Plasma: indications, controversies, and opportunities.

Plasma is overused as a blood product worldwide; however, data supporting appropriate use of plasma is scant. Its most common utilization is for treatment of coagulopathy in actively bleeding patients; it is also used for coagulation optimization prior to procedures with specific coagulation profile targets. A baseline literature review in PUBMED and Google Scholar was done (1 January 2000 to 1 June 2023), utilizing the following search terms: plasma, fresh frozen plasma, lyophilized plasma, indications, massive transfusion protocol, liver disease, warfarin reversal, cardiothoracic surgery, INR < 2. An initial review of the titles and abstracts excluded all articles that were not focused on transfusional medicine. Additional references were obtained from citations within the retrieved articles. This narrative review discusses the main indications for appropriate plasma use, mainly coagulation factor replacement, major hemorrhage protocol, coagulopathy in liver disease, bleeding in the setting of vitamin K antagonists, among others. The correlation between concentration of coagulation factors and INR, as well as the proper plasma dosing with its volume being weight-based, is also discussed. A high value approach to plasma utilization is supported with a review of the clinical situations where plasma is overutilized or unnecessary. Finally, a discussion of novel plasma products is presented for enhanced awareness.

Illuminating practitioner challenges in energy transitions.

Sustainable development (SD) is a concept that can be used to address complex challenges, including energy transitions. SD offers diverse strategies that provide useful direction in navigating tensions, trade-offs and synergies in energy transitions. The purpose of this research was to identify the challenges that energy practitioners are faced with in energy transitions and explore potential solutions. To achieve this purpose, we identified and explored the challenges faced by energy practitioners in Canada. Specifically, we conducted a survey of 34 energy practitioners from across Canada, as well as in-depth interviews with the Energy Futures Lab design team (which is a civil society initiative actively working on the energy transition in Canada). We identified the following challenges faced by energy practitioners in Canada: there is no simple, single solution for energy transitions; energy transitions have potentially conflicting considerations; energy systems have potentially conflicting goals; energy practitioners have different levels of trust and competencies in key actors; energy practitioners need to work across the political spectrum; and the costs and benefits of energy transitions are unevenly distributed. We discuss how the three strategies of SD (i.e., economic choice, political choice, social choice) could be applied to manage the intended and unintended tensions and trade-offs inherent in energy transitions. We conclude that the three SD strategies are not always equally valued by energy practitioners, but they have the potential to be useful in different energy transitions scenarios.

Stimulation of Pro-inflammatory Cytokines in Mixed Cultures of Peripheral Blood Mononuclear Cells and Anaerobic Bacteria.

In the last couple of decades, much progress has been made in studying bacteria living in humans. However, there is much more to learn about bacteria immune cell interactions. Here, we show that anaerobic bacteria do not grow when cultured overnight with human cells under atmospheric air. Air contains about 18% oxygen, which inhibits the growth of these bacteria while supporting the cultivation of human cells. The bacteria cultured with human peripheral blood mononuclear cells (PBMCs) inflamed with phytohemagglutinin (PHA) greatly increased the production of proinflammatory cytokines like tumor necrosis factor-alpha (TNFα) while inhibiting the production of monocyte chemoattractant protein-1 (MCP-1), an important chemokine.

The xylem of anisohydric Quercus alba L. is more vulnerable to embolism than isohydric codominants.

The coordination of plant leaf water potential (ΨL ) regulation and xylem vulnerability to embolism is fundamental for understanding the tradeoffs between carbon uptake and risk of hydraulic damage. There is a general consensus that trees with vulnerable xylem more conservatively regulate ΨL than plants with resistant xylem. We evaluated if this paradigm applied to three important eastern US temperate tree species, Quercus alba L., Acer saccharum Marsh. and Liriodendron tulipifera L., by synthesizing 1600 ΨL observations, 122 xylem embolism curves and xylem anatomical measurements across 10 forests spanning pronounced hydroclimatological gradients and ages. We found that, unexpectedly, the species with the most vulnerable xylem (Q. alba) regulated ΨL less strictly than the other species. This relationship was found across all sites, such that coordination among traits was largely unaffected by climate and stand age. Quercus species are perceived to be among the most drought tolerant temperate US forest species; however, our results suggest their relatively loose ΨL regulation in response to hydrologic stress occurs with a substantial hydraulic cost that may expose them to novel risks in a more drought-prone future.

COVID-19 frauds: An exploratory study of victimization during a global crisis.

Research Summary: The COVID-19 pandemic threated public health and safety and led to a number of virus-related fraud schemes. We surveyed over 2,200 American adults to investigate their experiences with COVID-19-related frauds. Our goals were to better understand fraud targeting and victimization, as well as the impacts of fraud on victims. Over a quarter of our sample reported purchasing either a COVID-19-related product or a service, yet 42.5% reported feeling targeted for fraud. Being a target of COVID-19 frauds is significantly linked to one's routine activities, however it is one's level of self-control that more strongly predicts victimization. COVID-19 anxieties mediate the impact of self-control on purchasing. Policy Implications: Legal interventions and increased regulations surrounding advertising are a potential mechanism for protecting consumers, yet "soft" interventions that interrupt routine activities might be more useful and applicable. The use of white-lists and publicly available websites that allow e-commerce sites and sellers to be verified would help enable higher levels of self-guardianship. It is also important to provide continuous and clear messaging about what is being done to protect consumers.

Adventures in critical reagent lot changes in ligand-binding assays: redevelopment, bridging and additional processing requirements.

Aim: Critical reagents have significant impact on ligand-binding assay performance. The critical reagents selected during method development should be well-evaluated, as the quality of these reagents will dictate performance of the assay over time. Critical reagents in ligand-binding assays are almost always produced using a biological system, so batch yield, purity and performance tend to vary greatly. Due to the essential nature of critical reagents in the assay, changes in critical reagents can have dramatic impact on the assay and results, so close monitoring of assay performance is required. Methodology & results: We present here three examples of critical reagent lot changes that required creative solutions to maintain assay performance. The first case study is an example of the impact of different lots of analyte within a quantitative assay that resulted in the need to redevelop the assay in a different format. Case study two outlines an assay where a surrogate matrix is the critical reagent in an assay and the difficulties encountered over the course of several years and lot changes. The third case study covers an immunogenicity assay with a commercial detection that did not have sufficient quantity to cover the entire study lifecycle. As a result of the reagent change, a new assay was developed. Discussion & conclusion: A robust plan for critical reagent generation and lifecycle management should be adapted in order to avoid costly delays and rework. The performance of an assay depends on the continuity of the critical reagent supply. Reagents should be carefully selected to include the binding and performance properties required for an assay.

Eastern US deciduous tree species respond dissimilarly to declining soil moisture but similarly to rising evaporative demand.

Hydraulic stress in plants occurs under conditions of low water availability (soil moisture; θ) and/or high atmospheric demand for water (vapor pressure deficit; D). Different species are adapted to respond to hydraulic stress by functioning along a continuum where, on one hand, they close stomata to maintain a constant leaf water potential (ΨL) (isohydric species), and on the other hand, they allow ΨL to decline (anisohydric species). Differences in water-use along this continuum are most notable during hydrologic stress, often characterized by low θ and high D; however, θ and D are often, but not necessarily, coupled at time scales of weeks or longer, and uncertainty remains about the sensitivity of different water-use strategies to these variables. We quantified the effects of both θ and D on canopy conductance (Gc) among widely distributed canopy-dominant species along the isohydric-anisohydric spectrum growing along a hydroclimatological gradient. Tree-level Gc was estimated using hourly sap flow observations from three sites in the eastern United States: a mesic forest in western North Carolina and two xeric forests in southern Indiana and Missouri. Each site experienced at least 1 year of substantial drought conditions. Our results suggest that sensitivity of Gc to θ varies across sites and species, with Gc sensitivity being greater in dry than in wet sites, and greater for isohydric compared with anisohydric species. However, once θ limitations are accounted for, sensitivity of Gc to D remains relatively constant across sites and species. While D limitations to Gc were similar across sites and species, ranging from 16 to 34% reductions, θ limitations to Gc ranged from 0 to 40%. The similarity in species sensitivity to D is encouraging from a modeling perspective, though it implies that substantial reduction to Gc will be experienced by all species in a future characterized by higher D.

Canopy isotopic investigation reveals different water uptake dynamics of maples and oaks.

Variations in drought responses exhibited by cohabiting tree species such as Acer sacharrum and Quercus alba have often been attributed to differences in rooting depth or water accessibility. A. sacharrum is thought to be a shallow rooted species, and is assumed to not have access to the deep and stable water resources available to Q. alba. As such, A. sacharrum conserves water by minimizing stomatal conductance under drought conditions whereas Q. alba does not. However, detailed records of sufficient temporal resolution which integrate water accessibility, meteorological drivers, and leaf level parameters (e.g., photosynthesis, stomatal conductance) are lacking, making such assumptions-though plausible- largely untested. In this study, we investigated the water accessibility of both maples (A. sacharrum) and oaks (Q. alba) during the late growing season using novel canopy stable isotope measurements. Our results showed that maples can draw from the same water pool as cohabitating oaks, but can also switch to a shallow water source in response to available moisture in the shallow soil profile. We also found that maples tended to use a deep water source under high vapor pressure deficit even when shallow soil water was available. On the other hand, oaks had consistent deep water access during our study period. It is noted that our measurements do not cover the whole growing season and should be extrapolated with caution. Such findings indicate that differences in leaf functions during drought between maples and oaks may be due to both soil water accessibility and atmospheric water demand.

Reforestation and surface cooling in temperate zones: Mechanisms and implications.

Land-use/cover change (LUCC) is an important driver of environmental change, occurring at the same time as, and often interacting with, global climate change. Reforestation and deforestation have been critical aspects of LUCC over the past two centuries and are widely studied for their potential to perturb the global carbon cycle. More recently, there has been keen interest in understanding the extent to which reforestation affects terrestrial energy cycling and thus surface temperature directly by altering surface physical properties (e.g., albedo and emissivity) and land-atmosphere energy exchange. The impacts of reforestation on land surface temperature and their mechanisms are relatively well understood in tropical and boreal climates, but the effects of reforestation on warming and/or cooling in temperate zones are less certain. This study is designed to elucidate the biophysical mechanisms that link land cover and surface temperature in temperate ecosystems. To achieve this goal, we used data from six paired eddy-covariance towers over co-located forests and grasslands in the temperate eastern United States, where radiation components, latent and sensible heat fluxes, and meteorological conditions were measured. The results show that, at the annual time scale, the surface of the forests is 1-2°C cooler than grasslands, indicating a substantial cooling effect of reforestation. The enhanced latent and sensible heat fluxes of forests have an average cooling effect of -2.5°C, which offsets the net warming effect (+1.5°C) of albedo warming (+2.3°C) and emissivity cooling effect (-0.8°C) associated with surface properties. Additional daytime cooling over forests is driven by local feedbacks to incoming radiation. We further show that the forest cooling effect is most pronounced when land surface temperature is higher, often exceeding -5°C. Our results contribute important observational evidence that reforestation in the temperate zone offers opportunities for local climate mitigation and adaptation.

Strain Imaging: An Everyday Tool for the Perioperative Echocardiographer.

Strain analysis allows for global and regional analysis of myocardial function and has been shown to be an independent predictor of outcomes after cardiac surgery. Strain imaging offers advantages over traditional EF measurements in that it is relatively angle independent, it is less dependent upon loading conditions, it is reproducible, it does not rely on geometric assumptions, and it can detect subclinical systolic dysfunction. Limitations of strain analysis include high temporal resolution requirements, a strong dependence on image quality, and inter-vendor variability. In addition, there is a paucity of data on the intraoperative applications of strain. The ASE has defined a global longitudinal strain of -20% measured by transthoracic echocardiography to be considered normal, with less negative values considered abnormal. Presently, there are no published guidelines on the normal values of strain with transesophageal echocardiography (TEE). However, multiple studies have shown that a reduction in intraoperative strain assessed with TEE has been shown to be an independent predictor of complications during cardiac surgery. Accordingly, further incorporation of intraoperative strain analysis with TEE could aid in prognostication for patients undergoing cardiac surgery. As perioperative strain analysis continues to advance, an understanding of these concepts is imperative for perioperative echocardiographers. It is the authors' goal to show that strain imaging can provide a reliable and objective measure that can be performed in real time to aid in decision-making and perioperative risk stratification.

Urologic Complications in 4000 Kidney Transplants Performed at the Saint Barnabas Health Care System.

Renal transplantation is the current standard treatment for end-stage renal disease and is associated with immunologic, vascular, and urologic complications. In this study we report urologic complications following ureteral reimplantation based on 1 urologist's experience at a single high-volume renal transplant institution. METHODS: A retrospective review was performed on all patients who underwent ureteral reimplantation by the transplant urologist at the time of their kidney transplant between July 1, 1993, and December 31, 2016. RESULTS: There was a total of 3951 ureteral reimplantations performed for 3890 renal transplants. The overall complication rate was 7% (276 patients). Vesicoureteral reflux was the most common complication (4.25%), followed by ureteral stricture (1.9%), urine leak (0.6%), and de novo ureteropelvic junction obstruction (0.25%). CONCLUSION: This study is a continuation of our previous case series. Over time, our overall rate of urologic complications has increased. Vesicoureteral reflux has remained the most common complication with increasing incidence compared with our prior reviews. One possible cause for increased incidence is our thorough longitudinal follow-up over more than 2 decades. Some patients who previously had no evidence of reflux eventually did in fact develop reflux. The incidence of ureteral stricture, urine leak, and ureteropelvic junction obstruction has overall remained stable over the past 23 years. In our program, 1 transplant urologist has performed almost all ureteroneocystostomies, leading to consistent management and generalizable results. Review of the literature shows variable rates of complications among different studies with multiple surgeons, disparate techniques, and short follow-up. Our study eliminates many of these confounding factors and provides more reliable, reproducible data.

Increased Dementia Mortality in West Virginia Counties with Mountaintop Removal Mining?

Atmospheric particulate matter (PM) is elevated in areas of mountaintop removal mining (MTM), a practice that has been ongoing in some counties of West Virginia (WV) USA since the 1970s. PM inhalation has been linked to central nervous system pathophysiology, including cognitive decline and dementia. Here we compared county dementia mortality statistics in MTM vs. non-MTM WV counties over a period spanning 2001-2015. We found significantly elevated age-adjusted vascular or unspecified dementia mortality/100,000 population in WV MTM counties where, after adjusting for socioeconomic variables, dementia mortality was 15.60 (±3.14 Standard Error of the Mean (S.E.M.)) times higher than that of non-MTM counties. Further analyses with satellite imaging data revealed a highly significant positive correlation between the number of distinct mining sites vs. both mean and cumulative vascular and unspecified dementia mortality over the 15 year period. This was in contrast to finding only a weak relationship between dementia mortality rates and the overall square kilometers mined. No effect of living in an MTM county was found for the rate of Alzheimer's type dementia and possible reasons for this are considered. Based on these results, and the current literature, we hypothesize that inhalation of PM associated with MTM contributes to dementia mortality of the vascular or unspecified types. However, limitations inherent in ecological-type studies such as this, preclude definitive extrapolation to individuals in MTM-counties at this time. We hope these findings will inspire follow-up cohort and case-controlled type studies to determine if specific causative factors associated with living near MTM can be identified. Given the need for caregiving and medical support, increased dementia mortality of the magnitude seen here could, unfortunately, place great demands upon MTM county public health resources in the future.

Evaluation of Tellurium as a Fuel Additive in Neodymium-Containing U-Zr Metallic Fuel.

Phase-stability in a U-Zr-Te-Nd multi-component metallic fuel for advanced nuclear reactors is systematically investigated by taking into account binary, ternary and quaternary interactions between elements involved. Historically, the onset of fuel-cladding chemical interactions (FCCI) greatly limits the burnup potential of U-Zr fuels primarily due to interactions between lanthanide fission products and cladding constituents. Tellurium (Te) is evaluated as a potential additive for U-Zr fuels to bind with lanthanide fission products, e.g. neodymium (Nd), negating or mitigating the FCCI effect. Potential fresh fuel alloy compositions with the Te additive, U-Zr-Te, are characterized. Te is found to completely bind with Zr within the U-Zr matrix. Alloys simulating the formation of the lanthanide element Nd within U-Zr-Te are also evaluated, where the Te-Nd binary interaction dominates and NdTe is found to form as a high temperature stable compound. The experimental observations agree well with the trends obtained from density functional theory calculations. According to the calculated enthalpy of mixing, Zr-Te compound formation is favored in the U-Zr-Te alloy whereas NdTe compound formation is favored in the U-Zr-Te-Nd alloy. Further, the calculated charge density distribution and density of states provide sound understanding of the mutual chemical interactions between elements and phase-stability within the multi-component fuel.

Assessment of maternal referral systems used for a rural Zambian hospital: the development of setting specific protocols for the identification of complications.

BACKGROUND: In resource-limited countries, it is estimated that up to 75% of maternal deaths are preventable. Maternal referral systems are an effective measure to help prevent these deaths. OBJECTIVE: The objective of this study was to delineate criteria that health care workers use to identify obstetrical emergencies and make referrals, in order to evaluate the effectiveness of the established referral system and to implement improvements to this system. METHODS: Using a qualitative study design, the individuals with the highest level of formal obstetrics training at 10 health posts that refer to a rural Zambian hospital were surveyed using semi-structured interviews regarding their referral protocols. Data were analyzed through open-coding. At the conclusion of the interview, standardized referral protocols for obstetric emergencies derived from published guidelines and local practices were distributed. RESULTS: Identified complications resulting in referral most commonly included post-partum hemorrhage (70%), prolonged labor (70%), malpresentation (50%), antepartum hemorrhage (40%), and retained placenta (40%). While numerous reasons for referral were identified, there was little consensus on the referral protocol used for each complication. Obstacles to successful referral most commonly included cellular network disruptions (70%), distance (50%), and lack of transportation (30%).The referral protocols distributed to health posts covered only 11 of the 23 complications cited as the most common reason for referral. CONCLUSION: The referral criteria and protocols were updated to include all of the reported complications. We propose this document for others working in resource-limited settings attempting to establish or evaluate a maternal referral systems.

Griffithsin carrageenan fast dissolving inserts prevent SHIV HSV-2 and HPV infections in vivo.

Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) strategies with proven in vivo efficacy rely on antiretroviral drugs, creating the potential for drug resistance and complicated treatment options in individuals who become infected. Moreover, on-demand products are currently missing from the PrEP development portfolio. Griffithsin (GRFT) is a non-antiretroviral HIV entry inhibitor derived from red algae with an excellent safety profile and potent activity in vitro. When combined with carrageenan (CG), GRFT has strong activity against herpes simplex virus-2 (HSV-2) and human papillomavirus (HPV) in vitro and in vivo. Here, we report that GRFT/CG in a freeze-dried fast dissolving insert (FDI) formulation for on-demand use protects rhesus macaques from a high dose vaginal SHIV SF162P3 challenge 4 h after FDI insertion. Furthermore, the GRFT/CG FDI also protects mice vaginally against HSV-2 and HPV pseudovirus. As a safe, potent, broad-spectrum, on-demand non-antiretroviral product, the GRFT/CG FDI warrants clinical development.

Metanephric Adenoma in the Pediatric Population: Diagnostic Challenges and Follow-up.

OBJECTIVE: To discuss the presenting features, imaging findings, and recommended management of patients with Metanephric adenoma (MA) focusing on the diagnostic challenges and indications for follow up. MATERIALS AND METHODS: In this case report, we present a case of a 10-year-old female with MA who eventually underwent nephron sparing surgery with a partial nephrectomy. We performed a literature review of previous cases of metanephric adenoma and their respective management and follow-up. RESULTS: Renal ultrasound demonstrated a heterogeneous, echogenic mass measuring 3.8 cm at the upper pole of the right kidney. Further investigations consisted of computed tomography scan, magnetic resonance imaging, and magnetic resonance angiography. The patient underwent robotic-assisted partial nephrectomy. The immunohistochemical staining pattern, gross, and microscopic appearance of the lesion were consistent with the diagnosis of MA. The combination of CK7, EMA, and S-100 negativity and WT1 and CD57 positivity is considered characteristic of metanephric adenoma as described in the literature. CONCLUSION: MA is a rare benign tumor and especially in the pediatric population can cause significant concern over a possible malignant lesion. Although, no follow-up recommendations currently exist in cases of completely resected MA, we standardly perform postoperative surveillance. Although Metanephric Adenoma is difficult to diagnose preoperatively, given the advances in nephron sparing surgery and the utilization of nonionizing radiation modalities for follow up, we can manage these patients safely and with lower morbidity by preserving renal parenchyma.

Production of Gas-Phase Uranium Fluoroanions Via Solubilization of Uranium Oxides in the [1-Ethyl-3-Methylimidazolium]+[F(HF)2.3]- Ionic Liquid.

A new methodology for gas-phase uranium ion formation is described in which UO2 is dissolved in neat N-ethyl,N'-methylimidazolium fluorohydrogenate ionic liquid [EMIm+][F(HF)2.3-], yielding a blue-green solution. The solution was diluted with acetonitrile and then analyzed by electrospray ionization mass spectrometry. UF6- (a U(V) species) was observed at m/z = 352, and other than cluster ions derived from the ionic liquid, nothing else was observed. When the sample was analyzed using infusion desorption chemical ionization, UF6- was the base peak, and it was accompanied by a less intense UF5- that most likely was formed by elimination of a fluorine radical from UF6-. Formation of UF6- required dissolution of UO2 followed by or concurrent with oxidation of uranium from the + 4 to the + 5 state and finally formation of the fluorouranate. Dissolution of UO3 produced a bright yellow solution indicative of a U(VI) species; however, electrospray ionization did not produce abundant U-containing ions. The abundant UF6- provides a vehicle for accurate measurement of uranium isotopic abundances free from interference from minor isotopes of other elements and a convenient ion synthesis route that is needed gas-phase structure and reactivity studies like infrared multiphoton dissociation and ion-molecule dissociation and condensation reactions. The reactive fluorohydrogenate ionic liquid may also enable conversion of uranium in oxidic matrices into uranium fluorides that slowly oxidize to uranyl fluoride under ambient conditions, liberating the metal for facile measurement of isotope ratios without extensive chemical separations. Graphical abstract ᅟ.

A novel technique to construct a neo-scrotum out of preputial skin for agenesis and underdeveloped scrotum.

INTRODUCTION: Congenital scrotal agenesis (CSA) is an extremely rare condition with fewer than 10 cases reported in the literature. These patients are often further complicated by undescended testicles as well as systemic developmental disorders. Herein, we report our experience and an innovative surgical technique for creation of a neo-scrotum in three children. MATERIALS AND METHODS: We evaluated the records of three children in our database who were labeled as having an absent (1 patient) or severely underdeveloped scrotum (2 patients). Patients were aged 6, 14, and 16 months. All patients were uncircumcised, and the decision was made to create a neo-scrotum using the foreskin. The prepuce was harvested on a pedicle of dartos and transposed over the perineal cleft to create a neo-scrotal pouch. The flap was allowed to heal for 12-14 weeks, at which time the orchidopexy was performed. RESULTS: The follow-up to the surgery was 5 years, 3 years, and 6 months, respectively. There were no instances of flap necrosis, dehiscence, or wound infection. The three children had a capacious, aesthetically pleasing scrotal sac, which in all cases accommodated both testicles. CONCLUSION: In our experience, a well-vascularized preputial skin flap rotated to the perineum based on its ventral dartos pedicle provides an excellent source of tissue for creation of a neo-scrotum. We believe that the esthetic outcome of our technique rivals that of other reported techniques.

Prepuce sparing: Use of Z-plasty for treatment of phimosis and scarred foreskin.

INTRODUCTION AND OBJECTIVES: The desire to preserve the prepuce is often based on cultural norms. Recently, the concept of "genital autonomy" has been invoked to delay circumcision (or any genital altering procedure) until the individual reaches maturity and can make his or her own decision. However, some uncircumcised boys develop one or more episodes of balanitis resulting in scarring of the prepuce and pathologic phimosis which is difficult to treat. Herein we report on the management of severe phimosis and preputial scarring using preputial Z-plasties. MATERIALS AND METHODS: We reviewed the records of 28 patients, aged 3-12 years who underwent prepuce-sparing surgery within the previous 5 years with a minimum follow-up of 6 months. All patients were uncircumcised, with severe phimosis defined as a tight, pinpoint opening. All patients failed to respond to 6-10 weeks of betamethasone treatment. All parents requested preservation of as much of the foreskin as possible. RESULTS: All patients healed satisfactorily, without infection, hematoma, or flap necrosis. One child developed mild scarring which responded to local steroid application. At follow-up evaluation, ranging from 6 to 24 months, the prepuce was fully retractable in all patients (Fig.). CONCLUSIONS: Excision of the scarred preputial ring results in a circular suture line, which is in essence a straight line, curved and connected at each end, and this is likely to contract over time. The principle of Z-plasty can be exploited to elongate and interrupt the straight line, preventing contracture thus widening and sparing the prepuce.