Naringenin chalcone carbon double-bond reductases mediate dihydrochalcone biosynthesis in apple leaves.

Dihydrochalcones (DHCs) are flavonoids produced as a side branch of the phenylpropanoid pathway. DHCs are found at high concentrations in apples (Malus spp.) but not in pears (Pyrus spp.) or other members of the Rosaceae. Biosynthesis of DHCs in apple has been hypothesized to occur via reduction of p-coumaroyl CoA by a Malus × domestica hydroxycinnamoyl CoA double-bond reductase (MdHCDBR) followed by the action chalcone synthase to produce phloretin or via direct reduction of naringenin chalcone to phloretin via an unknown enzyme. In this study, we report that genetic downregulation of MdHCDBR does not reduce DHC concentrations in apple leaves. We used comparative transcriptome analysis to identify candidate naringenin chalcone reductases (NCRs), designated MdNCR1a-c, expressed in apple leaves but not fruit. These MdNCR1 genes form an expanded gene cluster found exclusively in apple. Transient expression of MdNCR1 genes in Nicotiana benthamiana leaves indicated they produced DHCs at high concentrations in planta. Recombinant MdNCR1 utilized naringenin chalcone to produce phloretin at high efficiency. Downregulation of NCR genes in transgenic apple reduced foliar DHC levels by 85-95%. Reducing DHC production redirected flux to the production of flavonol glycosides. In situ localization indicated that NCR proteins were likely found in the vacuolar membrane. Active site analysis of AlphaFold models indicated that MdNCR1a-c share identical substrate binding pockets, but the pockets differ substantially in related weakly active/inactive NCR proteins. Identifying the missing enzyme required for DHC production provides opportunities to manipulate DHC content in apple and other fruits and has other applications, e.g., in biofermentation and biopharming.

Active crocodiles are less sociable.

How animals move and associate with conspecifics is rarely random, with a population's spatial structure forming the foundation on which the social behaviours of individuals form. Studies examining the spatial-social interface typically measure averaged behavioural differences between individuals; however, this neglects the inherent variation present within individuals and how it may impact the spatial-social interface. Here, we investigated differences in among-individual (co)variance in sociability, activity and site fidelity in a population of wild estuarine crocodiles, Crocodylus porosus, across a 10-year period. By monitoring 118 crocodiles using coded acoustic transmitters and an array of fixed underwater receivers, we discovered that not only did individual crocodiles repeatably differ (among-individual variation) in each behaviour measured but also in how consistently they expressed these behaviours through time (within-individual variation). As expected, crocodile activity and sociability formed a behavioural syndrome, with more active individuals being less sociable. Interestingly, we also found that individuals that were either more sociable or displayed greater site fidelity were also more specialized (lower within-individual variation) in these behaviours. Together, our results provide important empirical evidence for the interplay between spatial, temporal and social individual-level behavioural variation and how these contribute to forming behavioural niches. This article is part of the theme issue 'The spatial-social interface: a theoretical and empirical integration'.

Feeding frequency can affect the morphology of reproductive tract in broiler breeder hens.

This study examined the influence of feeding frequency on the morphology of the reproductive tract in broiler breeder hens, with a focus on the liver, ovary, and oviduct. A total of 364 hens and 52 roosters, starting at 31 wk of age and continuing until the end of their 38th week, were divided into 13 groups with varying feeding frequencies (1, 2, or 3 times daily). Significant changes in reproductive and metabolic parameters were observed, where feeding hens twice or thrice daily resulted in significantly reduced ovary weight and follicle counts (P < 0.001), while liver weight increased (P < 0.05). These findings suggesting complex interactions between feeding practices and reproductive efficiency.

Cytoskeleton Organization in Formation and Motility of Apicomplexan Parasites.

Apicomplexan parasites are a group of eukaryotic protozoans with diverse biology that have affected human health like no other group of parasites. These obligate intracellular parasites rely on their cytoskeletal structures for giving them form, enabling them to replicate in unique ways and to migrate across tissue barriers. Recent progress in transgenesis and imaging tools allowed detailed insights into the components making up and regulating the actin and microtubule cytoskeleton as well as the alveolate-specific intermediate filament-like cytoskeletal network. These studies revealed interesting details that deviate from the cell biology of canonical model organisms. Here we review the latest developments in the field and point to a number of open questions covering the most experimentally tractable parasites: Plasmodium, the causative agent of malaria; Toxoplasma gondii, the causative agent of toxoplasmosis; and Cryptosporidium, a major cause of diarrhea.

Patient and Caregiver Engagement in an Era of COVID-19: What Did We Learn and How Do We Move Forward?

Patient and caregiver engagement is a core component of high-quality healthcare systems. The COVID-19 pandemic revealed to us the fragility of patient and family engagement that was not as firmly rooted in the health system as expected. In this paper, we reflect on case examples from healthcare organizations across Canada where pivots and adaptations were made to patient engagement activities. We share core enablers of engagement in times of high system stress, drawing on illustrative examples. We then synthesize key learnings in relation to existing literature and conclude with reflective questions as we orient the work of engagement into the future.

Creating a Sustaining Culture for Patient Engagement.

Engagement-capable environments enable strategies and processes supporting patient engagement. However, research using this framework has not fully explored how leaders can help to shape organizational cultures that sustain engagement over time, even during crises such as the COVID-19 pandemic. Using interviews and documents from the Holland Bloorview Kids Rehabilitation Hospital in Toronto, ON, prior to and after the pandemic, we examine the maturation of their engagement practices and culture to illustrate how a supportive culture developed and shaped their responses to this crisis. Further exploration of such dynamics could inform leaders designing engagement strategies with greater impact and sustainment.

Beyond the Crisis: Transforming Health Systems Through Community Engagement.

How can we effectively partner during crises? How can partnership with communities, patients, caregivers, providers and leaders be sustained and even evolve during difficult times? The opening paper of this special issue (Kuluski et al. 2024) probed these questions. The six response papers in this issue emphasized engagement that moves from partnership with individuals and communities to efforts that are led by communities; trauma-informed approaches at an individual and organizational level; and shed light on the interdependency of culture and leadership. By broadening our engagement efforts with communities, we are more apt to co-produce improvements in care that also address the social determinants of health.

Effects of climate warming on energetics and habitat of the world's largest marine ectotherm.

Responses of organisms to climate warming are variable and complex. Effects on species distributions are already evident and mean global surface ocean temperatures are likely to warm by up to 4.1 °C by 2100, substantially impacting the physiology and distributions of ectotherms. The largest marine ectotherm, the whale shark Rhincodon typus, broadly prefers sea surface temperatures (SST) ranging from 23 to 30 °C. Whole-species distribution models have projected a poleward range shift under future scenarios of climate change, but these models do not consider intraspecific variation or phenotypic plasticity in thermal limits when modelling species responses, and the impact of climate warming on the energetic requirements of whale sharks is unknown. Using a dataset of 111 whale shark movement tracks from aggregation sites in five countries across the Indian Ocean and the latest Earth-system modelling produced from Coupled Model Intercomparison Project Phase 6 for the Intergovernmental Panel on Climate Change, we examined how SST and total zooplankton biomass, their main food source, may change in the future, and what this means for the energetic balance and extent of suitable habitat for whale sharks. Earth System Models, under three Shared Socioeconomic Pathways (SSPs; SSP1-2.6, SSP3-7.0 and SSP5-8.5), project that by 2100 mean SST in four regions where whale shark aggregations are found will increase by up to 4.9 °C relative to the present, while zooplankton biomass will decrease. This reduction in zooplankton is projected to be accompanied by an increase in the energetic requirements of whale sharks because warmer water temperatures will increase their metabolic rate. We found marked differences in projected changes in the extent of suitable habitat when comparing a whole-species distribution model to one including regional variation. This suggests that the conventional approach of combining data from different regions within a species' distribution could underestimate the amount of local adaptation in populations, although parameterising local models could also suffer from having insufficient data and lead to model mis-specification or highly uncertain estimates. Our study highlights the need for further research into whale shark thermal tolerances and energetics, the complexities involved in projecting species responses to climate change, and the potential importance of considering intraspecific variation when building species distribution models.

Diabetic Neuropathy: A Guide to Pain Management.

PURPOSE OF REVIEW: Diabetic neuropathy is a common complication of diabetes mellitus (DM) and can affect up to 50% of DM patients during their lifetime. Patients typically present with numbness, tingling, pain, and loss of sensation in the extremities. Since there is no treatment targeting the underlying mechanism of neuropathy, strategies focus on preventative care and pain management. RECENT FINDINGS: Up to 69% of patients with diabetic neuropathy receive pharmacological treatment for neuropathic pain. The United States Food and Drug Administration (FDA) confirmed four drugs for painful diabetic neuropathy (PDN): pregabalin, duloxetine, tapentadol, and the 8% capsaicin patch. Nonpharmacological treatments such as spinal cord stimulation (SCS) and transcutaneous electrical nerve stimulation (TENS) both show promise in reducing pain in DM patients. Despite the high burden associated with PDN, effective management remains challenging. This update covers the background and management of diabetic neuropathy, including its epidemiology, pathogenesis, preventative care, and current therapeutic strategies.

Effect of trauma on asylum seekers and refugees receiving a WHO psychological intervention: a mediation model.

Background: Scalable psychological interventions such as the WHO's Self-Help Plus (SH+) have been developed for clinical and non-clinical populations in need of psychological support. SH+ has been successfully implemented to prevent common mental disorders among asylum seekers and refugees who are growing in number due to increasing levels of forced migration. These populations are often exposed to multiple, severe sources of traumatisation, and evidence of the effect of such events on treatment is insufficient, especially for non-clinical populations.Objective: We aim to study the effect of potentially traumatic experiences (PTEs) and the mediating role of symptoms of posttraumatic stress disorder (PTSD) on the improvement following SH+.Method: Participants allocated to SH+ who received at least three sessions (N = 345) were extracted from two large, randomised, European prevention trials involving asylum seekers and refugees. Measures of distress, depression, functional impairment, and post-traumatic stress symptoms were administered at baseline and 6 months post-intervention, together with measures of well-being and quality of life. Adjusted models were constructed to examine the effect of PTEs on post-intervention improvement. The possible mediating role of PTSD symptoms in this relationship was then tested.Results: Increasing numbers of PTEs decreased the beneficial effect of SH+ for all measures. This relationship was mediated by symptoms of PTSD when analysing measures of well-being and quality of life. However, this did not apply for measures of mental health problems.Conclusions: Exposure to PTEs may largely reduce benefits from SH+. PTSD symptomatology plays a specific, mediating role on psychological well-being and quality of life of participants who experienced PTE. Healthcare professionals and researchers should consider the role of PTEs and PTSD symptoms in the treatment of migrants and refugees and explore possible feasible add-on solutions for cases exposed to multiple PTEs.

Increasing numbers of potentially traumatic experiences can decrease the beneficial effect of a manualized group psychotherapeutic intervention in migrants and refugees across multiple countries.In absence of a full threshold diagnosis of post-traumatic stress disorder, post-traumatic stress symptoms still mediate the relation between potentially traumatic experiences and some outcome improvements at follow-up.While the moderating role of number of potentially traumatic experiences applies to all outcomes (depression symptoms, psychological distress, functional impairment, well-being, and quality of life), the mediating role of post-traumatic stress symptoms in this relation only applies to well-being and quality of life.

Extracorporeal Femoro-Carotid Shunt for Transcarotid Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement may be performed with a transcarotid approach when peripheral vascular disease is prohibitive for transfemoral access. In this case, a patient who presented in cardiogenic shock secondary to severe aortic stenosis developed electroencephalographic changes during transcarotid TAVR. A temporary extracorporeal femoro-carotid shunt permitted successful TAVR.

The Prevalence of Hospitalized Parkinson's Disease Patients in All Case Hospitalization among Different Race/Ethnic Subgroups in Hawaii.

Background: Little is known about the epidemiology of Parkinson's disease (PD) patients in Native Hawaiian Or Other Pacific Islander (NHPI) and Asian American (AA) subgroups. Objective: To determine if the prevalence of hospitalized PD patients is different across age groups and racial/ethnic subgroups in Hawaii. Methods: We conducted a retrospective analysis of Hawaii statewide registry (2016-2020) hospitalization data for patients who were 50 years or older. PD patients were identified using an ICD 10 code: Parkinson's Disease (G20) as their primary/secondary hospitalization discharge diagnosis code. Demographic and clinical characteristics among racial/ethnic subgroups (White, Japanese, Filipino, Chinese, NHPI, or Other) were compared. Results: Of 146,844 total hospitalized patients (n = 429,879 records), 1.6% (n = 2,401) had a PD diagnosis. The prevalence of hospitalized PD patients was 2.3% among Japanese and Chinese, followed by 1.7% for Whites, 1.2% for Filipinos and was lowest for NHPI with 0.9% (p < 0.001). As patient's age increased, the prevalence of hospitalized PD patients increased, with 80-84 years old for the highest age range (3.4%). The prevalence of hospitalized PD patients at 80-84 years old varied across the race/ethnic subgroups (Chinese 4.3%, Japanese 4.0%, Whites 3.7%, Filipinos 2.5%, NHPI 2.3%). Conclusions: The prevalence of hospitalized PD patients among all case hospitalizations were lower for NHPI and Filipino compared to that of Japanese, Chinese, and Whites. As patients' age increased, the prevalence of hospitalized patients with PD increased, but less so in NHPI and Filipino groups. Further research is warranted to understand the reason for these observed differences among racial/ethnic subgroups.

Ethnic density and first episode psychosis in the British Pakistani population: findings from the East Lancashire Early Intervention Service.

BACKGROUND: Elevated risk of psychosis for ethnic minority groups has generally been shown to be mitigated by high ethnic density. However, past survey studies examining UK Pakistani populations have shown an absence of protective ethnic density effects, which is not observed in other South Asian groups. AIMS: To assess the ethnic density effect at a local neighbourhood level, in the UK Pakistani population in East Lancashire. METHOD: Data was collected by the East Lancashire Early Intervention Service, identifying all cases of first episode psychosis (FEP) within their catchment area between 2012 and 2020. Multilevel Poisson regression analyses were used to compare incidence rates between Pakistani and White majority groups, while controlling for age, gender and area-level deprivation. The ethnic density effect was also examined by comparing incidence rates across high and low density areas. RESULTS: A total of 455 cases of FEP (364 White, 91 Pakistani) were identified. The Pakistani group had a higher incidence of FEP compared to the White majority population. A clear effect of ethnic density on rates of FEP was shown, with those in low density areas having higher incidence rates compared to the White majority, whereas incidence rates in high density areas did not significantly differ. Within the Pakistani group, a dose-response effect was also observed, with risk of FEP increasing incrementally as ethnic density decreased. CONCLUSIONS: Higher ethnic density related to lower risk of FEP within the Pakistani population in East Lancashire, highlighting the impact of local social context on psychosis incidence.

Identifying core global mental health professional competencies: A multi-sectoral perspective.

Concerned with sustainably alleviating mental distress and promoting the right to health worldwide, global mental health (GMH) is practised across various contexts spanning the humanitarian-development-peace nexus. The inherently intersectoral and multidisciplinary nature of GMH calls for competency frameworks and training programmes that embody diversity, decolonisation and multiprofessionalism. Existing competency frameworks have failed to capture the multi-sectoral, inter-professional nature of contemporary GMH practice. In response to these needs, a qualitative content analysis of relevant job advertisements was conducted to distil a comprehensive set of professional competencies in contemporary GMH practice. Approximately 200 distinct skills and competencies were extracted from 70 job advertisements and organised into four meta-dimensions: 'skills', 'sector', 'self' and 'subject'. The first known systematic attempt at a multi-sectoral GMH competency framework, it offers a springboard for exploring vital yet overlooked professional competencies such as resilience, self-reflection, political skills and entrepreneurialism. On this basis, recommendations for building a competent, agile and effective GMH workforce with diversified and future-proof skillsets are proposed. The framework can also inform inter-professional training and curriculum design, and capacity-building initiatives aimed at early-career professional development, particularly in low- and middle-income settings.

From little things big things grow: enhancement of an acoustic telemetry network to monitor broad-scale movements of marine species along Australia's east coast.

BACKGROUND: Acoustic telemetry has become a fundamental tool to monitor the movement of aquatic species. Advances in technology, in particular the development of batteries with lives of > 10 years, have increased our ability to track the long-term movement patterns of many species. However, logistics and financial constraints often dictate the locations and deployment duration of acoustic receivers. Consequently, there is often a compromise between optimal array design and affordability. Such constraints can hinder the ability to track marine animals over large spatial and temporal scales. Continental-scale receiver networks have increased the ability to study large-scale movements, but significant gaps in coverage often remain. METHODS: Since 2007, the Integrated Marine Observing System's Animal Tracking Facility (IMOS ATF) has maintained permanent receiver installations on the eastern Australian seaboard. In this study, we present the recent enhancement of the IMOS ATF acoustic tracking infrastructure in Queensland to collect data on large-scale movements of marine species in the northeast extent of the national array. Securing a relatively small initial investment for expanding receiver deployment and tagging activities in Queensland served as a catalyst, bringing together a diverse group of stakeholders (research institutes, universities, government departments, port corporations, industries, Indigenous ranger groups and tourism operators) to create an extensive collaborative network that could sustain the extended receiver coverage into the future. To fill gaps between existing installations and maximise the monitoring footprint, the new initiative has an atypical design, deploying many single receivers spread across 2,100 km of Queensland waters. RESULTS: The approach revealed previously unknown broad-scale movements for some species and highlights that clusters of receivers are not always required to enhance data collection. However, array designs using predominantly single receiver deployments are more vulnerable to data gaps when receivers are lost or fail, and therefore "redundancy" is a critical consideration when designing this type of array. CONCLUSION: Initial results suggest that our array enhancement, if sustained over many years, will uncover a range of previously unknown movements that will assist in addressing ecological, fisheries, and conservation questions for multiple species.

Identification of two key genes involved in flavonoid catabolism and their different roles in apple resistance to biotic stresses.

Biosynthesis of flavonoid aglycones and glycosides is well established. However, key genes involved in their catabolism are poorly understood, even though the products of hydrolysis and oxidation play important roles in plant resistance to biotic stress. Here, we report on catabolism of dihydrochalcones (DHCs), the most abundant flavonoids in domesticated apple and wild Malus. Two key genes, BGLU13.1 and PPO05, were identified by activity-directed protein purification. BGLU13.1-A hydrolyzed phlorizin, (the most abundant DHC in domesticated apple) to produce phloretin which was then oxidized by PPO05. The process differed in some wild Malus, where trilobatin (a positional isomer of phlorizin) was mainly oxidized by PPO05. The effects of DHC catabolism on apple resistance to biotic stresses was investigated using transgenic plants. Either directly or indirectly, phlorizin hydrolysis affected resistance to the phytophagous pest two-spotted spider mite, while oxidation of trilobatin was involved in resistance to the biotrophic fungus Podosphaera leucotricha. DHC catabolism did not affect apple resistance to necrotrophic pathogens Valsa mali and Erwinia amylovara. These results suggest that different DHC catabolism pathways play different roles in apple resistance to biotic stresses. The role of DHC catabolism on apple resistance appeared closely related to the mode of invasion/damage used by pathogen/pest.

The Effect of a Group-Based Mindfulness and Acceptance Training on Psychological Flexibility and Adherence to Antiretroviral Therapy Among Adolescents in Uganda: An Open-Label Randomized Trial.

Adherence to antiretroviral therapy (ART) is lower in adolescents with HIV (AWH) than in any other age group, partly due to self-regulatory challenges during development. Mindfulness and acceptance training have been shown to support psychological flexibility, a self-regulatory skill that potentially improves adolescent adherence to medication. We assessed the effect of weekly group-based mindfulness and acceptance training sessions on ART adherence among older adolescents (15-19 years) in Kampala, Uganda. One hundred and twenty-two AWH (median age 17, range 15-19 years, 57% female) receiving care at a public health facility in Kampala were randomized 1:1 to receive 4 weekly 90-min group sessions facilitated by experienced trainers or standard-of-care ART services. The training involved (Session 1) clarifying values, (Session 2) skillfully relating to thoughts, (Session 3) allowing and becoming aware of experiences non-judgmentally, and (Session 4) exploring life through trial and error. At baseline, postintervention, and 3-month follow-up, psychological flexibility was measured using the Avoidance and Fusion Questionnaire for Youth (AFQ-Y8), and self-reported ART adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). At baseline, the intervention and standard-of-care arms had similar psychological flexibility (AFQ-Y8 score:15.45 ± 0.82; 15.74 ± 0.84) and ART adherence (MMAS-8 score: 5.32 ± 0.24; 5.13 ± 0.23). Retention through the study was moderate (71%). Completion of mindfulness and acceptance training was associated with a significant reduction in psychological inflexibility at the 3-month follow-up (AFQ-Y8 score: 12.63 ± 1.06; 14.05 ± 1.07, P = .006). However, no significant differences were observed in self-reported adherence to ART at the 3-month follow-up (MMAS-8 score: 5.43 ± 0.23; 4.90 ± 0.33, P = .522). Group-based mindfulness and acceptance training improved psychological flexibility in this population of adolescents on ART in Uganda but did not significantly improve ART adherence. Future research should explore integrated approaches that combine behavioral management training with other empowerment aspects to improve ART adherence among AWH.

Racial disparities in hospitalization characteristics among Native Hawaiians, Pacific Islanders and Asian American subgroups with Parkinson's disease.

BACKGROUND: Differences among Native Hawaiians/Pacific Islanders (NHPI) and Asian American (AA) subgroups have not been adequately studied in Parkinson's disease (PD). OBJECTIVE: To determine differences in demographics, comorbidities, and healthcare utilization among NHPI, AA subgroups, and White hospitalized PD patients. METHODS: We conducted a retrospective cross-sectional analysis of Hawai'is statewide registry (2016-2020). Patients with PD were identified using ICD10 code G20 and categorized as White, Japanese, Filipino, Chinese, NHPI, or Other. Variables collected included: age, sex, residence (county), primary source of payment, discharge status, length of stay, in-hospital expiration, Charlson Comorbidity Index (CCI) and Deep Brain Stimulation (DBS) utilization. Bivariate analyses were performed: differences in age and CCI were further examined by multivariable linear regression and proportional odds models. RESULTS: Of 229,238 hospitalizations, 2428 had PD (Japanese: 31.3 %, White: 30.4 %, Filipino: 11.3 %, NHPI: 9.6 %, Chinese: 8.0 %). NHPI were younger compared to rest of the subgroups [estimate in years (95 % CI): Whites: 4.4 (3.0-5.8), Filipinos: 4.3 (2.7-5.9), Japanese: 7.7 (6.4-9.1), Chinese: 7.9 (6.1-9.7), p < 0.001)]. NHPI had a higher CCI compared to White, Japanese, and Chinese (p < 0.001). Among AA subgroups, Filipinos were younger and had a higher CCI compared to Japanese and Chinese (p < 0.001). There were no significant differences in DBS utilization among subgroups. CONCLUSIONS: NHPI and Filipinos with PD were hospitalized at a younger age and had a greater comorbidity burden compared to other AAs and Whites. Further research, ideally prospective studies, are needed to understand these racial disparities.

Integrated Transcriptomic and Proteomic Analysis Identifies Novel Regulatory Genes Associated with Plant Growth Regulator-Induced Astringency in Grape Berries.

Astringency influences the sensory characteristics and flavor quality of table grapes. We tested the astringency sensory attributes of berries and investigated the concentration of flavan-3-ols/proanthocyanidins (PAs) in skins after the application of the plant growth regulators CPPU and GA3 to the flowers and young berries of the "Summer Black" grape. Our results showed that CPPU and GA3 applications increase sensory astringency perception scores and flavan-3-ol/proanthocyanidin concentrations. Using integrated transcriptomic and proteomic analysis, differentially expressed transcripts and proteins associated with growth regulator treatment were identified, including those for flavonoid biosynthesis that contribute to the changes in sensory astringency levels. Transient overexpression of candidate astringency-related regulatory genes in grape leaves revealed that VvWRKY71, in combination with VvMYBPA1 and VvMYC1, could promote the biosynthesis of proanthocyanidins, while overexpression of VvNAC83 reduced the accumulation of proanthocyanidins. However, in transient promoter studies in Nicotiana benthamiana, VvWRKY71 repressed the promoter of VvMYBPA2, while VvNAC83 had no significant effect on the promoter activity of four PA-related genes, and VvMYBPA1 was shown to activate its own promoter. This study provides new insights into the molecular mechanisms of sensory astringency formation induced by plant growth regulators in grape berries.

Second-stage Scrotoplasty with Autologous Tissue Augmentation after Metoidioplasty.

We present our technique for second-stage scrotoplasty with autologous tissue augmentation following gender-affirming metoidioplasty. This technique augments the scrotum while removing the upper labia majora and making the penis more visible and accessible. This procedure avoids the need for testicular prostheses and their potential for discomfort, displacement, extrusion, or infection. Our preliminary results show that the complication rate is low.