Initial Outcomes Using Cryoablation in Surgical Management of Slipping Rib Syndrome.

INTRODUCTION: Minimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE. METHODS: A retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected. RESULTS: A total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy. CONCLUSION: Intercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes. LEVEL OF EVIDENCE: III.

Registered Report: Transcriptional Analysis of Savings Memory Suggests Forgetting is Due to Retrieval Failure.

There is fundamental debate about the nature of forgetting: some have argued that it represents the decay of the memory trace, others that the memory trace persists but becomes inaccessible because of retrieval failure. These different accounts of forgetting lead to different predictions about savings memory, the rapid re-learning of seemingly forgotten information. If forgetting is because of decay, then savings requires re-encoding and should thus involve the same mechanisms as initial learning. If forgetting is because of retrieval failure, then savings should be mechanistically distinct from encoding. In this registered report, we conducted a preregistered and rigorous test between these accounts of forgetting. Specifically, we used microarray to characterize the transcriptional correlates of a new memory (1 d after training), a forgotten memory (8 d after training), and a savings memory (8 d after training but with a reminder on day 7 to evoke a long-term savings memory) for sensitization in Aplysia californica (n = 8 samples/group). We found that the reactivation of sensitization during savings does not involve a substantial transcriptional response. Thus, savings is transcriptionally distinct relative to a newer (1-d-old) memory, with no coregulated transcripts, negligible similarity in regulation-ranked ordering of transcripts, and a negligible correlation in training-induced changes in gene expression (r = 0.04 95% confidence interval (CI) [-0.12, 0.20]). Overall, our results suggest that forgetting of sensitization memory represents retrieval failure.

The evolution of secondary flow phenomena and their effect on primary shock conditions in shock tubes: Experimentation and numerical model.

Compressed gas-driven shock tubes are widely used for laboratory simulation of primary blasts by accurately replicating pressure profiles measured in live-fire explosions. These investigations require sound characterization of the primary blast wave, including the temporal and spatial evolution of the static and dynamic components of the blast wave. The goal of this work is to characterize the propagation of shock waves in and around the exit of a shock tube via analysis of the primary shock flow, including shock wave propagation and decay of the shock front, and secondary flow phenomena. To this end, a nine-inch shock tube and a cylindrical sensing apparatus were used to determine incident and total pressures outside of the shock tube, highlighting the presence of additional flow phenomena. Blast overpressure, impulse, shock wave arrival times, positive phase duration, and shock wave planarity were examined using a finite element model of the system. The shock wave remained planar inside of the shock tube and lost its planarity upon exiting. The peak overpressure and pressure impulse decayed rapidly upon exit from the shock tube, reducing by 92-95%. The primary flow phenomenon, or the planar shock front, is observed within the shock tube, while two distinct flow phenomena are a result of the shock wave exiting the confines of the shock tube. A vortex ring is formed as the shock wave exited the shock tube into the still, ambient air, which induces a large increase in the total pressure impulse. Additionally, a rarefaction wave was formed following shock front expansion, which traveled upstream into the shock tube, reducing the total and incident pressure impulses for approximately half of the simulated region.

Transcriptional changes before and after forgetting of a long-term sensitization memory in Aplysia californica.

Most long-term memories are forgotten, becoming progressively less likely to be recalled. Still, some memory fragments may persist, as savings memory (easier relearning) can be detected long after recall has become impossible. What happens to a memory trace during forgetting that makes it inaccessible for recall and yet still effective to spark easier re-learning? We are addressing this question by tracking the transcriptional changes that accompany learning and then forgetting of a long-term sensitization memory in the tail-elicited siphon withdrawal reflex of Aplysia californica. First, we tracked savings memory. We found that even though recall of sensitization fades completely within 1 week of training, savings memory is still detectable at 2 weeks post training. Next, we tracked the time-course of regulation of 11 transcripts we previously identified as potentially being regulated after recall has become impossible. Remarkably, 3 transcripts still show strong regulation 2 weeks after training and an additional 4 are regulated for at least 1 week. These long-lasting changes in gene expression always begin early in the memory process, within 1 day of training. We present a synthesis of our results tracking gene expression changes accompanying sensitization and provide a testable model of how sensitization memory is forgotten.

The influence of miniscrew insertion torque.

Objective: The aim of this in vitro study was to evaluate the progressive development of surface microdamage produced following the insertion of orthodontic miniscrews (OMs) into 1.5 mm thick porcine tibia bone using maximum insertion torque values of 12 Ncm, 18 Ncm, and 24 Ncm. Methods: Aarhus OMs (diameter 1.5 mm; length 6 mm) were inserted into 1.5 mm porcine bone using a torque limiting hand screwdriver set at 12 Ncm, 18 Ncm, and 24 Ncm. A custom rig equipped with a compression load cell was used to record the compression force exerted during manual insertion. A sequential staining technique was used to identify microdamage viewed under laser confocal microscopy. Virtual slices were created and stitched together to form a compressed two-dimensional composition of the microdamage. Histomorphometric parameters, including total damage area, diffuse damage area, maximum crack length, maximum damage radius, and maximum diffuse damage radius, were measured. Kruskal-Wallis Tests and Wilcoxon Rank-Sum Tests were used to analyse the generated data. Results: All OMs inserted using 12 Ncm failed to insert completely, while partial insertion was observed for two OMs inserted at 18 Ncm. Complete insertion was achieved for all OMs inserted at 24 Ncm. Histomorphometrically, OMs inserted using 24 Ncm produced a significantly larger diffuse damage area (P < 0.05; P < 0.05) and maximum diffuse damage radius (P < 0.05; P < 0.05), for both the entry and exit surfaces, respectively, compared with the 12 Ncm and 18 Ncm groups. Conclusions: Insertion torque can influence the degree of OM insertion and, subsequently, the amount of microdamage formed following insertion into 1.5 mm thick porcine tibia bone. An increase in insertion torque corresponds with greater insertion depth and larger amounts of microdamage.

Influence of cortical bone thickness on miniscrew microcrack formation.

INTRODUCTION: The aim of this in-vitro study was to investigate the influence of cortical bone thickness on the amount of surface microdamage produced after insertion of orthodontic miniscrews (OM) in porcine tibia bone. METHODS: Aarhus OMs (Medicon, Tuttlingen, Germany; diameter, 1.5 mm; length, 6 mm) were inserted into 1.0 mm (group A; n = 10), 1.5 mm (group B; n = 10), and 2.0 mm (group C; n = 10) of porcine cortical bone using a torque-limiting hand screwdriver set at 18 Ncm. A sequential staining technique was used to identify microdamage under laser confocal microscopy. Virtual slices were stitched together using ImageJ software (National Institutes of Health, Bethesda, Md) to form a compressed 2-dimensional composition of the microdamage. The ImageJ software was used to quantify the total damage area, diffuse damage area, maximum crack length, maximum damage radius, and maximum diffuse damage radius. Kruskal-Wallis tests and Wilcoxon rank sum tests were used to analyze the data. RESULTS: All OMs in group A (1.0 mm) were inserted completely; however, 2 OMs from group B (1.5 mm) and all OMs in group C (2.0 mm) failed to insert completely. The entry surface of group C (2.0 mm) exhibited significantly higher amounts of total damage, diffuse damage area, maximum crack length, and maximum crack damage radius compared with groups A (1.0 mm) and B (1.5 mm). The maximum crack length observed on the entry and exit surfaces ranged from 1.03 to 3.06 mm. CONCLUSIONS: In this study, we demonstrated a higher level of microdamage after the insertion of OMs into 2.0-mm thick cortical bone compared with 1.0-mm thick cortical bone. Therefore, clinicians need to consider the thickness of the cortical bone at the insertion site, because mechanisms to reduce cortical bone thickness would likely reduce the amount of microdamage formed. A safety zone of 3.5 mm from the OM is also recommended for OMs inserted into 1.0- and 1.5-mm cortical bone thicknesses to minimize any detrimental effects after targeted remodeling.

Late onset postpartum preeclampsia 3 months after delivery.

Preeclampsia is defined by the American College of Obstetrics and Gynecology (ACOG) as "the occurrence of new onset hypertension plus new-onset proteinuria" [1]. Up-to-Date elaborates a little further on this by defining preeclampsia as "the new onset of hypertension and proteinuria, or hypertension and end-organ dysfunction with or without proteinuria, after 20 weeks of gestation in a previously normotensive woman. It may also develop postpartum. Severe hypertension or signs/symptoms of end-organ injury represent the severe end of the disease spectrum" [2] In 2013, the American College of Obstetricians and Gynecologists removed proteinuria as a key component in the diagnosis of preeclampsia. They also removed massive proteinuria (previously, 5 g/24 hours) and fetal growth restriction as possible features of severe disease. They found that were was a poor correlation in many outcomes between massive proteinuria and fetal growth restriction when managed similarly, with or without preeclampsia as a diagnosis. Oliguria was also removed as a characteristic of severe disease. [3] There have been several cases reported in the literature as well as by Obstetricians citing the incidence of preeclampsia occurring upwards of 6 to even 12 weeks postpartum. We hope to demonstrate what we believe to be a case of postpartum preeclampsia at 89 days postpartum.

Hydromorphone vs fentanyl for epidural analgesia and anesthesia.

BACKGROUND: Epidural analgesia/anesthesia is used during surgery because it dramatically relieves pain and attenuates the stress response. Because limited data exist regarding the relative merits of hydromorphone (HM) and fentanyl (FENT), the objective was to determine which was more safe and effective. METHODS: Prospective case-matched, observational study evaluated elective surgery patients: 30 HM and 60 FENT. Variables were measured perioperatively. RESULTS: Of the 90 patients, mean age was 52 years; simplified acute physiology score was 26 ± 10; and American Society of Anesthesiologists score was 2.4 HM vs 2.7 FENT, P = .03. HM patients were more apt to be excessively sedated (16% HM vs 1% FENT, P = .007) and have poor mental unresponsiveness (6% HM vs 0% FENT, P = .04). The incidence of hypotension was not different, 76% HM vs 80% FENT, not significant. CONCLUSIONS: In a closely case-matched population, FENT caused less excessive sedation and unresponsiveness. FENT patients had better intraoperative urine output and tended to have less repeated episodes of hypotension.

Stochastic humoral immunity to Bacillus anthracis protective antigen: identification of anti-peptide IgG correlating with seroconversion to Lethal Toxin neutralization.

A substantial fraction of individuals vaccinated against anthrax have low to immeasurable levels of serum Lethal Toxin (LeTx)-neutralizing activity. The only known correlate of protection against Bacillus anthracis in the currently licensed vaccine is magnitude of the IgG response to Protective Antigen (PA); however, some individuals producing high serum levels of anti-PA IgG fail to neutralize LeTx in vitro. This suggests that non-protective humoral responses to PA may be immunodominant in some individuals. Therefore, to better understand why anthrax vaccination elicits heterogeneous levels of protection, this study was designed to elucidate the relationship between anti-PA fine specificity and LeTx neutralization in response to PA vaccination. Inbred mice immunized with recombinant PA produced high levels of anti-PA IgG and neutralized LeTx in vitro and in vivo. Decapeptide binding studies using pooled sera reproducibly identified the same 9 epitopes. Unexpectedly, sera from individual mice revealed substantial heterogeneity in the anti-PA IgG and LeTx neutralization responses, despite relative genetic homogeneity, shared environment and exposure to the same immunogen. This heterogeneity permitted the identification of specificities that correlate with LeTx-neutralizing activity. IgG binding to six decapeptides comprising two PA epitopes, located in domains I and IV, significantly correlate with seroconversion to LeTx neutralization. These results indicate that stochastic variation in humoral immunity is likely to be a major contributor to the general problem of heterogeneity in vaccine responsiveness and suggest that vaccine effectiveness could be improved by approaches that focus the humoral response toward protective epitopes in a greater fraction of vaccinees.

MHC class II and non-MHC class II genes differentially influence humoral immunity to Bacillus anthracis lethal factor and protective antigen.

Anthrax Lethal Toxin consists of Protective Antigen (PA) and Lethal Factor (LF), and current vaccination strategies focus on eliciting antibodies to PA. In human vaccination, the response to PA can vary greatly, and the response is often directed toward non-neutralizing epitopes. Variable vaccine responses have been shown to be due in part to genetic differences in individuals, with both MHC class II and other genes playing roles. Here, we investigated the relative contribution of MHC class II versus non-MHC class II genes in the humoral response to PA and LF immunization using three immunized strains of inbred mice: A/J (H-2k at the MHC class II locus), B6 (H-2b), and B6.H2k (H-2k). IgG antibody titers to LF were controlled primarily by the MHC class II locus, whereas IgG titers to PA were strongly influenced by the non-MHC class II genetic background. Conversely, the humoral fine specificity of reactivity to LF appeared to be controlled primarily through non-MHC class II genes, while the specificity of reactivity to PA was more dependent on MHC class II. Common epitopes, reactive in all strains, occurred in both LF and PA responses. These results demonstrate that MHC class II differentially influences humoral immune responses to LF and PA.

Anthrax lethal toxin-induced gene expression changes in mouse lung.

A major virulence factor of Bacillus anthracis is the anthrax Lethal Toxin (LeTx), a bipartite toxin composed of Protective Antigen and Lethal Factor. Systemic administration of LeTx to laboratory animals leads to death associated with vascular leakage and pulmonary edema. In this study, we investigated whether systemic exposure of mice to LeTx would induce gene expression changes associated with vascular/capillary leakage in lung tissue. We observed enhanced susceptibility of A/J mice to death by systemic LeTx administration compared to the C57BL/6 strain. LeTx-induced groups of both up- and down-regulated genes were observed in mouse lungs 6 h after systemic administration of wild type toxin compared to lungs of mice exposed to an inactive mutant form of the toxin. Lungs of the less susceptible C57BL/6 strain showed 80% fewer differentially expressed genes compared to lungs of the more sensitive A/J strain. Expression of genes known to regulate vascular permeability was modulated by LeTx in the lungs of the more susceptible A/J strain. Unexpectedly, the largest set of genes with altered expression was immune specific, characterized by the up-regulation of lymphoid genes and the down-regulation of myeloid genes. Transcripts encoding neutrophil chemoattractants, modulators of tumor regulation and angiogenesis were also differentially expressed in both mouse strains. These studies provide new directions for the investigation of vascular leakage and pulmonary edema induced by anthrax LeTx.

Candidacidal activity of synthetic peptides based on the antimicrobial domain of the neutrophil-derived protein, CAP37.

The primary bactericidal domain of CAP37, a cationic antimicrobial protein with potent activity against Gram-negative organisms was previously shown to reside between amino acids 20 through 44 (NQGRHFCGGALIHARFVMTAASCFQ) of the native protein. In this study, we explored the efficacy of four synthetic CAP37 peptide analogs, based on this sequence, against various Candida species including fluconazole-sensitive and -resistant isolates of C. albicans. Three of the peptides demonstrated strong antifungal activity for C. albicans, including fluconazole-resistant isolates of C. albicans and were active against C. guilliermondii, C. tropicalis, C. pseudotropicalis, C. parapsilosis, and C. dubliniensis. The peptides were ineffective against C. glabrata, C. krusei, and Saccharomyces cerevisiae. For C. albicans isolates, the peptides had relatively greater activity against blastoconidia than hyphal forms, although strong antifungal activity was observed with pseudohyphal forms of the various Candida species tested. Kinetic studies demonstrated fungicidal rather than fungistatic activity. These findings indicate that synthetic peptides based on the antimicrobial domain of CAP37 also have activity against eukaryotic organisms suggesting a broader range of activity than originally demonstrated and show for the first time their potent fungicidal activity.

The major neutralizing antibody responses to recombinant anthrax lethal and edema factors are directed to non-cross-reactive epitopes.

Anthrax lethal and edema toxins (LeTx and EdTx, respectively) form by binding of lethal factor (LF) or edema factor (EF) to the pore-forming moiety protective antigen (PA). Immunity to LF and EF protects animals from anthrax spore challenge and neutralizes anthrax toxins. The goal of the present study is to identify linear B-cell epitopes of EF and to determine the relative contributions of cross-reactive antibodies of EF and LF to LeTx and EdTx neutralization. A/J mice were immunized with recombinant LF (rLF) or rEF. Pools of LF or EF immune sera were tested for reactivity to rLF or rEF by enzyme-linked immunosorbent assays, in vitro neutralization of LeTx and EdTx, and binding to solid-phase LF and EF decapeptides. Cross-reactive antibodies were isolated by column absorption of EF-binding antibodies from LF immune sera and by column absorption of LF-binding antibodies from EF immune sera. The resulting fractions were subjected to the same assays. Major cross-reactive epitopes were identified as EF amino acids (aa) 257 to 268 and LF aa 265 to 274. Whole LF and EF immune sera neutralized LeTx and EdTx, respectively. However, LF sera did not neutralize EdTx, nor did EF sera neutralize LeTx. Purified cross-reactive immunoglobulin G also failed to cross-neutralize. Cross-reactive B-cell epitopes in the PA-binding domains of whole rLF and rEF occur and have been identified; however, the major anthrax toxin-neutralizing humoral responses to these antigens are constituted by non-cross-reactive epitopes. This work increases understanding of the immunogenicity of EF and LF and offers perspective for the development of new strategies for vaccination against anthrax.

Sequential B-cell epitopes of Bacillus anthracis lethal factor bind lethal toxin-neutralizing antibodies.

The bipartite anthrax lethal toxin (LeTx) consisting of protective antigen (PA) and lethal factor (LF) is a major virulence factor contributing to death from systemic Bacillus anthracis infection. The current vaccine elicits antibodies directed primarily to PA; however, in experimental settings serologic responses to LF can neutralize LeTx and contribute to protection against infection. The goals of the present study were to identify sequential B-cell epitopes of LF and to determine the capacity of these determinants to bind neutralizing antibodies. Sera of recombinant LF-immunized A/J mice exhibited high titers of immunoglobulin G anti-LF reactivity that neutralized LeTx in vitro 78 days after the final booster immunization and protected the mice from in vivo challenge with 3 50% lethal doses of LeTx. These sera bound multiple discontinuous epitopes, and there were major clusters of reactivity on native LF. Strikingly, all three neutralizing, LF-specific monoclonal antibodies tested bound specific peptide sequences that coincided with sequential epitopes identified in polyclonal antisera from recombinant LF-immunized mice. This study confirms that LF induces high-titer protective antibodies in vitro and in vivo. Moreover, the binding of short LF peptides by LF-specific neutralizing monoclonal antibodies suggests that generation of protective antibodies by peptide vaccination may be feasible for this antigen. This study paves the way for a more effective anthrax vaccine by identifying discontinuous peptide epitopes of LF.