The influence of neonatal BCG vaccination on in vitro cytokine responses to Plasmodium falciparum.

BACKGROUND: Bacillus Calmette-Guérin (BCG) vaccination has off-target protective effects against infections unrelated to tuberculosis. Among these, murine and human studies suggest that BCG vaccination may protect against malaria. We investigated whether BCG vaccination influences neonatal in vitro cytokine responses to Plasmodium falciparum. Blood samples were collected from 108 participants in the Melbourne Infant Study BCG for Allergy and Infection Reduction (MIS BAIR) randomised controlled trial (Clinical trials registration NCT01906853, registered July 2013), seven days after randomisation to neonatal BCG (n = 66) or no BCG vaccination (BCG-naïve, n = 42). In vitro cytokine responses were measured following stimulation with P. falciparum-infected erythrocytes (PfIE) or E. coli. RESULTS: No difference in the measured cytokines were observed between BCG-vaccinated and BCG-naïve neonates following stimulation with PfIE or E. coli. However, age at which blood was sampled was independently associated with altered cytokine responses to PfIE. Being male was also independently associated with increased TNF-a responses to both PfIE and E. coli. CONCLUSION: These findings do not support a role for BCG vaccination in influencing in vitro neonatal cytokine responses to P. falciparum. Older neonates are more likely to develop P. falciparum-induced IFN-γ and IFN-γ-inducible chemokine responses implicated in early protection against malaria and malaria pathogenesis.

Cationic cholesterol-dependent LNP delivery to lung stem cells, the liver, and heart.

Adding a cationic helper lipid to a lipid nanoparticle (LNP) can increase lung delivery and decrease liver delivery. However, it remains unclear whether charge-dependent tropism is universal or, alternatively, whether it depends on the component that is charged. Here, we report evidence that cationic cholesterol-dependent tropism can differ from cationic helper lipid-dependent tropism. By testing how 196 LNPs delivered mRNA to 22 cell types, we found that charged cholesterols led to a different lung:liver delivery ratio than charged helper lipids. We also found that combining cationic cholesterol with a cationic helper lipid led to mRNA delivery in the heart as well as several lung cell types, including stem cell-like populations. These data highlight the utility of exploring charge-dependent LNP tropism.

Optimization of Gradient-Echo Echo-Planar Imaging for T2* Contrast in the Brain at 0.5 T.

Gradient-recalled echo (GRE) echo-planar imaging (EPI) is an efficient MRI pulse sequence that is commonly used for several enticing applications, including functional MRI (fMRI), susceptibility-weighted imaging (SWI), and proton resonance frequency (PRF) thermometry. These applications are typically not performed in the mid-field (<1 T) as longer T2* and lower polarization present significant challenges. However, recent developments of mid-field scanners equipped with high-performance gradient sets offer the possibility to re-evaluate the feasibility of these applications. The paper introduces a metric "T2* contrast efficiency" for this evaluation, which minimizes dead time in the EPI sequence while maximizing T2* contrast so that the temporal and pseudo signal-to-noise ratios (SNRs) can be attained, which could be used to quantify experimental parameters for future fMRI experiments in the mid-field. To guide the optimization, T2* measurements of the cortical gray matter are conducted, focusing on specific regions of interest (ROIs). Temporal and pseudo SNR are calculated with the measured time-series EPI data to observe the echo times at which the maximum T2* contrast efficiency is achieved. T2* for a specific cortical ROI is reported at 0.5 T. The results suggest the optimized echo time for the EPI protocols is shorter than the effective T2* of that region. The effective reduction of dead time prior to the echo train is feasible with an optimized EPI protocol, which will increase the overall scan efficiency for several EPI-based applications at 0.5 T.

Urethroplasty Methods for Stricture Repair After Gender Affirming Phalloplasty: High Failure Rates in a Hostile Surgical Field.

OBJECTIVE: To report our experience with 71 postphalloplasty urethral strictures in order to discuss the performance characteristics of different urethroplasty techniques in urethral stricture after phalloplasty. METHODS: We conducted a retrospective chart review of 85 urethroplasties performed for stricture repair in 71 patients with phalloplasty for gender affirmation between August 2017 and May 2020. Stricture location, urethroplasty type, complication rate, and recurrence rate were recorded. RESULTS: The most common stricture type was distal anastomotic (40/71, 56%). The most common initial repair type was excision and primary anastomosis (EPA) (33/85, 39%), followed by first-stage Johanson urethroplasty (32/85, 38%). The stricture recurrence rate after initial repair of all types was 52% (44/85). The recurrence rate of stricture after EPA was 58% (19/33). The recurrence rate after staged urethroplasty was 25% (2/8) for patients who successfully completed a first and second stage. 30% (3/10) of patients who completed a first stage and opted out of a second stage required a revision to achieve successful lifetime voiding from the surgical urethrostomy. CONCLUSION: EPA after phalloplasty has a high failure rate. Nontransecting anastomotic urethroplasty has slightly lower failure rate, and staged Johanson-type surgeries have the highest success rates after phalloplasty.

Expanding the Reach of Monoclonal Antibodies: A Review of Synthetic Nucleic Acid Delivery in Immunotherapy.

Harnessing the immune system to combat disease has revolutionized medical treatment. Monoclonal antibodies (mAbs), in particular, have emerged as important immunotherapeutic agents with clinical relevance in treating a wide range of diseases, including allergies, autoimmune diseases, neurodegenerative disorders, cancer, and infectious diseases. These mAbs are developed from naturally occurring antibodies and target specific epitopes of single molecules, minimizing off-target effects. Antibodies can also be designed to target particular pathogens or modulate immune function by activating or suppressing certain pathways. Despite their benefit for patients, the production and administration of monoclonal antibody therapeutics are laborious, costly, and time-consuming. Administration often requires inpatient stays and repeated dosing to maintain therapeutic levels, limiting their use in underserved populations and developing countries. Researchers are developing alternate methods to deliver monoclonal antibodies, including synthetic nucleic acid-based delivery, to overcome these limitations. These methods allow for in vivo production of monoclonal antibodies, which would significantly reduce costs and simplify administration logistics. This review explores new methods for monoclonal antibody delivery, including synthetic nucleic acids, and their potential to increase the accessibility and utility of life-saving treatments for several diseases.

Patients Who Decompensate and Trigger Rapid Response Immediately Upon Hospital Admission Have Higher Mortality Than Equivalent Patients Without Rapid Responses.

BACKGROUND: Rapid response teams (RRTs) have impacted the management of decompensating patients, potentially improving mortality. Few studies address the significance of RRT timing relative to hospital admission. We aimed to identify outcomes of adult patients who trigger immediate RRT activation, defined as within 4 hours of admission and compare with RRT later in admission or do not require RRT activation, and identify risk factors that predispose toward immediate RRT activation. METHODS: A retrospective case-control study was performed using an RRT activation database, comprising 201,783 adult inpatients at an urban, academic, tertiary care hospital. This group was subdivided by timing of RRT activation regarding admission: within the first 4 hours (immediate RRT), between 4 and 24 hours (early RRT), and after 24 hours (late RRT). The primary outcome was 28-day all-cause mortality. Individuals triggering an immediate RRT were compared with demographically matched controls. Mortality was adjusted for age, Quick Systemic Organ Failure Assessment score, intensive care unit admission, and Elixhauser Comorbidity Index. RESULTS: Patients with immediate RRT had adjusted 28-day all-cause mortality of 7.1% (95% confidence interval [CI], 5.6%-8.5%) and death odds ratio of 3.27 (95% CI, 2.5-4.3) compared with those who did not (mortality, 2.9%; 95%CI, 2.8%-2.9%; P < 0.0001). Patients triggering an immediate RRT were more likely to be Black, be older, and have higher Quick Systemic Organ Failure Assessment scores than those who did not trigger RRT activation. CONCLUSIONS: In this cohort, patients who require immediate RRT experienced higher 28-day all-cause mortality, potentially because of evolving or unrecognized critical illness. Further exploring this phenomenon may create opportunities for improved patient safety.

Nanoparticle stereochemistry-dependent endocytic processing improves in vivo mRNA delivery.

Stereochemistry can alter small-molecule pharmacokinetics, safety and efficacy. However, it is unclear whether the stereochemistry of a single compound within a multicomponent colloid such as a lipid nanoparticle (LNP) can influence its activity in vivo. Here we report that LNPs containing stereopure 20α-hydroxycholesterol (20α) delivered mRNA to liver cells up to 3-fold more potently than LNPs containing a mixture of both 20α- and 20ß-hydroxycholesterols (20mix). This effect was not driven by LNP physiochemical traits. Instead, in vivo single-cell RNA sequencing and imaging revealed that 20mix LNPs were sorted into phagocytic pathways more than 20α LNPs, resulting in key differences between LNP biodistribution and subsequent LNP functional delivery. These data are consistent with the fact that nanoparticle biodistribution is necessary, but not sufficient, for mRNA delivery, and that stereochemistry-dependent interactions between LNPs and target cells can improve mRNA delivery.

Supporting Professionals in Critical Care Medicine: Burnout, Resiliency, and System-Level Change.

Burnout is occurring in epidemic proportions among intensive care unit physicians and other health-care professionals-accelerated by pandemic-driven stress. The impact of burnout is far-reaching, threatening the health of individual workers, the safety and quality of care our patients receive, and eroding the infrastructure of health care in general. Drivers of burnout include excessive quantity of work (nights, weekends, and acuity surges); excessive menial tasks; incivility, poor communication, and challenges to team success; and frequent moral distress and end-of-life issues. This article provides system-based practice and individual strategies to address these drivers and improve the well-being of our team and our patients.

COVID-19: Lessons Learned, Lessons Unlearned, Lessons for the Future.

The COVID-19 pandemic has affected clinicians in many different ways. Clinicians have their own experiences and lessons that they have learned from their work in the pandemic. This article outlines a few lessons learned from the eyes of CHEST Critical Care Editorial Board members, namely practices which will be abandoned, novel practices to be adopted moving forward, and proposed changes to the health care system in general. In an attempt to start the discussion of how health care can grow from the pandemic, the editorial board members outline their thoughts on these lessons learned.

High Surgical Complication Rates after Silicone Implant Use for Improvement of Glans Ridge Appearance.

Background: Construction of the glans is an important aspect of gender-affirming phalloplasty. In these surgeries, the glans ridge is commonly constructed using the Norfolk technique or a similar technique. In cases of glans ridge flattening after creation, we generally recommend a redo/revision glansplasty, which is often curative. However, in situations when the glans ridge flattens again, we developed a silicone glans implant technique in an effort to create a satisfactory and lasting glans ridge. Methods: We conducted a pilot study of our first 12 glans implant cases. A retrospective chart review and brief, ad-hoc patient survey measured patient demographics, implant status, and patient satisfaction. Results: A total of 12 patients received a silicone glans implant between November 2017 and February 2020. One patient had the glans implant removed before the survey, and also could not be contacted. Three patients did not respond to the survey. Of the eight patients who responded, only five (5/8, 63%) patients still had the silicone implant at the time of the survey. The average satisfaction score was 3.25 (range 1 = very satisfied and 5 = very dissatisfied). Common complaints cited included dissatisfaction with implant appearance, as well as infection, discomfort, and pain. Conclusions: Patients and surgeons should be aware of the possibility of a novel silicone implant technique to create a glansplasty in those with failed/flattened previous glansplasty surgery. However, the technique is in development: patient satisfaction remains spotty and complication rates are high, although technical improvements may increase future success rates.

Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications.

BACKGROUND: Penile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals. AIM: To observe complications with transmasculine penile prosthesis surgery over time and across surgical conditions. METHODS: Retrospective chart review of all transmasculine patients with phalloplasty undergoing penile prosthesis placement between 4/14/2017 and 2/11/2020 (80 patients). OUTCOMES: Independent variables include implant type, previous genital surgeries, and simultaneous genital surgeries. Dependent variables include prosthesis infection and mechanical complication (device malfunction, dislodgement, erosion). RESULTS: There was an overall complication requiring surgery rate of 36% and infection rate of 20% (15/67 for inflatable prostheses and 1/13 for semirigid), with 14% (11/80) experiencing infection requiring removal. Differences in infection rates appeared insignificant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. There was a significant relationship between infection and case number, with the probability of infection decreasing over time. Device loss at 9 months was 21% overall. Preoperative conditions of the neophallus such as prior stricture correction and perioperative factors such as simultaneous clean and clean-contaminated procedures seemed to pose no additional increase in complication rates. CLINICAL IMPLICATIONS: Type and number of prior and simultaneous non-prosthetic surgeries should not be considered as a risk factor for penile prosthesis after phalloplasty for transmasculine patients, even those that are clean-contaminated STRENGTHS & LIMITATIONS: Our cohort size is large compared to currently available studies, although not large enough to generate sufficient power for group comparisons. We have reported every genital surgical step between phalloplasty and penile prosthesis placement and recorded complications with subsequent devices after failure. Patient-reported outcomes were not collected. CONCLUSION: We demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates. Our data suggest that surgical experience may further decrease complications over time. B. L. Briles, R. Y. Middleton, K. E. Celtik, et al. Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications. J Sex Med 2022;19:641-649.

Endotracheal Tube Size Is Associated With Mortality in Patients With Status Asthmaticus.

BACKGROUND: There is limited evidence on the clinical importance of the endotracheal tube (ETT) size selection in patients with status asthmaticus who require invasive mechanical ventilation. We set out to explore the clinical outcomes of different ETT internal diameter sizes in subjects mechanically ventilated with status asthmaticus. METHODS: This was a retrospective study of intubated and non-intubated adults admitted for status asthmaticus between 2014-2021. We examined in-hospital mortality across subgroups with different ETT sizes, as well as non-intubated subjects, using logistic and generalized linear mixed-effects models. We adjusted for demographics, Charlson comorbidities, the first Sequential Organ Failure Assessment score, intubating personnel and setting, COVID-19, and the first PaCO2 . Finally, we calculated the post-estimation predictions of mortality. RESULTS: We enrolled subjects from 964 status asthmaticus admissions. The average age was 46.9 (SD 14.5) y; 63.5% of the encounters were women and 80.6% were Black. Approximately 72% of subjects (690) were not intubated. Twenty-eight percent (275) required endotracheal intubation, of which 3.3% (32) had a 7.0 mm or smaller ETT (ETT ≤ 7 group), 16.5% (159) a 7.5 mm ETT (ETT ≤ 7.5 group), and 8.6% (83) an 8.0 mm or larger ETT (ETT ≥ 8 group). The adjusted mortality was 26.7% (95% CI 13.2-40.2) for the ETT ≤ 7 group versus 14.3% ([(95% CI 6.9-21.7%], P = .04) for ETT ≤ 7.5 group and 11.0% ([95% CI 4.4-17.5], P = .02) for ETT ≥ 8 group, respectively. CONCLUSIONS: Intubated subjects with status asthmaticus had higher mortality than non-intubated subjects. Intubated subjects had incrementally higher observed mortality with smaller ETT sizes. Physiologic mechanisms can support this dose-response relationship.

Species-dependent in vivo mRNA delivery and cellular responses to nanoparticles.

Nanoparticles are tested in mice and non-human primates before being selected for clinical trials. Yet the extent to which mRNA delivery, as well as the cellular response to mRNA drug delivery vehicles, is conserved across species in vivo is unknown. Using a species-independent DNA barcoding system, we have compared how 89 lipid nanoparticles deliver mRNA in mice with humanized livers, primatized livers and four controls: mice with 'murinized' livers as well as wild-type BL/6, Balb/C and NZB/BlNJ mice. We assessed whether functional delivery results in murine, non-human primate and human hepatocytes can be used to predict delivery in the other species in vivo. By analysing in vivo hepatocytes by RNA sequencing, we identified species-dependent responses to lipid nanoparticles, including mRNA translation and endocytosis. These data support an evidence-based approach to making small-animal preclinical nanoparticle studies more predictive, thereby accelerating the development of RNA therapies.

The Digestive Diverticula in the Carnivorous Nudibranch, Melibe leonina, Do Not Contain Photosynthetic Symbionts.

A number of nudibranchs, including Melibe engeli and Melibe pilosa, harbor symbiotic photosynthetic zooxanthellae. Melibe leonina spends most of its adult life on seagrass or kelp, capturing planktonic organisms in the water column with a large, tentacle-lined oral hood that brings food to its mouth. M. leonina also has an extensive network of digestive diverticula, located just beneath its translucent integument, that are typically filled with pigmented material likely derived from ingested food. Therefore, the focus of this project was to test the hypothesis that M. leonina accumulates symbiotic photosynthetic dinoflagellates in these diverticula. First, we conducted experiments to determine if M. leonina exhibits a preference for light, which would allow chloroplasts that it might be harboring to carry out photosynthesis. We found that most M. leonina preferred shaded areas and spent less time in direct sunlight. Second, we examined the small green circular structures in cells lining the digestive diverticula. Like chlorophyll, they exhibited autofluorescence when illuminated at 480 nm, and they were also about the same size as chloroplasts and symbiotic zooxanthellae. However, subsequent electron microscopy found no evidence of chloroplasts in the digestive diverticula of M. leonina; the structures exhibiting autofluorescence at 480 nm were most likely heterolysosomes, consistent with normal molluscan digestion. Third, we did not find evidence of altered oxygen consumption or production in M. leonina housed in different light conditions, suggesting the lack of any significant photosynthetic activity in sunlight. Fourth, we examined the contents of the diverticula, using HPLC, thin layer chromatography, and spectroscopy. The results of these studies indicate that the diverticula did not contain any chlorophyll, but rather harbored other pigments, such as astaxanthin, which likely came from crustaceans in their diet. Together, all of these data suggest that M. leonina does sequester pigments from its diet, but not for the purpose of symbiosis with photosynthetic zooxanthellae. Considering the translucent skin of M. leonina, the pigmented diverticula may instead provide camouflage.

Varios nudibranquios, incluidos Melibe engeli y Melibe pilosa, albergan zooxantelas fotosintéticas simbióticas. Melibe leonina pasa la mayoría de su vida adulta en pastos marinos o quelpo, donde captura organismos planctónicos en la columna de agua con una gran capucha oral forrada por tentáculos que llevan comida a su boca. Melibe leonina también tiene una extensa red de divertículos digestivos, ubicados justo debajo de su tegumento translúcido, que generalmente están llenos de material pigmentado probablemente derivado de alimentos ingeridos. Por lo tanto, el objetivo de este proyecto fue evaluar la hipótesis de que M. leonina acumula dinoflagelados fotosintéticos simbióticos en estos divertículos. Primero, realizamos experimentos para determinar si M. leonina se orienta hacia la luz, lo cual permitiría a los cloroplastos que podría albergar el realizar la fotosíntesis. Descubrimos que la mayoría de M. leonina prefería las áreas sombreadas y pasaba menos tiempo bajo la luz solar directa. En segundo lugar, examinamos las pequeñas estructuras circulares verdes en las células que recubren los divertículos digestivos. Al igual que la clorofila, exhibieron autofluorescencia cuando se iluminaban a 480 nm, y también tenían aproximadamente el mismo tamaño que los cloroplastos y las zooxantelas simbióticas. No obstante, la microscopía electrónica no produjo evidencia de cloroplastos en los divertículos digestivos de M. leonina. Es probable que las estructuras que exhibieron autofluorescencia en 480 nm fuesen heterolisosomas, lo cual es consistente con la digestión normal de moluscos. En tercer lugar, no encontramos evidencia de un consumo o producción de oxígeno alterado en M. leonina alojadas varias condiciones lumínicas, lo cual sugiere la ausencia de actividad fotosintética significativa en la presencia de luz solar. En cuarto lugar, examinamos el contenido de los divertículos mediante HPLC, cromatografía en capa fina, y espectroscopia. Los resultados de estos estudios indican que los divertículos no contenían clorofila, pero si otros pigmentos como la astaxantina que probablemente provenía de crustáceos en su dieta. Nuestros datos sugieren que M. leonina secuestra pigmentos de su dieta, pero no con el propósito de la simbiosis con zooxantelas fotosintéticas. Teniendo en cuenta la piel translúcida de M. leonina, los divertículos pigmentados podrían quizás proporcionar camuflaje.

Planned and Unplanned Delayed Anterolateral Thigh Flap Phalloplasty.

BACKGROUND: Pedicled anterolateral thigh (ALT) flap phalloplasty can be limited by inadequate perfusion. Vascular delay increases perfusion, as delay causes blood vessel formation by limiting the blood supply available to a flap before transfer. We hypothesized that delayed ALT flap phalloplasty would decrease rates of partial flap or phallus loss and other postoperative complications when compared with previously reported complication rates of undelayed single-stage ALT phalloplasty in our practice. METHODS: A retrospective medical record review was performed on all phalloplasty patients in our practice between January 2016 and September 2019. We found those patients who had completed delayed ALT flap phalloplasty with at least 6 months of delay and 12 months of follow-up. For these patients, we recorded postoperative complications, simultaneous surgeries, subsequent surgeries, and demographic characteristics. RESULTS: Five female-to-male transsexuals underwent delayed ALT flap phalloplasty (two were unplanned procedures, three were planned). Planned delay: The average time between Stage 1 and Stage 2 was 6.5 months. Complications for the planned delay cohort were as follows: partial loss of the neophallus not requiring repair (33%), urethral stricture requiring surgical repair (33%). Unplanned delay: The average time between Stage 1 and Stage 2 was 9.1 months. The following complication was seen in the unplanned delay cohort: urethral stricture requiring surgical repair (50%). CONCLUSIONS: Vascular delay of ALT flap phalloplasty is a successful emergency salvage procedure. Planned delay of ALT flaps provided similar results compared with those previously reported by our practice with standard single-stage approach.

Optimization of Second-stage Metoidioplasty.

OBJECTIVE: To describe a planned 2-staged metoidioplasty. Metoidioplasty is a genital gender-affirmation surgery aimed at creating a neophallus, scrotum (if desired), and flat male-type perineum (if desired) from natal tissues. It generally requires a planned second-stage to place testes prostheses, address complications, and perform additional surgical steps to maximally lengthen the phallus. The details of this procedure are sparsely mentioned in the literature. We found that phallus length can be optimized in the second-stage by applying surgical principles already established in the surgical treatment of adult acquired buried penis. MATERIAL AND METHODS: We conducted a retrospective chart review of patients after metoidioplasty between August 2015 and June 2020, and isolated those that underwent second-stage metoidioplasty. Each procedure was done by 1 of 4 surgeons in a single practice in 2 locations, San Francisco, CA, and Austin, TX. Details of procedures required, complications, and demographic information were recorded. RESULTS: Out of the 75 patients that had undergone metoidioplasty, 37 (37 of 75, 49%) underwent a second-stage metoidioplasty. Reduction of upper scrotal blocking tissue was the most common procedure performed during a second-stage metoidioplasty (31 of 37, 84%), followed by escutcheonectomy/penile lift (30 of 37, 81%), bilateral implant placement (20 of 37, 54%), chordee repair (13 of 37, 35%), and unilateral implant placement (1 of 37, 3%). 6 of the 37 patients (16%) developed major complications. 5 of the 37 (5 of 37, 15%) second-stage patients required a redo second-stage metoidioplasty. CONCLUSION: Second-stage metoidioplasties are commonly performed on patients to optimize results of phallic lengthening and release, and to repair complications that arise after single-stage metoidioplasty. Escutcheonectomy/penile lift, placement of scrotal implants, repair of chordee, and upper scrotal blocking tissue reduction are procedures that are often performed during a second-stage metoidioplasty.

Arteriovenous Fistula Rescues Radial Forearm Phalloplasty: A Case Report on Patients with Microvascular Obstruction.

Radial forearm free flap phalloplasty (RFFFP) is the most common surgery performed for genital reconstruction of female-to-male transgender patients. However, up to 19% require anastomotic re-exploration. The postoperative creation of an arteriovenous fistula (AVF) to bypass obstruction and salvage RFFFP was first reported in 1996 and has subsequently been reported by 1 high-volume center in Belgium. METHODS: Here, we present 2 cases in which intraoperative microvascular obstruction threatened the viability of the RFFF of transgender phalloplasty patients. In each patient, an AVF was created between the radial artery and cephalic vein in the distal flap either after being transferred out of the operating room, as has previously been described, or during initial operation. RESULTS: In both cases, the creation of a distal AVF salvaged the neophallus. Importantly, the patient that had been transferred out of the operating room before reintervention suffered partial flap necrosis compared with no flap loss in the patient who had an AVF created during initial surgery. One AVF was ligated 18 days postoperative, whereas the other was never formally closed. CONCLUSIONS: These cases demonstrate that AVF can be reliably used for RFFFP salvage both intraoperatively and for reintervention. They also suggest that earlier detection of persistent vascular compromise and utilization of AVF can further minimize flap loss. Finally, in contrast with the prior explanation of this technique, timing of AVF ligation may be less critical than previously described. Microsurgeons are reminded that this technique may save complicated flaps in the uncommon case of microcirculatory flap obstruction.