Graftless Syndactyly Release.

Syndactyly release aims to address skin deficits by resurfacing web spaces and sides of digits to allow independent digital motion while minimizing the risk of web creep and scar contractures. Conventional methods include the use of a dorsal and interdigitating flaps with full-thickness skin grafts. More recently, there have been several descriptions of "graftless" syndactyly release without skin grafts, thus avoiding a further (usually distant) donor site. However, the indications of when and when not to use these techniques remain unclear. In addition, the inevitable scarring from extra recruitment of local adjacent skin is perhaps underemphasized. In this article, we revisit the trilobed flap technique which serves to balance the amount of skin needed for resurfacing digits while minimizing local donor site scarring. The geometry and nuances of the flap inset are illustrated in detail to guide those embarking on this technique. The trilobed syndactyly release technique is a reproducible, safe, and reliable method for the release of simple syndactyly.

Free functioning gracilis transfer for brachial plexus reconstruction using the internal mammary vessels as recipients: A case report.

Adult brachial plexus injuries are often associated with concomitant trauma to the axillary or subclavian vessels. In patients planned for free functioning gracilis transfer (FFGT) this poses a challenge to reconstructive surgeons where using the standard donor vessels can lead to endangering the circulation in the affected extremity or risk flap loss due to the poor perfusion pressures. This case report describes the use of a FFGT for upper limb reconstruction in a 22-year-old patient with a pan plexus injury and concomitant axillary artery injury following a high energy motorcycle accident. Ipsilateral internal mammary vessels were used as donor vessels after removing the 3rd and 4th costal cartilages. The gracilis muscle was harvested in its whole length, including a small transverse skin paddle, and transferred to the upper extremity. It was secured to the clavicle proximally, weaved into the Flexor Digitorum Profundus tendons distally and neurotised by the spinal accessory nerve. The procedure and postoperative course were uneventful and the follow up at 18 months showed MRC grade 4 in elbow flexion with only a slight contour deformity at the donor chest site. This is the first report demonstrating the use of internal mammary vessels for FFGT reconstruction in the upper extremity after removing two costal cartilages to achieve sufficient pedicle length.

Toward the explainability, transparency, and universality of machine learning for behavioral classification in neuroscience.

The use of rigorous ethological observation via machine learning techniques to understand brain function (computational neuroethology) is a rapidly growing approach that is poised to significantly change how behavioral neuroscience is commonly performed. With the development of open-source platforms for automated tracking and behavioral recognition, these approaches are now accessible to a wide array of neuroscientists despite variations in budget and computational experience. Importantly, this adoption has moved the field toward a common understanding of behavior and brain function through the removal of manual bias and the identification of previously unknown behavioral repertoires. Although less apparent, another consequence of this movement is the introduction of analytical tools that increase the explainabilty, transparency, and universality of the machine-based behavioral classifications both within and between research groups. Here, we focus on three main applications of such machine model explainabilty tools and metrics in the drive toward behavioral (i) standardization, (ii) specialization, and (iii) explainability. We provide a perspective on the use of explainability tools in computational neuroethology, and detail why this is a necessary next step in the expansion of the field. Specifically, as a possible solution in behavioral neuroscience, we propose the use of Shapley values via Shapley Additive Explanations (SHAP) as a diagnostic resource toward explainability of human annotation, as well as supervised and unsupervised behavioral machine learning analysis.

Incubation of palatable food craving is associated with brain-wide neuronal activation in mice.

Studies using rodent models have shown that relapse to drug or food seeking increases progressively during abstinence, a behavioral phenomenon termed "incubation of craving." Mechanistic studies of incubation of craving have focused on specific neurobiological targets within preselected brain areas. Recent methodological advances in whole-brain immunohistochemistry, clearing, and imaging now allow unbiased brain-wide cellular resolution mapping of regions and circuits engaged during learned behaviors. However, these whole-brain imaging approaches were developed for mouse brains, while incubation of drug craving has primarily been studied in rats, and incubation of food craving has not been demonstrated in mice. Here, we established a mouse model of incubation of palatable food craving and examined food reward seeking after 1, 15, and 60 abstinence days. We then used the neuronal activity marker Fos with intact-brain mapping procedures to identify corresponding patterns of brain-wide activation. Relapse to food seeking was significantly higher after 60 abstinence days than after 1 or 15 days. Using unbiased ClearMap analysis, we identified increased activation of multiple brain regions, particularly corticostriatal structures, following 60 but not 1 or 15 abstinence days. We used orthogonal SMART2 analysis to confirm these findings within corticostriatal and thalamocortical subvolumes and applied expert-guided registration to investigate subdivision and layer-specific activation patterns. Overall, we 1) identified brain-wide activity patterns during incubation of food seeking using complementary analytical approaches and 2) provide a single-cell resolution whole-brain atlas that can be used to identify functional networks and global architecture underlying the incubation of food craving.

Successful Delayed Neurolysis of the Median Nerve in a Teenager 7 years After Supracondylar Fracture: A Case Report and Review of the Literature.

ABSTRACT: Supracondylar humeral fractures are the commonest elbow fractures in childhood, associated with a high rate of neurological complications. We present the case of a 14-year-old adolescent girl with persisting daily pain, lack of sensation, and strength to her left hand after a displaced supracondylar fracture 7 years earlier. At the time of the fracture, she underwent closed reduction and percutaneous Kirschner wire fixation. During revision surgery, half of the median nerve was found embedded in bone at the level consistent with the healed fracture site. Neurolysis of the fascicles adherent to the bone was performed. Postoperatively, the patient had complete recovery of sensation, reduced pain, and a 2.5-fold improvement of grip strength. This case shows that there is a role for delayed neurolysis in children.

Multidisciplinary management of anal intraepithelial neoplasia and rate of progression to cancer: A retrospective cohort study.

PURPOSE: To describe the regional burden of AIN and rate of progression to cancer in patients managed in specialist and non-specialist clinic settings. METHODS: Patients with a histopathological diagnosis of AIN between 1994 and 2018 were retrospectively identified. Clinicopathological characteristics including high-risk status (chronic immunosuppressant use or HIV positive), number and type of biopsy (punch/excision) and histopathological findings were recorded. The relationship between clinicopathological characteristics and progression to cancer was assessed using logistic regression. RESULTS: Of 250 patients identified, 207 were eligible for inclusion: 144 from the specialist and 63 from the non-specialist clinic. Patients in the specialist clinic were younger (<40 years 31% vs 19%, p = 0.007), more likely to be male (34% vs 16%, p = 0.008) and HIV positive (15% vs 2%, p = 0.012). Patients in the non-specialist clinic were less likely to have AIN3 on initial pathology (68% vs 79%, p = 0.074) and were more often followed up for less than 36 months (46% vs 28%, p = 0.134). The rate of progression to cancer was 17% in the whole cohort (20% vs 10%, p = 0.061). On multivariate analysis, increasing age (OR 3.02, 95%CI 1.58-5.78, p < 0.001), high risk status (OR 3.53, 95% CI 1.43-8.74, p = 0.006) and increasing number of excisions (OR 4.88, 95%CI 2.15-11.07, p < 0.001) were related to progression to cancer. CONCLUSION: The specialist clinic provides a structured approach to the follow up of high-risk status patients with AIN. Frequent monitoring with specialist assessments including high resolution anoscopy in a higher volume clinic are required due to the increased risk of progression to anal cancer.

Acute type A aortic dissection in-hours versus out-of-hours: A systematic review and meta-analysis.

OBJECTIVE: We sought to compare clinical outcomes in patients with acute type A aortic dissection that undergone surgical repair during in-hours (IH) versus out-of-hours (OOH). METHODS: An electronic literature search was done till March 2020 to include studies with comparative cohorts of IH versus OOH. Primary outcomes were 30-day mortality, stroke, and reoperation for bleeding; secondary outcomes were acute kidney injury, total hospital stay, and intensive care unit stay. RESULTS: Six articles with a total of 3744 patients met the inclusion criteria. Mean age was similar, 60 ± 12 versus 60 ± 13 in IH versus OOH (p = .25). Aortic root and total arch replacement were similar in both cohorts, 22% in IH versus 25% in OOH (risk ratio [RR], 1.10; 95% confidence interval [CI: 0.78, 1.55]; p = .58) and 29% in IH versus 32% in OOH (RR, 0.96; 95% CI [0.89, 1.04], p = .37) respectively. Reoperation for bleeding and stroke rate were similar, with 18% in IH versus 23% in OOH (RR, 0.89; 95% CI [0.73, 1.08]; p = .24), and 12% in IH versus 13% in OOH (RR, 0.83; 95% CI [0.66, 1.03]; p = .09) respectively. Thirty-day mortality was significantly lower in IH (RR, 0.81; 95% CI [0.72, 0.90]; p = .0001). CONCLUSION: There was higher 30-day mortality rate during OOH surgery, yet this difference diminished following sensitivity analysis. There were no significant differences in major postoperative outcomes. Therefore, operating on such cases should be decided on clinical priority without delay.

The role of simulation in burns education.

Burns are devastating injuries which represent a significant global health burden. In the UK alone, it is estimated that 175 000 people suffer from burns injuries requiring hospital attention every year. The global treatment of burns can be improved through a more systematic team-based approach, which can be achieved through simulation training. Simulation has an increasingly important role in medical education, not only allowing practitioners to apply their knowledge in a controlled and safe environment, but also allowing them to gain technical and non-technical skills. This article explores the role of simulation as an important and effective tool for burns education worldwide.