Historic breeding practices contribute to germplasm divergence in leaf specialized metabolism and ecophysiology in cultivated sunflower (Helianthus annuus).

PREMISE: The use of hybrid breeding systems to increase crop yields has been the cornerstone of modern agriculture and is exemplified in the breeding and improvement of cultivated sunflower (Helianthus annuus). However, it is poorly understood what effect supporting separate breeding pools in such systems, combined with continued selection for yield, may have on leaf ecophysiology and specialized metabolite variation. METHODS: We analyzed 288 lines of cultivated H. annuus to examine the genomic basis of several specialized metabolites and agronomically important traits across major heterotic groups. RESULTS: Heterotic group identity supports phenotypic divergences between fertility restoring and cytoplasmic male-sterility maintainer lines in leaf ecophysiology and specialized metabolism. However, the divergence is not associated with physical linkage to nuclear genes that support current hybrid breeding practices in cultivated H. annuus. Additionally, we identified four genomic regions associated with leaf ecophysiology and specialized metabolism that colocalize with previously identified QTLs for quantitative self-compatibility traits and with S-protein homolog (SPH) proteins, a recently discovered family of proteins associated with self-incompatibility and self/nonself recognition in Papaver rhoeas (common poppy) with suggested conserved downstream mechanisms among eudicots. CONCLUSIONS: Further work is necessary to confirm the self-incompatibility mechanisms in cultivated H. annuus and their relationship to the integrative and polygenic architecture of leaf ecophysiology and specialized metabolism in cultivated sunflower. However, because self-compatibility is a derived quantitative trait in cultivated H. annuus, trait linkage to divergent phenotypic traits may have partially arisen as a potential unintended consequence of historical breeding practices and selection for yield.

Ethical Considerations in the Management of Orthopedic Surgery Waste: Balancing Environmental Protection and Participant Safety.

The healthcare sector significantly contributes to global greenhouse gas (GHG) emissions, with orthopedic surgery generating substantial waste, including single-use devices and hazardous materials. These practices exacerbate climate change and environmental degradation. This article explores the environmental and ethical implications of waste management in orthopedic surgery, focusing on the need for sustainable practices. Key approaches include recycling and reusing materials, implementing closed-loop supply chains, and promoting sustainable procurement. Case studies from various countries, such as Asia (India, Pakistan, Bangladesh), Africa, and Latin America, highlight the challenges and progress in managing medical waste, emphasizing the substantial potential for recycling preoperative waste. Ethical considerations revolve around ensuring safe waste handling to protect healthcare workers, patients, and communities while maintaining high standards of care. This should be done as per infection control and biomedical waste protocols. National and international ethical guidelines extend their discussion to the principles of biomedical and health ethics (autonomy, beneficence, non-maleficence, and justice), especially regarding informed consent and the reuse of medical devices. Patients should be fully informed about environmental and waste management practices, with an emphasis on transparency and voluntary participation. The reuse of external fixators, while cost-effective, raises questions about ownership, safety, and cost transparency. The article underscores the importance of adopting eco-friendly practices and green technologies in healthcare to mitigate the sector's carbon footprint. Initiatives such as energy-efficient buildings, renewable energy sources, and comprehensive recycling programs are vital. The conclusion calls for regulatory bodies and healthcare organizations to enforce guidelines for ethical waste management, balancing cost-effective practices with patient autonomy and environmental responsibility. Ethical waste management in orthopedic surgery is crucial for protecting the environment and the service providers and ensuring the well-being of all stakeholders involved.

Multidisciplinary Management of Morbidities Associated with Chronic Graft-Versus-Host Disease.

Chronic graft-versus-host disease (cGVHD) represents a common long-term complication after allogeneic hematopoietic stem cell transplantation (HSCT). It imposes a significant morbidity burden and is the leading cause of non-relapse mortality among long-term HSCT survivors. cGVHD can manifest in nearly any organ, severely affecting the quality of life of a transplant survivor. While the mainstay of treatment has remained systemic immunosuppression with glucocorticoids, progress has been made within the last few years with approvals of three oral agents to treat steroid-refractory cGVHD: ibrutinib, ruxolitinib, and belumosudil. Iatrogenesis contributes a significant portion of the morbidity experienced by patients with cGVHD, primarily from glucocorticoids. This review highlights the myriad impacts of cGVHD, including and beyond the traditional organ systems captured by the National Institutes of Health Consensus Criteria, including iatrogenic complications of long-term immunosuppression. It presents the implications of cGVHD and its treatment on cardiovascular and metabolic health, bone density, endocrine function, sexual health, and ocular and pulmonary disease and outlines a framework around the comprehensive multidisciplinary approach for its evaluation and management.

Inferior Shoulder Dislocation: A Report of Three Cases Reduced Using the 'Two-Step Manoeuvre'.

Inferior shoulder dislocations are uncommon, accounting for a very small percentage of all shoulder dislocations. A reduction technique has been developed which involves a two-step process: the first involves converting the inferior dislocation into an anterior one and the second involves reducing the humeral head back into its anatomical position within the glenohumeral joint. Traditional methods, such as the overhead traction-counter traction technique, often require multiple attempts, the involvement of several medical professionals, and the use of significant sedation and analgesia, which can be more intensive for the patient. Inferior dislocations that are positioned beneath the coracoid process present a particular challenge. Although they might seem suitable for reduction using methods typically applied for anterior dislocations, their positioning is often too inferior for these techniques to be effective. This two-step reduction technique has been utilised successfully in sub-coracoid and sub-glenoid inferior shoulder dislocations. The method has proven advantageous as a single practitioner can perform it, usually requires only one attempt, involves minimal force, and can be done under conscious sedation. These benefits make it a valuable alternative to traditional approaches for reducing inferior shoulder dislocations.

Hair Today, OR Tomorrow: A Multicenter Case Series of Gastric Bezoars in Children Diagnosed With Point-of-Care Ultrasound.

ABSTRACT: Point-of-care ultrasound (POCUS) can expedite the diagnosis of pediatric abdominal pathologies including appendicitis and intussusception. In this patient series, we present cases from multiple pediatric emergency departments that demonstrate the use of POCUS in the diagnosis of trichobezoars in children. POCUS findings include the presence of an intragastric hyperechoic mass or a hyperechoic arch and associated posterior acoustic shadowing. These findings in the appropriate clinical context should prompt further diagnostic imaging and/or surgical consultation for removal.

From Pregnancy Pains to Paralysis: An Erroneous Intrathecal Digoxin Administration Case Report and Review of Medical Errors.

Digoxin is a Na-K ATPase inhibitor commonly used to treat heart failure and atrial fibrillation. It is only approved for oral or intravenous (IV) use. There is no approved indication for intrathecal administration. Only four previously reported cases of intrathecal digoxin administration in pregnant patients are in the literature. We present a patient who had an unfortunate case of erroneous intrathecal Digoxin administration following an elective Cesarean section. Post-delivery, the patient's mental status deteriorated. She became unresponsive and remained comatose for 11 days. Brain magnetic resonance imaging (MRI) showed diffuse, patchy hyperintensities involving bilateral frontotemporal lobes and basal ganglia. A spine MRI showed extensive cervical and thoracic cord edema. At discharge, the patient was paraplegic with no sensation or motor response below the level of T10. At the 90-day follow-up, she had intact mental status and minimal improvement in motor strength and sensation below T10 and was reportedly breastfeeding. This is an unfortunate case of severe neurological deficits resulting from a grave medical error, which continues to be a prevalent issue in the United States healthcare system.

Lung Ultrasound Score for Prediction of Surfactant Administration in Preterm Infants with Respiratory Failure.

OBJECTIVE: We investigated the predictive value of a lung ultrasound score (LUS) for surfactant administration in a United States Level 4 Neonatal Intensive Care Unit. STUDY DESIGN: Thirty infants born at <37 weeks gestational age with respiratory distress syndrome associated respiratory failure requiring continuous positive airway pressure were included. A LUS was obtained within six hours of life. Surfactant administration in the first five days of life was recorded. Receiver operating characteristic (ROC) analysis for LUS and surfactant administration was performed. RESULTS: Median completed gestational age was 33 weeks (31-34 weeks interquartile range) and median birth weight was 2.0 kg (1.5-2.3 kg). LUS for predicting an initial surfactant dose had an area under the ROC curve of 0.97. A score > 9 provided 100% sensitivity and 91% specificity for predicting administration of an initial surfactant dose. CONCLUSION: A LUS > 9 provided excellent sensitivity and specificity for predicting which infants will receive surfactant for associated respiratory failure.

Value of Dual Arterial Access for Improved Angiographic Control for Double-Lumen Arterial Balloon Onyx Embolization of Multifeeder Complex Cranial Dural Arteriovenous Fistulas: A Technical Nuance.

BACKGROUND: Here we describe our experience managing intracranial dural arteriovenous fistulas (DAVFs) via endovascular embolization using a transarterial embolization (TAE) technique with liquid embolic agents. We illustrate the technical nuance of using dual arterial access for angiographic control runs in complex DAVFs supplied by multiple feeders from 2 distinct arterial systems. METHODS: Retrospective analysis of intracranial DAVF embolization as a single treatment technique at our institution from 2013 to 2023. RESULTS: Twenty-three patients with intracranial DAVF who underwent endovascular treatment as their initial treatment were included. All embolizations were approached transarterially with Onyx (n = 19), n-butyl cyanoacrylate (n = 2), or a combination (n = 2). Twenty-two patients (96%) had angiographic evidence of complete fistula obliteration after initial embolization. Six DAVF TAEs were performed with dual arterial access for simultaneous embolic delivery and angiographic control intraoperatively. Two patients recanalized twice postprocedure, 1 of whom was found to have incidental new DAVF at follow-up. Median patient follow-up was 12 months (interquartile range, 6-36 months), with a median modified Rankin Scale score on discharge of 1 and a Glasgow Outcome Scale score at 3 months of 5. CONCLUSIONS: In this initial series of patients with DAVF managed by endovascular embolization, dual arterial access was feasible, safe, and effective in achieving fistula obliteration. Dual-arterial access conveniently provides simultaneous access for control angiography and embosylate delivery intraoperatively.

Comparative Evaluation of the Accuracy of Dynamic Navigation and Free Hand Methods During Zygomatic Implant Placement: A Randomized Controlled Trial.

To assess and compare the precision and predictability of zygomatic implants in atrophic maxilla using conventional and dynamic navigation methods. This study was a randomized controlled clinical trial conducted in patients requiring zygomatic implant placements in the atrophic maxilla. Forty zygomatic implants were placed in systemically healthy individuals. Zygomatic implant placement was done using the freehand technique in the control group, and the test group involved implant placement using a dynamic navigation system, and the entry, apex, and angular deviations were evaluated. The mean deviations at the site of entry (2D) in the navigation system (2.531.42) as compared with the freehand (4.151.29) were statistically significant. The variation in the freehand group was greater than the navigation method at the apex (3D) (P < .05). The navigation method had a higher accuracy in angular deviation than the freehand method (4.02 ± 1.80 and 12.67 ± 2.11). Also, the accuracy was checked on the right and left sides in both the conventional and dynamic groups. The dynamic navigation technology had better predictability in terms of accuracy and precision, and it is the need of the hour for clinicians to master this technology and thereby aid in better prognostic level of implant placements.

MDA5-autoimmunity and interstitial pneumonitis contemporaneous with the COVID-19 pandemic (MIP-C).

BACKGROUND: Anti-MDA5 (Melanoma differentiation-associated protein-5) positive dermatomyositis (MDA5+-DM) is characterised by rapidly progressive interstitial lung disease (ILD) and high mortality. MDA5 is an RNA sensor and a key pattern recognition receptor for the SARS-CoV-2 virus. METHODS: This is a retrospective observational study of a surge in MDA5 autoimmunity, as determined using a 15 muscle-specific autoantibodies (MSAs) panel, between Janurary 2018 and December 2022 in Yorkshire, UK. MDA5-positivity was correlated with clinical features and outcome, and regional SARS-CoV-2 positivity and vaccination rates. Gene expression patterns in COVID-19 were compared with autoimmune lung disease and idiopathic pulmonary fibrosis (IPF) to gain clues into the genesis of the observed MDA5+-DM outbreak. FINDINGS: Sixty new anti-MDA5+, but not other MSAs surged between 2020 and 2022, increasing from 0.4% in 2019 to 2.1% (2020), 4.8% (2021) and 1.7% (2022). Few (8/60) had a prior history of confirmed COVID-19, peak rates overlapped with regional SARS-COV-2 community positivity rates in 2021, and 58% (35/60) had received anti-SARS-CoV-2 vaccines. 25/60 cases developed ILD which rapidly progression with death in 8 cases. Among the 35/60 non-ILD cases, 14 had myositis, 17 Raynaud phenomena and 10 had dermatomyositis spectrum rashes. Transcriptomic studies showed strong IFIH1 (gene encoding for MDA5) induction in COVID-19 and autoimmune-ILD, but not IPF, and IFIH1 strongly correlated with an IL-15-centric type-1 interferon response and an activated CD8+ T cell signature that is an immunologic hallmark of progressive ILD in the setting of systemic autoimmune rheumatic diseases. The IFIH1 rs1990760TT variant blunted such response. INTERPRETATION: A distinct pattern of MDA5-autoimmunity cases surged contemporaneously with circulation of the SARS-COV-2 virus during COVID-19. Bioinformatic insights suggest a shared immunopathology with known autoimmune lung disease mechanisms. FUNDING: This work was supported in part by the National Institute for Health Research (NIHR) Leeds Biomedical Research Centre (BRC), and in part by the National Institutes of Health (NIH) grant R01-AI155696 and pilot awards from the UC Office of the President (UCOP)-RGPO (R00RG2628, R00RG2642 and R01RG3780) to P.G. S.S was supported in part by R01-AI141630 (to P.G) and in part through funds from the American Association of Immunologists (AAI) Intersect Fellowship Program for Computational Scientists and Immunologists.

The Risk of Adhesive Bowel Obstruction in Children With Appendicitis: A Systematic Review.

OBJECTIVE: Complicated appendicitis is associated with a higher risk of postoperative complications, including adhesive bowel obstruction. The aim of this meta-analysis is to investigate the difference in rates of postoperative bowel obstruction in paediatric patients with complicated versus simple appendicitis and whether this is influenced by the surgical approach. METHODS: A systematic literature search following PRISMA guidelines was conducted using MEDLINE, Embase and Cochrane Library for studies that analysed incidence of adhesive bowel obstruction in paediatric patients after appendicectomy. Studies from 1998 to 2022 were included in analysis. The study protocol was registered on PROSPERO (ID CRD42022309769). RESULTS: Pooled analysis of 6 studies with low risk of bias and adequate follow up periods, considering 58,962 cases of appendicectomy, revealed complex appendicitis was associated with a near two-fold increase in incidence of SBO (pooled odds ratio 2.02 (95% CI 1.35-2.69)). Interestingly, a similar pooled analysis of 10 studies, considering 62,433 cases of appendicectomy, revealed no significant difference between open and laparoscopic management of complex appendicitis (pooled odds ratio 0.93 (95% CI 0.24 to 1.62)). CONCLUSION: Complex appendicitis is associated with a two-fold increase in the rates of adhesive bowel obstruction. Whilst there are cosmetic advantages of a laparoscopic approach, surgical expertise should be favoured in decision making relating to surgical approach (laparoscopic versus open) as the evidence for a laparoscopic approach reducing risks of adhesive bowel obstruction is not convincing. LEVEL OF EVIDENCE: Level II.

Interactions between integrin α9ß1 and VCAM-1 promote neutrophil hyperactivation and mediate poststroke DVT.

ABSTRACT: Venous thromboembolic events are significant contributors to morbidity and mortality in patients with stroke. Neutrophils are among the first cells in the blood to respond to stroke and are known to promote deep vein thrombosis (DVT). Integrin α9 is a transmembrane glycoprotein highly expressed on neutrophils and stabilizes neutrophil adhesion to activated endothelium via vascular cell adhesion molecule 1 (VCAM-1). Nevertheless, the causative role of neutrophil integrin α9 in poststroke DVT remains unknown. Here, we found higher neutrophil integrin α9 and plasma VCAM-1 levels in humans and mice with stroke. Using mice with embolic stroke, we observed enhanced DVT severity in a novel model of poststroke DVT. Neutrophil-specific integrin α9-deficient mice (α9fl/flMrp8Cre+/-) exhibited a significant reduction in poststroke DVT severity along with decreased neutrophils and citrullinated histone H3 in thrombi. Unbiased transcriptomics indicated that α9/VCAM-1 interactions induced pathways related to neutrophil inflammation, exocytosis, NF-κB signaling, and chemotaxis. Mechanistic studies revealed that integrin α9/VCAM-1 interactions mediate neutrophil adhesion at the venous shear rate, promote neutrophil hyperactivation, increase phosphorylation of extracellular signal-regulated kinase, and induce endothelial cell apoptosis. Using pharmacogenomic profiling, virtual screening, and in vitro assays, we identified macitentan as a potent inhibitor of integrin α9/VCAM-1 interactions and neutrophil adhesion to activated endothelial cells. Macitentan reduced DVT severity in control mice with and without stroke, but not in α9fl/flMrp8Cre+/- mice, suggesting that macitentan improves DVT outcomes by inhibiting neutrophil integrin α9. Collectively, we uncovered a previously unrecognized and critical pathway involving the α9/VCAM-1 axis in neutrophil hyperactivation and DVT.

Bailout Options for Intra-operative Implant and Instrumentation Related Incidents and Complications During Arthroscopic Knee Surgery-A Retrospective Study.

Background: Arthroscopic knee procedures are one amongst the common surgical interventions for problems in the knee. It is technically more demanding than an open procedure and is associated with several potential complications. During arthroscopy procedures, several technical challenges may arise, and even experienced surgeons may encounter new issues. However, careful attention to the surgical technique can help prevent or resolve them. Methodology: The study was conducted on all patients who underwent knee arthroscopy procedure during study period. We recorded details of the implants used and any unexpected situations related to them, as well as how they were managed. Instrumentation-related parameters such as screwdriver issues, radiofrequency ablator issues, scope damages, shaver complications, probe complications, and meniscus suture passing devices were also assessed. Results: In total, there were 12 (3.73%) implant and instrument-related incidents and complications, of which 5 (1.55%) were implant-related and 7 (2.17%) were instrument related. Among the instrumentation-related incidents and complications, two (0.62%) were screwdriver breakage incidents, two (0.62%) were radiofrequency ablator-related incidents, one was arthroscopic probe (0.31%) related incident, one (0.31%) was meniscus suture passing device related complication and one (0.31%) was arthroscope related incident. Conclusion: Surgeons must be ready to anticipate and effectively manage any technical difficulties that may arise during the procedure, maintaining composure in the face of unexpected challenges and guiding the team. In most cases, incidents can be addressed intra operatively and may not have long-term effects on patient outcomes. It is crucial to have multiple implant and instrument backup options available for successful surgery.

Mid-term Results of Total Hip Arthroplasty for Posttraumatic Osteoarthritis after Acetabular Fracture.

Purpose: The prognosis of total hip replacement (THR) after open reduction and internal fixation (ORIF) versus THR following non-operative treatment of acetabular fractures is unclear. Few studies have been conducted in this regard. Therefore, the purpose of the current study was to perform an assessment and compare the functional outcomes for study subjects in the ORIF and non-ORIF groups during the follow-up period compared to baseline. Materials and Methods: This longitudinal comparative study, which included 40 patients who underwent THR for either posttraumatic arthritis after fixation of an acetabular fracture or arthritis following conservative management of a fracture, was conducted for 60 months. Twenty-four patients had undergone ORIF, and 16 patients had undergone nonoperative/conservative management for acetabular fractures. Following THR, the patients were followed up for monitoring of functional outcomes for the Harris hip score (HHS) and comparison between the ORIF and non-ORIF groups was performed. Results: The HHS showed significant improvement in both ORIF and non-ORIF groups. At the end of the mean follow-up period, no significant variation in scores was observed between the groups, i.e., ORIF group (91.61±6.64) compared to non-ORIF group (85.74±11.56). A significantly higher number of re-interventions were required for medial wall fractures and combined fractures compared to posterior fractures (P<0.05). Conclusion: THR resulted in improved functional outcome during follow-up in both the groups; however, the ORIF group was observed to have better functional outcome. Re-intervention was not required for any of the posterior fractures at the end of the mean follow-up period.

Can ChatGPT help patients answer their otolaryngology questions?

Background: Over the past year, the world has been captivated by the potential of artificial intelligence (AI). The appetite for AI in science, specifically healthcare is huge. It is imperative to understand the credibility of large language models in assisting the public in medical queries. Objective: To evaluate the ability of ChatGPT to provide reasonably accurate answers to public queries within the domain of Otolaryngology. Methods: Two board-certified otolaryngologists (HZ, RS) inputted 30 text-based patient queries into the ChatGPT-3.5 model. ChatGPT responses were rated by physicians on a scale (accurate, partially accurate, incorrect), while a similar 3-point scale involving confidence was given to layperson reviewers. Demographic data involving gender and education level was recorded for the public reviewers. Inter-rater agreement percentage was based on binomial distribution for calculating the 95% confidence intervals and performing significance tests. Statistical significance was defined as p < .05 for two-sided tests. Results: In testing patient queries, both Otolaryngology physicians found that ChatGPT answered 98.3% of questions correctly, but only 79.8% (range 51.7%-100%) of patients were confident that the AI model was accurate in its responses (corrected agreement = 0.682; p < .001). Among the layperson responses, the corrected coefficient was of moderate agreement (0.571; p < .001). No correlation was noted among age, gender, or education level for the layperson responses. Conclusion: ChatGPT is highly accurate in responding to questions posed by the public with regards to Otolaryngology from a physician standpoint. Public reviewers were not fully confident in believing the AI model, with subjective concerns related to less trust in AI answers compared to physician explanation. Larger evaluations with a representative public sample and broader medical questions should immediately be conducted by appropriate organizations, governing bodies, and/or governmental agencies to instill public confidence in AI and ChatGPT as a medical resource. Level of Evidence: 4.

Cellular Senescence Program is Sensitive to Physical Differences in Polymeric Tissue Scaffolds.

A typical cellular senescence program involves exposing cells to DNA-damaging agents such as ionization radiation or chemotherapeutic drugs, which cause multipronged changes, including increased cell size and volume, the onset of enhanced oxidative stress, and inflammation. In the present study, we examined if the senescence onset decision is sensitive to the design, porosity, and architecture of the substrate. To address this, we generated a library of polymeric scaffolds widely used in tissue engineering of varied stiffness, architecture, and porosity. Using irradiated A549 lung cancer cells, we examined the differences between cellular responses in these 3D scaffold systems and observed that senescence onset is equally diminished. When compared to the two-dimensional (2D) culture formats, there were profound changes in cell size and senescence induction in three-dimensional (3D) scaffolds. We further establish that these observed differences in the senescence state can be attributed to the altered cell spreading and cellular interactions on these substrates. This study elucidates the role of scaffold architecture in the cellular senescence program.

Pediatric Airway Balloon Dilation: Urge for Safety Redesign.

Airway balloons are widely used by otolaryngologists to treat laryngotracheal stenosis. We review an adverse event and interventions that may prevent similar occurrences. There are no other reports of similar incidents in the Food and Drug Administration Manufacturer and User Facility Device Experience. We implore Acclarent to redesign their airway balloon device to prevent accidental airway irrigation.

The use of artificial dermal substitutes for repair of the donor site following harvesting of a radial forearm free flap: A systematic review.

BACKGROUND: Artificial dermal substitutes (ADMs) have been trialled to improve outcomes at the donor site following the harvesting of a radial forearm free flap (RFFF). This systematic review compares donor site aesthetic and functional outcomes, with the use of an ADM versus conventional practice. METHODS: The databases Medline, Embase, Cochrane Library, Web of Science (Core Collection), and Scopus were searched for retrospective, prospective, and case-control studies and randomised control trials (RCTs) involving any ADM. Studies with adult patients having undergone RFFF harvesting and donor site repair with an ADM, commenting on appropriate clinical outcomes and without high risk of bias, were included. Direction-of-effect analysis was performed on relevant groupings of studies since heterogeneity in outcome measurement precluded meta-analyses. RESULTS: Across eight non-comparative studies included, 132 patients had donor site coverage with AlloDerm™, Integra™, Matriderm™, or Rapiderm. Across 11 comparative studies included, 240 patients had donor site coverage with fish-skin matrix, AlloDerm™, amniotic membrane, MegaDerm™, Hyalomatrix, Integra™, or Matriderm™. Five out of 11 comparative studies demonstrated superior aesthetic outcomes with ADMs according to at least one aesthetic metric compared to controls, whilst 6/11 demonstrated superior functional outcomes with ADMs. No study demonstrated poorer aesthetic or functional outcomes with an ADM compared to conventional practice. CONCLUSIONS: In summary, the lack of studies reporting poorer outcomes with them compared to conventional practices, and a cumulative effect direction in their favour, provide strong indications in support of the use of AlloDerm™, Integra™, or Matriderm™ grafts. Further comparative studies, including RCTs, are needed to reinforce these initial indications.