations were successful and achieved normal hair regrowth. In five of the six successful cases, we performed a single-artery anastomosis. CONCLUSION: Scalp avulsion is rare around the world but occurs relatively frequently in our country due to the lack of safe and secure working conditions in agriculture and industry. In cases where multiple arterial anastomoses are not possible, the present findings suggest that one branch of the superficial temporal artery may be sufficient to reperfuse the replanted scalp and achieve excellent aesthetic results.

The spectrum of central nervous system infections in an adult referral hospital in Hanoi, Vietnam.

OBJECTIVES: To determine prospectively the causative pathogens of central nervous system (CNS) infections in patients admitted to a tertiary referral hospital in Hanoi, Vietnam. METHODS: From May 2007 to December 2008, cerebrospinal fluid (CSF) samples from 352 adults with suspected meningitis or encephalitis underwent routine testing, staining (Gram, Ziehl-Nielsen, India ink), bacterial culture and polymerase chain reaction targeting Neisseria meningitidis, Streptococcus pneumoniae, S. suis, Haemophilus influenzae type b, Herpes simplex virus (HSV), Varicella Zoster virus (VZV), enterovirus, and 16S ribosomal RNA. Blood cultures and clinically indicated radiology were also performed. Patients were classified as having confirmed or suspected bacterial (BM), tuberculous (TBM), cryptococcal (CRM), eosinophilic (EOM) meningitis, aseptic encephalitis/meningitis (AEM), neurocysticercosis and others. RESULTS: 352 (male: 66%) patients were recruited: median age 34 years (range 13-85). 95/352 (27.3%) diagnoses were laboratory confirmed and one by cranial radiology: BM (n = 62), TBM (n = 9), AEM (n = 19), CRM (n = 5), and neurocysticercosis (n = 1, cranial radiology). S. suis predominated as the cause of BM [48/62 (77.4%)]; Listeria monocytogenese (n = 1), S. pasteurianus (n = 1) and N. meningitidis (n = 2) were infrequent. AEM viruses were: HSV (n = 12), VZV (n = 5) and enterovirus (n = 2). 5 patients had EOM. Of 262/352 (74.4%) patients with full clinical data, 209 (79.8%) were hospital referrals and 186 (71%) had been on antimicrobials. 21 (8%) patients died: TBM (15.2%), AEM (10%), and BM (2.8%). CONCLUSIONS: Most infections lacked microbiological confirmation. S. suis was the most common cause of BM in this setting. Improved diagnostics are needed for meningoencephalitic syndromes to inform treatment and prevention strategies.

Influenza A H5N1 clade 2.3.4 virus with a different antiviral susceptibility profile replaced clade 1 virus in humans in northern Vietnam.

BACKGROUND: Prior to 2007, highly pathogenic avian influenza (HPAI) H5N1 viruses isolated from poultry and humans in Vietnam were consistently reported to be clade 1 viruses, susceptible to oseltamivir but resistant to amantadine. Here we describe the re-emergence of human HPAI H5N1 virus infections in Vietnam in 2007 and the characteristics of the isolated viruses. METHODS AND FINDINGS: Respiratory specimens from patients suspected to be infected with avian influenza in 2007 were screened by influenza and H5 subtype specific polymerase chain reaction. Isolated H5N1 strains were further characterized by genome sequencing and drug susceptibility testing. Eleven poultry outbreak isolates from 2007 were included in the sequence analysis. Eight patients, all of them from northern Vietnam, were diagnosed with H5N1 in 2007 and five of them died. Phylogenetic analysis of H5N1 viruses isolated from humans and poultry in 2007 showed that clade 2.3.4 H5N1 viruses replaced clade 1 viruses in northern Vietnam. Four human H5N1 strains had eight-fold reduced in-vitro susceptibility to oseltamivir as compared to clade 1 viruses. In two poultry isolates the I117V mutation was found in the neuraminidase gene, which is associated with reduced susceptibility to oseltamivir. No mutations in the M2 gene conferring amantadine resistance were found. CONCLUSION: In 2007, H5N1 clade 2.3.4 viruses replaced clade 1 viruses in northern Vietnam and were susceptible to amantadine but showed reduced susceptibility to oseltamivir. Combination antiviral therapy with oseltamivir and amantadine for human cases in Vietnam is recommended.