Diversity of the free helical rim flap: A case series tailoring the microsurgical technique to esthetically optimize full-thickness nasal defect reconstructions.

INTRODUCTION: The free helical rim (FHR) flap offers like-with-like reconstruction for full-thickness nasal defects. A case series of nasal reconstruction using an FHR flap was presented, detailing surgical steps and refinements, as well as functional and esthetic outcomes. METHODS AND MATERIALS: This is a retrospective cohort study of composite nasal defect reconstruction with FHR flap from August 2018 to March 2020. Descriptive data were analyzed by SPSS software. RESULTS: Six cases were recruited, four were unilateral alar defects, one was hemi-nose, and one was ala plus tip. The average size of the defect was 2.5 × 2.8 cm2. Three FHR flaps were designed with retrograde pedicles and three with anterograde pedicles. The facial artery and veins were the recipient vessels in all cases. Vascular grafts were used in all six cases. Descending branch of the lateral circumflex femoral (DLCxF) artery and vein functioned as interposition vascular conduits in five cases. Superficial forearm vein grafts were used in one case. One patient needed flap re-exploration due to venous congestion. One patient had partial flap necrosis due to delayed infection, and one developed delayed wound dehiscence in the irradiated wound. The average follow-up was 18 months. CONCLUSION: The FHR flap has consistent vascular anatomy. It can be raised as an anterograde or retrograde flap for a contralateral or ipsilateral inset. FHR flap can be used in extensive composite nasal defects. This case series demonstrates that interposition vascular grafts are invariably needed and the possibility of using forearm vessels as grafts instead of DLCxF artery and vein.

Quantitative evaluation of aerosol generation during manual facemask ventilation.

Manual facemask ventilation, a core component of elective and emergency airway management, is classified as an aerosol-generating procedure. This designation is based on one epidemiological study suggesting an association between facemask ventilation and transmission during the SARS-CoV-1 outbreak in 2003. There is no direct evidence to indicate whether facemask ventilation is a high-risk procedure for aerosol generation. We conducted aerosol monitoring during routine facemask ventilation and facemask ventilation with an intentionally generated leak in anaesthetised patients. Recordings were made in ultraclean operating theatres and compared against the aerosol generated by tidal breathing and cough manoeuvres. Respiratory aerosol from tidal breathing in 11 patients was reliably detected above the very low background particle concentrations with median [IQR (range)] particle counts of 191 (77-486 [4-1313]) and 2 (1-5 [0-13]) particles.l-1 , respectively, p = 0.002. The median (IQR [range]) aerosol concentration detected during facemask ventilation without a leak (3 (0-9 [0-43]) particles.l-1 ) and with an intentional leak (11 (7-26 [1-62]) particles.l-1 ) was 64-fold (p = 0.001) and 17-fold (p = 0.002) lower than that of tidal breathing, respectively. Median (IQR [range]) peak particle concentration during facemask ventilation both without a leak (60 (0-60 [0-120]) particles.l-1 ) and with a leak (120 (60-180 [60-480]) particles.l-1 ) were 20-fold (p = 0.002) and 10-fold (0.001) lower than a cough (1260 (800-3242 [100-3682]) particles.l-1 ), respectively. This study demonstrates that facemask ventilation, even when performed with an intentional leak, does not generate high levels of bioaerosol. On the basis of this evidence, we argue facemask ventilation should not be considered an aerosol-generating procedure.

Aerosolisation during tracheal intubation and extubation in an operating theatre setting.

Aerosol-generating procedures such as tracheal intubation and extubation pose a potential risk to healthcare workers because of the possibility of airborne transmission of infection. Detailed characterisation of aerosol quantities, particle size and generating activities has been undertaken in a number of simulations but not in actual clinical practice. The aim of this study was to determine whether the processes of facemask ventilation, tracheal intubation and extubation generate aerosols in clinical practice, and to characterise any aerosols produced. In this observational study, patients scheduled to undergo elective endonasal pituitary surgery without symptoms of COVID-19 were recruited. Airway management including tracheal intubation and extubation was performed in a standard positive pressure operating room with aerosols detected using laser-based particle image velocimetry to detect larger particles, and spectrometry with continuous air sampling to detect smaller particles. A total of 482,960 data points were assessed for complete procedures in three patients. Facemask ventilation, tracheal tube insertion and cuff inflation generated small particles 30-300 times above background noise that remained suspended in airflows and spread from the patient's facial region throughout the confines of the operating theatre. Safe clinical practice of these procedures should reflect these particle profiles. This adds to data that inform decisions regarding the appropriate precautions to take in a real-world setting.

Impact of implementing respiratory point-of-care testing in a regional haemato-oncology unit.

Respiratory point-of-care testing (POCT) for the detection of influenza A, influenza B and respiratory syncytial virus (RSV) was implemented in response to recent RSV outbreaks at a regional haemato-oncology unit in Glasgow. This descriptive study, undertaken pre- and post-POCT implementation, suggests that POCT reduces the time taken to receive results and increases diagnostic rates in outpatients. It is likely that the reduction in turnaround time afforded by POCT also leads to a faster time to antiviral treatment, prompt isolation and a reduction in the number of hospital-acquired infections.

Regulation of energy metabolism during social interactions in rainbow trout: a role for AMP-activated protein kinase.

Rainbow trout (Oncorhynchus mykiss) confined in pairs form social hierarchies in which subordinate fish typically experience fasting and high circulating cortisol levels, resulting in low growth rates. The present study investigated the role of AMP-activated protein kinase (AMPK) in mediating metabolic adjustments associated with social status in rainbow trout. After 3 days of social interaction, liver AMPK activity was significantly higher in subordinate than dominant or sham (fish handled in the same fashion as paired fish but held individually) trout. Elevated liver AMPK activity in subordinate fish likely reflected a significantly higher ratio of phosphorylated AMPK (phospho-AMPK) to total AMPK protein, which was accompanied by significantly higher AMPKα1 relative mRNA abundance. Liver ATP and creatine phosphate concentrations in subordinate fish also were elevated, perhaps as a result of AMPK activity. Sham fish that were fasted for 3 days exhibited effects parallel to those of subordinate fish, suggesting that low food intake was an important trigger of elevated AMPK activity in subordinate fish. Effects on white muscle appeared to be influenced by the physical activity associated with social interaction. Overall, muscle AMPK activity was significantly higher in dominant and subordinate than sham fish. The ratio of phospho-AMPK to total AMPK protein in muscle was highest in subordinate fish, while muscle AMPKα1 relative mRNA abundance was elevated by social dominance. Muscle ATP and creatine phosphate concentrations were high in dominant and subordinate fish at 6 h of interaction and decreased significantly thereafter. Collectively, the findings of the present study support a role for AMPK in mediating liver and white muscle metabolic adjustments associated with social hierarchy formation in rainbow trout.

MRI screening-detected breast lesions in high-risk young women: the value of targeted second-look ultrasound and imaging-guided biopsy.

AIM: To analyse the value of targeted second-look ultrasound and imaging-guided biopsy in high-risk young women eligible for screening magnetic resonance imaging (MRI) in a tertiary referral centre in Perth, Western Australia. MATERIALS AND METHODS: A retrospective analysis of eligible high-risk young women who underwent screening breast MRI and targeted second-look ultrasound between June 2012 and June 2014 was performed with review of data. RESULTS: Over a 2-year period, 139 women underwent high-risk screening MRI. Of these, 30 women (with a total of 45 lesions) were recalled for targeted second-look ultrasound. Thirty-four MRI-detected lesions were identified on targeted ultrasound with 19 of them proceeding to ultrasound-guided biopsy, while the remaining 15 lesions were considered benign on ultrasound, were not biopsied, and were stable on follow-up imaging 12 months later. One lesion proceeded to an MRI-guided biopsy to confirm a benign result. Of the 11 lesions not seen on ultrasound, nine underwent MRI biopsy, one proceeded directly to hook wire localisation and excision, and one did not return for biopsy and was lost to follow-up. The overall biopsy rate was 14.4%. The cancer detection rate was 1.4%. CONCLUSION: The results of this study indicate that targeted second-look ultrasound and ultrasound-guided biopsy is a cost-effective and time-efficient approach for MRI-detected lesions in young women at high risk of developing breast cancer. MRI-guided biopsy should be considered for ultrasonographically occult suspicious lesions as there is a low, but definite, risk of cancer.

Predicting the chance of live birth for women undergoing IVF: a novel pretreatment counselling tool.

STUDY QUESTION: Which pretreatment patient variables have an effect on live birth rates following assisted conception? SUMMARY ANSWER: The predictors in the final multivariate logistic regression model found to be significantly associated with reduced chances of IVF/ICSI success were increasing age (particularly above 36 years), tubal factor infertility, unexplained infertility and Asian or Black ethnicity. WHAT IS KNOWN ALREADY: The two most widely recognized prediction models for live birth following IVF were developed on data from 1991 to 2007; pre-dating significant changes in clinical practice. These existing IVF outcome prediction models do not incorporate key pretreatment predictors, such as BMI, ethnicity and ovarian reserve, which are readily available now. STUDY DESIGN, SIZE, DURATION: In this cohort study a model to predict live birth was derived using data collected from 9915 women who underwent IVF/ICSI treatment at any CARE (Centres for Assisted Reproduction) clinic from 2008 to 2012. Model validation was performed on data collected from 2723 women who underwent treatment in 2013. The primary outcome for the model was live birth, which was defined as any birth event in which at least one baby was born alive and survived for more than 1 month. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data were collected from 12 fertility clinics within the CARE consortium in the UK. Multivariable logistic regression was used to develop the model. Discriminatory ability was assessed using the area under receiver operating characteristic (AUROC) curve, and calibration was assessed using calibration-in-the-large and the calibration slope test. MAIN RESULTS AND THE ROLE OF CHANCE: The predictors in the final model were female age, BMI, ethnicity, antral follicle count (AFC), previous live birth, previous miscarriage, cause and duration of infertility. Upon assessing predictive ability, the AUROC curve for the final model and validation cohort was (0.62; 95% confidence interval (CI) 0.61-0.63) and (0.62; 95% CI 0.60-0.64) respectively. Calibration-in-the-large showed a systematic over-estimation of the predicted probability of live birth (Intercept (95% CI) = -0.168 (-0.252 to -0.084), P < 0.001). However, the calibration slope test was not significant (slope (95% CI) = 1.129 (0.893-1.365), P = 0.28). Due to the calibration-in-the-large test being significant we recalibrated the final model. The recalibrated model showed a much-improved calibration. LIMITATIONS, REASONS FOR CAUTION: Our model is unable to account for factors such as smoking and alcohol that can affect IVF/ICSI outcome and is somewhat restricted to representing the ethnic distribution and outcomes for the UK population only. We were unable to account for socioeconomic status and it may be that by having 75% of the population paying privately for their treatment, the results cannot be generalized to people of all socioeconomic backgrounds. In addition, patients and clinicians should understand this model is designed for use before treatment begins and does not include variables that become available (oocyte, embryo and endometrial) as treatment progresses. Finally, this model is also limited to use prior to first cycle only. WIDER IMPLICATIONS OF THE FINDINGS: To our knowledge, this is the first study to present a novel, up-to-date model encompassing three readily available prognostic factors; female BMI, ovarian reserve and ethnicity, which have not previously been used in prediction models for IVF outcome. Following geographical validation, the model can be used to build a user-friendly interface to aid decision-making for couples and their clinicians. Thereafter, a feasibility study of its implementation could focus on patient acceptability and quality of decision-making. STUDY FUNDING/COMPETING INTEREST: None.

Salpingostomy in the treatment of hydrosalpinx: a systematic review and meta-analysis.

STUDY QUESTION: What is the chance of natural conception when salpingostomy is used to treat hydrosalpinx?. SUMMARY ANSWER: The natural clinical pregnancy rate following salpingostomy is 27%, in the hands of experienced surgeons who publish their results. WHAT IS KNOWN ALREADY: Tubal surgery is not commonly offered for women with hydrosalpinges since the advent of assisted conception treatment. This is the first systematic review to investigate natural conception rates following salpingostomy in the treatment of hydrosalpinx. STUDY DESIGN, SIZE, DURATION: A systematic review and meta-analysis of 22 observational studies encompasses 2810 patients undergoing salpingostomy and attempting natural conception. PARTICIPANTS/MATERIALS, SETTING, METHODS: Literature searches were conducted to retrieve observational studies which reported salpingostomy for hydrosalpinx. Databases searched included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and CINAHL, with no language restriction. Only studies that focused on salpingostomy (rather than other tubal conserving surgeries) for the treatment of hydrosalpinx were included. A total of 22 studies matched the inclusion criteria. MAIN RESULTS AND THE ROLE OF CHANCE: The pooled natural clinical pregnancy rate from the 22 observational studies (including 2810 patients) was 27% (95% confidence interval (CI): 25-29%) after salpingostomy was performed for hydrosalpinx. The cumulative clinical pregnancy rates were 8.7% (95% CI: 6.6-11.5%) at 6 months, 13.3% (95% CI: 10.6-16.7%) at 9 months, 20.0% (95% CI: 17.5-22.8%) at 12 months, 21.2% (95% CI: 18.6-24.1%) at 18 months and 25.5% (95% CI: 22.2-29.4%) at 24 months after salpingostomy. The pooled live birth rate (10 studies, 1469 patients) was 25% (95% CI: 22-28%) after salpingostomy was performed for hydrosalpinx. The pooled ectopic pregnancy rate (19 studies, 2662 patients) was 10% (95% CI: 9-11%). The pooled miscarriage rate (seven studies, 924 patients) was 7% (95% CI: 6-9%). The included studies scored well on the Newcastle Ottawa quality assessment scale. LIMITATIONS, REASONS FOR CAUTION: Strict inclusion criteria were used in the conduct of the systematic review. However, the studies included are clinically heterogeneous in many aspects including patient characteristics, surgical technique and duration of follow-up after salpingostomy. WIDER IMPLICATIONS OF THE FINDINGS: The findings of this systematic review suggest that salpingostomy is an alternative treatment strategy to tubal clipping or salpingectomy in patients presenting to fertility services with hydrosalpinx. Further prospective, large and high quality studies are needed to identify the subpopulation that would most benefit from tube conserving surgery. STUDY FUNDING/COMPETING INTERESTS: No external funding was either sought or obtained for this study. The authors have no competing interests to declare. TRIAL REGISTRATION NUMBER: N/A.

Comparison of Solomon technique with selective laser ablation for twin-twin transfusion syndrome: a systematic review.

OBJECTIVE: To compare the Solomon and selective techniques for fetoscopic laser ablation (FLA) for the treatment of twin-twin transfusion syndrome (TTTS) in monochorionic-diamniotic twin pregnancies. METHODS: This was a systematic review conducted in accordance with the PRISMA statement. Electronic searches were performed for relevant citations published from inception to September 2014. Selected studies included pregnancies undergoing FLA for TTTS that reported on recurrence of TTTS, occurrence of twin anemia-polycythemia sequence (TAPS) or survival. RESULTS: From 270 possible citations, three studies were included, two cohort studies and one randomized controlled trial (RCT), which directly compared the Solomon and selective techniques for FLA. The odds ratios (OR) of recurrent TTTS when using the Solomon vs the selective technique in the two cohort studies (n = 249) were 0.30 (95% CI, 0.00-4.46) and 0.45 (95% CI, 0.07-2.20). The RCT (n = 274) demonstrated a statistically significant reduction in risk of recurrent TTTS with the Solomon technique (OR, 0.21 (95% CI, 0.04-0.98); P = 0.03). The ORs for the development of TAPS following the Solomon and the selective techniques were 0.20 (95% CI, 0.00-2.46) and 0.61 (95% CI, 0.05-5.53) in the cohort studies and 0.16 (95% CI, 0.05-0.49) in the RCT, with statistically significant differences for the RCT only (P < 0.001). Observational evidence suggested overall better survival with the Solomon technique, which was statistically significant for survival of at least one twin. The RCT did not demonstrate a significant difference in survival between the two techniques, most probably owing to the small sample size and lack of power. CONCLUSION: This systematic review of observational, comparative cohort and RCT data suggests a trend towards a reduction in TAPS and recurrent TTTS and an increase in twin survival, with no increase in the occurrence of complications or adverse events, when using the Solomon compared to the selective technique for the treatment of TTTS. These findings need to be confirmed by an appropriately-powered RCT with long-term neurological follow-up.

Indications for diagnostic open biopsy of mammographic screen-detected lesions preoperatively diagnosed as fibroadenomas by needle biopsy and their outcomes.

AIM: To identify the clinical, radiological, and histopathological factors that resulted in a diagnostic open biopsy of mammographic screen-detected lesions diagnosed preoperatively as fibroadenomas by needle biopsy. MATERIALS AND METHODS: BreastScreen WA data over 10 year period from 1 January 1999 to 31 December 2008 was reviewed. RESULTS: Among the 760,027 women screened in Western Australia between 1999 and 2008, 31 had a fine-needle aspiration (FNA) or a core biopsy (CB) diagnosing a fibroadenoma and subsequently underwent a diagnostic open biopsy (DOB). Three were preoperatively diagnosed as fibroadenoma by initial FNA but subsequent CB showed that these were not fibroadenomas and, therefore, were excluded from the present series. Of the 28 cases, DOB identified 21 fibroadenomas, two cellular fibroadenomas, two benign phyllodes tumours, one malignant phyllodes tumour, one fibroadenoma containing ductal carcinoma in situ (DCIS), and one case of a 40mm adenosis tumour with a small 5mm fibroadenoma. The lesions ranged from 5-100mm in size with an average size of 28mm. DOB and CB results were concordant in 25 (89%) of the cases. The primary clinical indications for undergoing DOB included indeterminate histopathological findings of cellular fibroadenomas versus phyllodes tumour (n = 10), enlarging size (n = 4), large size (n = 5), fibroadenomas with atypia (n = 1), discordant radiological and pathological findings (n = 3), patient preference (n = 1), association with a second screen-detected lesion requiring excision (n = 2), and an unknown indication (n = 1). CONCLUSION: CB diagnosis of fibroadenomas is a safe diagnosis unless it has atypical clinical, radiological, or pathological features.

Additional information from chromosomal microarray analysis (CMA) over conventional karyotyping when diagnosing chromosomal abnormalities in miscarriage: a systematic review and meta-analysis.

BACKGROUND: Approximately 50% of spontaneous miscarriages are associated with chromosome abnormalities. Identification of these karyotypic abnormalities helps to estimate recurrence risks in future pregnancies. Chromosomal microarray analysis (CMA) is transforming clinical cytogenetic practice with its ability to examine the human genome at increasingly high resolution. OBJECTIVES: The aim of this study was to determine whether CMA testing on the products of conception following miscarriage provides better diagnostic information compared with conventional karyotyping. SEARCH STRATEGY: MEDLINE (from 1996 to December 2012), EMBASE (from 1974 to December 2012), and CINAHL (from 1996 to December 2012) databases were searched electronically. SELECTION CRITERIA: Studies were selected if CMA was used on products of conception following miscarriage, alongside conventional karyotyping. DATA COLLECTION AND ANALYSIS: Nine papers were included in the systematic review and meta-analysis. All statistical analyses were performed using stata 11.0 (Stata Corp., College Station, TX, USA). MAIN RESULTS: There was agreement between CMA and karyotyping in 86.0% of cases (95% CI 77.0-96.0%). CMA detected 13% (95% CI 8.0-21.0) additional chromosome abnormalities over conventional full karyotyping. In addition, traditional, full karyotyping detected 3% (95% CI 1.0-10.0%) additional abnormalities over CMA. The incidence of a variant of unknown significance (VOUS) being detected was 2% (95% CI 1.0-10.0%). AUTHOR'S CONCLUSIONS: Compared with karyotyping, there appears to be an increased detection rate of chromosomal abnormalities when CMA is used to analyse the products of conception; however, some of these abnormalities are VOUS, and this information should be provided when counselling women following miscarriage and when taking consent for the analysis of miscarriage products by CMA.

Gill remodeling in crucian carp during sustained exercise and the effect on subsequent swimming performance.

Gill remodeling can be extensive in crucian carp, where up to a 7.5-fold increase in gill surface area has been observed during exposure to hypoxia through a reduction in the interlamellar cell mass (ILCM) and increased lamellar protrusion that has been hypothesized to be signaled by the need to maximize oxygen uptake under a given condition. Sustained aerobic exercise may have the greatest influence on oxygen demand in fish; however, its effect on gill remodeling in crucian carp has not been investigated. The specific objectives of this study were to determine (i) whether sustained aerobic exercise induces gill remodeling in the crucian carp, (ii) whether gill remodeling following sustained exercise affects the maximum critical swimming speed (U(crit)) and maximal oxygen consumption rate ([Formula: see text]), and (iii) whether gill remodeling following sustained exercise is associated with trade-offs related to ionoregulation. We measured [Formula: see text] in crucian carp at each step during an initial U(crit) test (U(crit1)), forced them to swim at 70% of U(crit) for 40 h, and then conducted a second U(crit) test (U(crit2)). From rest to U(crit1) (7-8 h), we observed a significant increase in protruding lamella height and area of the gills and a reduction in ILCM height and volume, likely associated with partial shedding of the ILCM, indicating that gill remodeling during exercise is rapid. Further changes were observed between U(crit1) and U(crit2), with statistically significant increases in protruding lamellar height, basal length and area, and a statistically significant reduction in protruding lamellar thickness and ILCM height and volume. Interestingly, there was no significant difference between U(crit1) and U(crit2) values, nor in maximal [Formula: see text] measured at U(crit1) and U(crit2). Furthermore, there was no significant difference in plasma osmolarity, [Na(+)], or [Cl(-)] in fish at rest, following U(crit1) or U(crit2). Thus, while these data support the hypothesis that the need to maximize oxygen uptake is an important signal for gill remodeling, which can occur quite rapidly (within 7 h at 15°C), the physiological implications of remodeling during exercise are less clear.

Cystic lesion of the ventriculus terminalis in an adult.

We present a 40-year-old man with conus medullaris syndrome secondary to a cystic lesion of the ventriculus terminalis (CLVT) and review the relevant literature. The patient presented with 4 years of worsening right leg weakness, and examination showed bilateral fasciculations and hyporeflexia. MRI showed a cystic lesion at T11-12. He was managed with a T11-12 laminectomy and fenestration of an intramedullary cyst. A total of 32 patients, including ours, have been described since 1968: 24 were female with a mean age of 46.6 years. All patients presented symptomatically: five were managed conservatively, four using percutaneous aspiration under MRI guidance, and 22 with open surgery. We conclude that symptomatic patients are best managed surgically, although percutaneous aspiration is an emerging technique.

The long-term effectiveness of clozapine and lamotrigine in a patient with treatment-resistant rapid-cycling bipolar disorder.

The challenges in the management of treatment-resistant rapid-cycling bipolar disorder are multifaceted and represent a significant burden to the patient. There is a need for more exploration into the potential utility of various combination therapies in the setting of severe affective states. A 52-year-old woman with a history of severe treatment-resistant rapid-cycling bipolar affective disorder (BPAD) was hospitalized for the treatment of a severe mixed episode. The introduction of lamotrigine and clozapine in combination proved remarkably effective and well tolerated in both the acute management and in subsequent maintenance. The patient has remained asymptomatic during the 5-year follow-up without any further mood disturbance. Lamotrigine and clozapine are among the less-prescribed agents for BPAD and there is as yet little research into their use in combination. It is possible that these agents have complementary modes of action on various facets of the affective pathology, resulting in superior mood stabilization in this patient.