Anterior Chest Wall Reconstruction After Separation of Thoraco-Omphalopagus Conjoined Twins With Cadaveric Rib Grafts and Omental Flap.

BACKGROUND: Anterior chest wall defects have a wide range of etiologies in the pediatric population, ranging from infection, tumor, and trauma to congenital diseases. The reconstructive goals include restoring skeletal stability, obliterating dead space, preserving cardiopulmonary mechanics, and protecting vital underlying mediastinal organs. Although various reconstructive methods have been described in the literature, selecting the optimal method is challenging for the growing pediatric skeleton. Here, we report a case of previously thoraco-omphalopagus twins who underwent successful separation and reconstruction and presented for definitive anterior chest wall reconstruction. METHODS: A pair of previously thoraco-omphalopagus conjoined twins underwent definitive anterior chest wall defect reconstruction using cadaveric ribs and omental flap. Twin A received 2 cadaveric ribs, whereas twin B had a much larger sternal defect that required 3 cadaveric ribs combined with an omental flap for soft tissue chest coverage. Both twins were followed up for 8 months. RESULTS: Twin A's postoperative course was uneventful, and she was discharged on postoperative day 6. Twin B's course was complicated, and she was discharged on supported ventilation on postoperative day 10. At 8 months postoperatively, both twins healed well, and chest radiographs confirmed the stability of the chest reconstructions. The rib grafts in the twin with a tracheostomy were not mobile, and the patient had a solid sternum with adequate pulmonary expansion. The construct initially did not facilitate pulmonary functioning, but after a healing process, it eventually allowed for the twin with the tracheostomy who required pulmonary assistance to no longer need this device. CONCLUSIONS: Cryopreserved cadaveric ribs and omental flaps offer safe and reliable reconstructive methods to successfully reconstruct congenital anterior chest wall skeletal defects in the growing pediatric population. The involvement of multidisciplinary team care is key to optimizing the outcomes.

In vivo germination of Bacillus anthracis spores during murine cutaneous infection.

BACKGROUND: Germination is a key step for successful Bacillus anthracis colonization and systemic dissemination. Few data are available on spore germination in vivo, and the necessity of spore and host cell interactions to initiate germination is unclear. METHODS: To investigate the early interactions between B. anthracis spores and cutaneous tissue, spores were inoculated in an intraperitoneal cell-free device in guinea pigs or into the pinna of mice. Germination and bacterial growth were analyzed through colony-forming unit enumeration and electron microscopy. RESULTS: In the guinea pig model, germination occurred in vivo in the absence of cell contact. Similarly, in the mouse ear, germination started within 15 minutes after inoculation, and germinating spores were found in the absence of surrounding cells. Germination was not observed in macrophage-rich draining lymph nodes, liver, and spleen. Edema and lethal toxin production were not required for germination, as a toxin-deficient strain was as effective as a Sterne-like strain. B. anthracis growth was locally controlled for 6 hours. CONCLUSIONS: Spore germination involving no cell interactions can occur in vivo, suggesting that diffusible germinants or other signals appear sufficient. Different host tissues display drastic differences in germination-triggering capacity. Initial control of bacterial growth suggests a therapeutic means to exploit host innate defenses to hinder B. anthracis colonization.

Cancer Core Europe: Leveraging Institutional Synergies to Advance Oncology Research and Care Globally.

Cancer Core Europe brings together the expertise, resources, and interests of seven leading cancer institutes committed to leveraging collective innovation and collaboration in precision oncology. Through targeted efforts addressing key medical challenges in cancer and partnerships with multiple stakeholders, the consortium seeks to advance cancer research and enhance equitable patient care.

Social support for overcoming fear of contagion at the start of the COVID-19 pandemic. Cross-sectional study in Latin America.

Background: The psychological impact of the COVID-19 pandemic on healthcare professionals has been widely studied, along with different strategies to minimize it. However, professionals' assessment of the social support received and the factors that mitigated their fear of contagion have not been described. This study aimed to assess healthcare professionals' satisfaction with the social support and information received and their efforts to self-isolate to avoid infecting loved ones in Chile, Colombia, and Ecuador. Methods: A cross-sectional online survey, conducted from July to September 2020 in three Latin American countries, elicited healthcare professionals' satisfaction with social support from colleagues, their community, the media, and scientific societies; as well as the information received about the evolution of the pandemic and measures to avoid contagion. The EASE scale was used to measure acute stress. Results: Survey responses were received from 700 professionals. The response rate per country exceeded the estimated sample size except in the case of Colombia, which was 81.4%. In general, peer support was highly valued, though satisfaction was lower in high-risk units (p < 0.001). Those who directly assisted COVID-19 patients perceived the least community support (p = 0.023). Professionals from high-risk units (p = 0.013) and those who experienced greater acute stress (p = 0.05) assigned the lowest rating to the information offered by the centre on the pandemic. Men perceived more support from colleagues and better information from the centre than women (p < 0.05). Just 10.7% of professionals changed their residence during the pandemic, but those who worked in high-risk areas self-isolated more frequently (p = 0.026). Conclusion: In the early stages of the COVID-19 pandemic, healthcare professionals in Chile, Colombia, and Ecuador greatly valued the support received from their peers. Being infected with COVID-19, working in high-risk areas, experiencing higher self-reported acute stress, and having an infected co-worker were predictors for self-isolation to protect their relatives. These results point to the appropriateness of putting in place institutional resources based on peer support and specific communication strategies and action protocols to build resilience and responsiveness to future health crises.

Robotic Rectus Abdominis Harvest for Pelvic Reconstruction after Abdominoperineal Resection.

The use of robotic surgical systems to perform abdominoperineal resection (APR) has recently become more prevalent. This minimally invasive approach produces fewer scars and potentially less morbidity for the patient. The rectus abdominis muscle is often used for reconstruction after APR if primary closure is not feasible or the surgical site is at high risk of wound complications. Since the traditional open harvest of this flap creates large incisions that negate the advantages of minimally invasive APR, there has been growing interest in harvesting the rectus abdominis in a similarly robotic fashion. This article reviews the technique, benefits, and limitations of this robotic technique. Compared to the traditional open harvest, robotic harvest of the rectus abdominis leaves smaller scars, provides technical benefits for the surgeon, and offers possible morbidity benefits for the patient. These advantages should be weighed against the added expense and learning curve inherent to robotic surgery.

Extracorporeal Pedicles for Free Flap Reconstruction in Diabetic Lower Extremity Wounds.

Diabetic foot ulcers are a severe complication of diabetes, and their management requires a multidisciplinary approach for optimal management. When treating these ulcers, limb salvage remains the ultimate goal. In this article, we present the "hanging" free flap for the reconstruction of chronic lower extremity diabetic ulcers. This two-staged approach involves standard free flap harvest and inset; however, following inset the "hanging" pedicle is covered within a skin graft instead of making extraneous incisions within the undisturbed soft tissues or tunnels that can compress the vessels. After incorporation, a second-stage surgery is performed in 4 to 6 weeks which entails pedicle division, flap inset revision, and end-to-end reconstruction of the recipient vessel. Besides decreasing the number of incisions on diabetic patients, our novel technique utilizing the "hanging" pedicle simplifies flap monitoring and inset and allows reconstruction of recipient vessels to reestablish distal blood flow.

Gelatin-Coated Magnetic Nanowires for High-Sensitivity Optical Labels.

The encapsulation of magnetic nickel nanowires (NiNWs) with gelatin is proposed as an alternative for optical label detection. Magnetic nanowires can be detected at very low concentrations using light-scattering methods. This detection capacity could be helpful in applications such as transducers for molecular and biomolecular sensors; however, potential applications require the attachment of specific binding molecules to the nanowire structure. In the present study, a method is presented which is helpful in coating magnetic nanowires with gelatin, a material with the potential to handle specific decoration and functionalization of the nanowires; in the first case, silver nanoparticles (AgNPs) are efficiently used to decorate the nanowires. Furthermore, it is shown that the synthesized gelatin-coated particles have excellent detectability to the level of 140 pg/mL; this level of detection outperforms more complex techniques such as ICP-OES (~3 ng/mL for Ni) and magnetoresistance sensing (~10 ng/mL for magnetic nanoparticles).

Performance Outcome Measures in Padel: A Scoping Review.

Padel is a modern doubles racket sport which has become popular around the world in the last decades. There has been an increase in the quantity of scientific research about this sport in the last years. Therefore, the main objective of this scoping review is to provide an updated contextualization of research regarding padel. PRISMA ScR was used in order to search for articles fulfilling the inclusion criteria in five fields of interest: the anthropometric profile, physiology and physical performance, biomechanics, the epidemiology of injuries, and match analyses Seventy-seven records were included in the study. Padel is an emerging sport both in sport and research terms. This scoping review provides coaches and researchers with all the knowledge available in the five fields of interest. Furthermore, this study enables them to make a map of the current state of the research about padel, and it opens up doors to future investigations.

RNF43 mutations predict response to anti-BRAF/EGFR combinatory therapies in BRAFV600E metastatic colorectal cancer.

Anti-BRAF/EGFR therapy was recently approved for the treatment of metastatic BRAFV600E colorectal cancer (mCRCBRAF-V600E). However, a large fraction of patients do not respond, underscoring the need to identify molecular determinants of treatment response. Using whole-exome sequencing in a discovery cohort of patients with mCRCBRAF-V600E treated with anti-BRAF/EGFR therapy, we found that inactivating mutations in RNF43, a negative regulator of WNT, predict improved response rates and survival outcomes in patients with microsatellite-stable (MSS) tumors. Analysis of an independent validation cohort confirmed the relevance of RNF43 mutations to predicting clinical benefit (72.7% versus 30.8%; P = 0.03), as well as longer progression-free survival (hazard ratio (HR), 0.30; 95% confidence interval (CI), 0.12-0.75; P = 0.01) and overall survival (HR, 0.26; 95% CI, 0.10-0.71; P = 0.008), in patients with MSS-RNF43mutated versus MSS-RNF43wild-type tumors. Microsatellite-instable tumors invariably carried a wild-type-like RNF43 genotype encoding p.G659fs and presented an intermediate response profile. We found no association of RNF43 mutations with patient outcomes in a control cohort of patients with MSS-mCRCBRAF-V600E tumors not exposed to anti-BRAF targeted therapies. Overall, our findings suggest a cross-talk between the MAPK and WNT pathways that may modulate the antitumor activity of anti-BRAF/EGFR therapy and uncover predictive biomarkers to optimize the clinical management of these patients.

Hinge Flap of Rectus Abdominis Muscle Combined with Component Separation Technique: Clinical Cases.

Some techniques to reconstruct the abdominal wall have been published, including the component separation procedure. The contribution of the rectus abdominis flap in the reconstruction of a giant incisional hernia is reported. The authors report three clinical cases in which the component separation technique was insufficient to reconstruct a giant midline incisional hernia. As a salvage technique, the rectus abdominis flap was dissected in the form of a hinge. The postoperative period was successful in all patients, combining both techniques. The rectus abdominis hinge flap could be used as a complementary technique to component separation to reconstruct a giant midline incisional hernia. There are several options to reconstruct the abdominal wall, such as anterior transposition of the posterior rectus sheath,1 or rotation of the anterior sheath toward the midline. This strategy is known as open book.2 The rectus turnover flap is also used.3 The anterior component separation technique closes defects less than 20 cm width.4 If it is wider, the reconstruction is more difficult. When the operative plan fails in the operating room, an additional technique should be considered. We report on the cases in which we use the rectus abdominis hinge flap.

Update on Thumb Basal Joint Arthritis Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance. SUMMARY: Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.

Gender Differences in Neuromuscular, Haematological and Urinary Responses during Padel Matches.

Research on the acute physiological response to a padel match is limited. The present study aimed to: (a) evaluate neuromuscular, urinary, and hematological responses after simulated padel competition (SC) and (b) analyze possible gender differences. In this study, 28 high-level padel players participated (men = 13, age = 26.83 ± 6.57 years; women = 15, age = 30.07 ± 4.36 years). The following parameters were analyzed before and after SC: neuromuscular (hand grip strength, squat jump (SJ), countermovement jump (CMJ), and Abalakov jump (ABK)), hematological (red blood cells, hemoglobin, and hematocrit), and urinary (pH, specific gravity, microalbuminuria, and red blood cells). Significant gender differences were found in neuromuscular and hematological responses, with men obtaining higher values (p < 0.05). For the SC influence, changes were noted in ABK and microalbuminuria (p < 0.05). The percentages of change in hand grip strength, SJ (height and watts), CMJ (height), and ABK (height) were higher for men than women (p < 0.05). SC negatively influenced the neuromuscular parameters to a greater extent in women. Our results could be related to gender differences in game actions, the temporal structure, and anthropometric and physiological characteristics. Game dynamics and a different organic response between male and female padel playing were confirmed.

ERANET JTC 2011: Submission and Activation of an International Academic Translational Project in Advanced Breast Cancer. Experience From the ET-FES Study.

Background: Academic research is important to face unmet medical needs. The Oncological community encounters many hurdles in setting up multicenter investigator-driven trials mainly due to administrative complexity. The purpose of a network organization at a multinational level is to facilitate clinical trials through standardization, coordination, and education for drug development and regulatory approval. Methods: The application of an European grant foresees the creation of a consortium which aims at facilitating multi-center academic clinical trials. Results: The ERA-NET TRANSCAN Call 2011 on "Validation of biomarkers for personalized cancer medicine" was released on December 2011. This project included Italian, Spanish, French and German centers. The approval process included Consortium constitution, project submission, Clinical Trial Submission, and activation on a national level. The different timescales for submitting study documents in each Country and the misalignment of objections by each Competent Authority CA, generated several requests for changes to the study documents which meant amendments had to be made; as requested by the 2001/20/EC Directive, the alignment of core documents is mandatory. This procedure impacted significantly on study activation timelines. Time to first patient in was 14, 10, 28, and 31 months from the date of submission in Italy, France, Spain, and Germany, respectively. Accrual was stopped on 22nd January 2021 due to an 18F FES shortage as the primary reason but also for having exceeded the project deadlines with consequent exhaustion of the funds allocated for the project. Conclusions: Pharmaceutical companies might be reluctant to fund research projects aimed at treatment individualization if the approval for a wider indication has already been achieved. Academic trials therefore become fundamental for promoting trials which are not attractive to big pharma. It was very difficult and time consuming to activate an academic clinical trial, for this reason, a study may become "old" as new drugs entered into the market. National institutions should promote the development of clinical research infrastructures and network with competence in regulatory, ethical, and legal skills to speed up academic research.

Encapsulated Bacillus anthracis interacts closely with liver endothelium.

BACKGROUND: The Bacillus anthracis poly-gamma-D-glutamate capsule is essential for virulence. It impedes phagocytosis and protects bacilli from the immune system, thus promoting systemic dissemination. METHODS: To further define the virulence mechanisms brought into play by the capsule, we characterized the interactions between encapsulated nontoxinogenic B. anthracis and its host in vivo through histological analysis, perfusion, and competition experiments with purified capsule. RESULTS: Clearance of encapsulated bacilli from the blood was rapid (>90% clearance within 5 min), with 75% of the bacteria being trapped in the liver. Competition experiments with purified capsule polyglutamate inhibited this interaction. At the septicemic phase of cutaneous infection with spores, the encapsulated bacilli were trapped in the vascular spaces of the liver and interacted closely with the liver endothelium in the sinusoids and terminal and portal veins. They often grow as microcolonies containing capsular material shed by the bacteria. CONCLUSION: We show that, in addition to its inhibitory effect on the interaction with the immune system, the capsule surrounding B. anthracis plays an active role in mediating the trapping of the bacteria within the liver and may thus contribute to anthrax pathogenesis. Because other microorganisms produce polyglutamate, it may also represent a general mechanism of virulence or in vivo survival.

Reconstructive Techniques in Melanoma for the Surgical Oncologist.

Wounds resulting from wide local excision of melanoma vary in size and complexity, and require individualized solutions to achieve satisfactory closure. Goals of reconstruction include restoration of form, function, and aesthetics while minimizing donor site morbidity without compromising the effectiveness and safety of oncologic melanoma treatment. Optimal reconstruction relies on an in-depth understanding of the defect, locoregional anatomy and vasculature, available donor tissues, and basic wound healing and surgical principles. This article provides a broad overview of preoperative patient, timing, and wound considerations; various surgical techniques for complex reconstruction throughout the body; and postoperative care and complication management.

Caring for patients with cancer in the COVID-19 era.

The current COVID-19 pandemic challenges oncologists to profoundly re-organize oncological care in order to dramatically reduce hospital visits and admissions and therapy-induced immune-related complications without compromising cancer outcomes. Since COVID-19 is a novel disease, guidance by scientific evidence is often unavailable, and impactful decisions are inevitably made on the basis of expert opinions. Here we report how the seven comprehensive cancer centers of Cancer Core Europe have organized their healthcare systems at an unprecedented scale and pace to make their operations 'pandemic proof'. We identify and discuss many commonalities, but also important local differences, and pinpoint critical research priorities to enable evidence-based remodeling of cancer care during the COVID-19 pandemic. Also, we discuss how the current situation offers a unique window of opportunity for assessing the effects of de-escalating anticancer regimens, which may fast-forward the development of more-refined and less-toxic treatments. By sharing our joint experiences, we offer a roadmap for proceeding and aim to mobilize the global research community to generate the data that are critically needed to offer the best possible care to patients.

Author Correction: Caring for patients with cancer in the COVID-19 era.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Primary involvement of pharynx and peyer's patch in inhalational and intestinal anthrax.

Bacillus anthracis causes three forms of anthrax: inhalational, gastrointestinal, and cutaneous. Anthrax is characterized by both toxemia, which is caused by secretion of immunomodulating toxins (lethal toxin and edema toxin), and septicemia, which is associated with bacterial encapsulation. Here we report that, contrary to the current view of B. anthracis pathogenesis, B. anthracis spores germinate and establish infections at the initial site of inoculation in both inhalational and cutaneous infections without needing to be transported to draining lymph nodes, and that inhaled spores establish initial infection in nasal-associated lymphoid tissues. Furthermore, we found that Peyer's patches in the mouse intestine are the primary site of bacterial growth after intragastric inoculation, thus establishing an animal model of gastrointestinal anthrax. All routes of infection progressed to the draining lymph nodes, spleen, lungs, and ultimately the blood. These discoveries were made possible through the development of a novel dynamic mouse model of B. anthracis infection using bioluminescent non-toxinogenic capsulated bacteria that can be visualized within the mouse in real-time, and demonstrate the value of in vivo imaging in the analysis of B. anthracis infection. Our data imply that previously unrecognized portals of bacterial entry demand more intensive investigation, and will significantly transform the current perception of inhalational, gastrointestinal, and cutaneous B. anthracis pathogenesis.

The Basics of Integra Dermal Regeneration Template and its Expanding Clinical Applications.

First developed for coverage of burn wounds, Integra (Integra LifeSciences) is a synthetic acellular dermal regeneration template that provides a base for revascularization and neodermal formation. The use of Integra has slowly grown and has now become an important consideration along the reconstructive ladder. This article reviews the basic science of Integra and provides an overview of the many expanding applications based on anatomic location.

Advances in Fetal Surgery: Current and Future Relevance in Plastic Surgery.

Scarless healing has long been the holy grail for plastic surgery. While historically fetal surgery has tempted plastic surgeons with the allure of scarless correction of congenital abnormalities, the risks far outweighed the benefits and these interventions never materialized. Current advances in fetal surgery with minimally invasive fetoscopic surgery have made these early fetal interventions safer, leading to expanding applications. While the plastic surgeon's role is limited as of yet, this article provides a review of the history of fetal surgery and the advances that may become relevant to the future plastic surgeon.