Spontaneous Intercostal Artery Bleeding in a Patient With Buerger's Disease: A Case Report.

Intercostal artery (ICA) injury and bleeding are well-known complications of thoracic procedures and trauma; however, spontaneous ICA bleeding is a rare condition usually associated with specific underlying disorders that typically lead to the weakening of vasculature. Herein, we present a 42-year-old male with a history of Buerger's disease who developed spontaneous bleeding of the second left ICA after undergoing lower limb angioplasty. The bleeding was complicated by a large hemothorax and retropleural hematoma, resulting in hemorrhagic shock that necessitated massive transfusion, embolization, and eventual thoracotomy with evacuation.

The characteristics and predictors of mortality in periprosthetic fractures around the knee.

Aims: Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Methods: Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality. Results: Out of a total of 1,667 patients in the PPF study database, 420 patients were included. The in-hospital mortality rate was 6.4%. Multivariable analyses suggested that American Society of Anesthesiologists (ASA) grade, history of peripheral vascular disease (PVD), history of rheumatic disease, fracture around a loose implant, and cerebrovascular accident (CVA) during hospital stay were each independently associated with mortality. Each point increase in ASA grade independently correlated with a four-fold greater mortality risk (odds ratio (OR) 4.1 (95% confidence interval (CI) 1.19 to 14.06); p = 0.026). Patients with PVD have a nine-fold increase in mortality risk (OR 9.1 (95% CI 1.25 to 66.47); p = 0.030) and patients with rheumatic disease have a 6.8-fold increase in mortality risk (OR 6.8 (95% CI 1.32 to 34.68); p = 0.022). Patients with a fracture around a loose implant (Unified Classification System (UCS) B2) have a 20-fold increase in mortality, compared to UCS A1 (OR 20.9 (95% CI 1.61 to 271.38); p = 0.020). Mode of management was not a significant predictor of mortality. Patients managed with revision arthroplasty had a significantly longer length of stay (median 16 days; p = 0.029) and higher rates of return to theatre, compared to patients treated nonoperatively or with fixation. Conclusion: The mortality rate in PPFs around the knee is similar to that for native distal femur and neck of femur fragility fractures. Patients with certain modifiable risk factors should be optimized. A national PPF database and standardized management guidelines are currently required to understand these complex injuries and to improve patient outcomes.

Predictors of mortality in periprosthetic fractures of the hip: Results from the national PPF study.

INTRODUCTION: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip. METHODS: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality. RESULTS: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality. CONCLUSION: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance.

Continuous vs. intermittent terlipressin infusion for portal hypertension: a systematic review and meta-analysis.

Background: Portal hypertension, a major complication of chronic liver disease, often leads to life-threatening variceal bleeding, managed effectively with vasoactive drugs like terlipressin. However, the most optimal method of terlipressin administration, continuous versus intermittent infusion, remains a subject of debate, necessitating this systematic review and meta-analysis for evidence-based decision-making in managing this critical condition. Methods: This systematic review and meta-analysis adhered to the PRISMA standards and explored multiple databases until 6 April 2023, such as MEDLINE through PubMed, Scopus, Web of Science, and CENTRAL. Independent reviewers selected randomized controlled trials (RCTs) that met specific inclusion criteria. After assessing study quality and extracting necessary data, statistical analysis was performed using Review Manager (RevMan), with results presented as risk ratios (RR) or mean differences. Results: Five RCTs (n=395 patients) were included. The continuous terlipressin group had a significantly lower risk of rebleeding (RR=0.43, P=0.0004) and treatment failure (RR=0.22, P=0.02) and fewer total adverse effects (RR=0.52, P<0.00001) compared to the intermittent group. However, there were no significant differences between the two groups in mean arterial pressure (P=0.26), length of hospital stays (P=0.78), and mortality rates (P=0.65). Conclusion: This study provides robust evidence suggesting that continuous terlipressin infusion may be superior to intermittent infusions in reducing the risk of rebleeding, treatment failure, and adverse effects in patients with portal hypertension. However, further large-scale, high-quality RCTs are required to confirm these findings and to investigate the potential benefits of continuous terlipressin infusion on mortality and hospital stays.

Economic Uses of Salt-Tolerant Plants.

Climate change is likely to affect the ability of world agricultural systems to provide food, fibre, and fuel for the growing world population, especially since the area of salinised land will increase. However, as few species of plants (less than 1% of all plant species) can tolerate saline soils, we believe it is important to evaluate their potential as crops for salinised soils. We have analysed the economic and potential economic uses of plants that are listed in the database eHALOPH, including the most tolerant species, halophytes. For nine main categories of economic value, we found a total of 1365 uses amongst all species listed in eHALOPH as of July 2022; this number reduced to 918 amongst halophytes. We did not find any obvious differences in rankings between the more tolerant halophytes and the whole group of salt-tolerant plants, where the order of use was medical, followed by forage, traditional medicine, food and drink, fuel, fuelwood, and bioenergy. While many species are potentially important as crops, the effects of salt concentration on their uses are much less well documented. Increasing salt concentration can increase, decrease, or have no effect on the concentration of antioxidants found in different species, but there is little evidence on the effect of salinity on potential yield (the product of concentration and biomass). The effect of salinity on forage quality again varies with species, often being reduced, but the overall consequences for livestock production have rarely been evaluated. Salt-tolerant plants have potential uses in the bioremediation of degraded land (including revegetation, phytoremediation, and extraction of NaCl) as well as sources of biofuels, although any use of saline water for the sustainable irrigation of salt-tolerant crops must be viewed with extreme caution.

Comparing surgical outcomes of approaches to adrenalectomy - a systematic review and network meta-analysis of randomised clinical trials.

BACKGROUND: No randomised clinical trials (RCTs) have simultaneously compared the safety of open (OA), transperitoneal laparoscopic (TLA), posterior retroperitoneal (PRA), and robotic adrenalectomy (RA) for resecting adrenal tumours. AIM: To evaluate outcomes for OA, TLA, PRA, and RA from RCTs. METHODS: A NMA was performed according to PRISMA-NMA guidelines. Analysis was performed using R packages and Shiny. RESULTS: Eight RCTs with 488 patients were included (mean age: 48.9 years). Overall, 44.5% of patients underwent TLA (217/488), 37.3% underwent PRA (182/488), 16.4% underwent RA (80/488), and just 1.8% patients underwent OA (9/488). The mean tumour size was 35 mm in largest diameter with mean sizes of 44.3 mm for RA, 40.9 mm for OA, 35.5 mm for TLA, and 34.4 mm for PRA (P < 0.001). TLA had the lowest blood loss (mean: 50.6 ml), complication rates (12.4%, 14/113), and conversion to open rates (1.3%, 2/157), while PRA had the shortest intra-operative duration (mean: 94 min), length of hospital stay (mean: 3.7 days), lowest visual analogue scale pain scores post-operatively (mean: 3.7), and was most cost-effective (mean: 1728 euros per case). At NMA, there was a significant increase in blood loss for OA (mean difference (MD): 117.00 ml (95% confidence interval (CI): 1.41-230.00)) with similar blood loss observed for PRA (MD: - 10.50 (95% CI: - 83.40-65.90)) compared to TLA. CONCLUSION: LTA and PRA are important contemporary options in achieving favourable outcomes following adrenalectomy. The next generation of RCTs may be more insightful for comparison surgical outcomes following RA, as this approach is likely to play a future role in minimally invasive adrenalectomy. PROSPERO REGISTRATION: CRD42022301005.

Digest, stain and bleach: Three steps to achieving rapid microplastic fluorescence analysis in wastewater samples.

Efforts associated with common analytical techniques for microplastics including spectroscopic and thermo-analytical techniques are limiting the ability to perform large-scale monitoring of microplastics in the aquatic environment, because the analytical equipment required is costly and the analysis itself time consuming. Thus, there is a need to develop low cost, rapid alternative monitoring approaches. One possible alternative is the use of selective fluorescence staining of microplastic particles directly applied to environmental samples. However, to the best of our knowledge this has not yet been successfully implemented for wastewater samples. In this study, sludge samples are used as surrogates for wastewater alongside six different polymers to develop a combined sample preparation and staining protocol that could selectively stain microplastics without significant interference from the natural constituents of the sludge. Results confirmed that using Fenton's reagent to remove the organic matter before staining the sample with Nile red (NR) and subsequently bleaching it by sodium hypochlorite resulted in the best workflow to selectively stain microplastics and then analyze them in wastewater samples using fluorescence microscopy.

Microplastic sampling from wastewater treatment plant effluents: Best-practices and synergies between thermoanalytical and spectroscopic analysis.

Wastewater treatment plants (WWTPs) may represent point sources for microplastic discharge into the environment. Quantification of microplastic in effluents of WWTPs has been targeted by several studies although standardized methods are missing to enable a comparability of results. This study discusses theoretical and practical perspectives on best practices for microplastic sampling campaigns of WWTPs. One focus of the study was the potential for synergies between thermoanalytical and spectroscopic analysis to gain more representative sampling using the complementary information provided by the different analytical techniques. Samples were obtained before and after sand filtration from two WWTPs in Germany using cascade filtration with size classes of 5,000 - 100 µm, 100 - 50 µm, and 50 - 10 µm. For spectroscopic methods samples were treated by a Fenton process to remove natural organic matter, whereas TED-GC-MS required only sample extraction from the filter cascade. µFTIR spectroscopy was used for the 100 µm and 50 µm basket filters and µRaman spectroscopy was applied to analyze particles on the smallest basket filter (10 µm). TED-GC-MS was used for all size classes as it is size independent. All techniques showed a similar trend, where PE was consistently the most prominent polymer in WWTP effluents. Based on this insight, PE was chosen as surrogate polymer to investigate whether it can describe the total polymer removal efficiency of tertiary sand filters. The results revealed no significant difference (ANOVA) between retention efficiencies of tertiary sand filtration obtained using only PE and by analyzing all possible polymers with µFTIR and µRaman spectroscopy. Findings from this study provide valuable insights on advantages and limitations of cascade filtration, the benefit of complementary analyses, a suitable design for future experimental approaches, and recommendations for future investigations.

Successful maintenance of process and outcomes for oesophageal cancer surgery in Ireland during the first wave of the COVID-19 pandemic.

INTRODUCTION: The emergence of the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the coronavirus disease COVID-19 has impacted enormously on non-COVID-19-related hospital care. Curtailment of intensive care unit (ICU) access threatens complex surgery, particularly impacting on outcomes for time-sensitive cancer surgery. Oesophageal cancer surgery is a good example. This study explored the impact of the pandemic on process and short-term surgical outcomes, comparing the first wave of the pandemic from April to June in 2020 with the same period in 2019. METHODS: Data from all four Irish oesophageal cancer centres were reviewed. All patients undergoing resection for oesophageal malignancy from 1 April to 30 June inclusive in 2020 and 2019 were included. Patient, disease, and peri-operative outcomes (including COVID-19 infection) were compared. RESULTS: In 2020, 45 patients underwent oesophagectomy, and 53 in the equivalent period in 2019. There were no differences in patient demographics, co-morbidities, or use of neoadjuvant therapy. The median time to surgery from neoadjuvant therapy was 8 weeks in both 2020 and 2019. There were no significant differences in operative interventions between the two time periods. There was no difference in operative morbidity in 2020 and 2019 (28% vs 40%, p = 0.28). There was no in-hospital mortality in either period. No patient contracted COVID-19 in the perioperative period. CONCLUSIONS: Continuing surgical resection for oesophageal cancer was feasible and safe during the COVID-19 pandemic in Ireland. The national response to this threat was therefore successful by these criteria in the curative management of oesophageal cancer.

Extended reality anatomy undergraduate teaching: A literature review on an alternative method of learning.

BACKGROUND: The majority of undergraduate anatomy learning has shifted online, or to a mixture of virtual and face-to-face teaching, due to the COVID-19 pandemic. Cadaveric shortages have also influenced the need for alternative methods of anatomical education. This study examines the current literature on the use of extended reality technologies (XR) such as Virtual reality (VR), Augmented reality (AR), and Mixed reality (MR) for anatomy teaching and explores its potential for implementation in medical education. METHODS: A literature review was performed of PubMed, ProQuest, Science Direct, and Springer databases. Included studies were assessed for user satisfaction, perceived effectiveness, cost, acceptability and side effects. RESULTS: The database search identified 1687 papers, of which 45 papers were included in this review. Both AR and VR had high rates of satisfaction and acceptability as a supplementary teaching aid amongst undergraduate participants. AR was found to have higher effectiveness than VR. VR is more expensive than AR. Results and comparisons were limited due to short length of study. CONCLUSIONS: VR is a popular choice with undergraduates as an aid to supplement teaching, in spite of the associated cost and side effects such as nausea. AR has shown the most potential for independent study. Larger and long-term studies are required to determine true effectiveness, and consideration of the clinical relevance of these technologies.

COVID-19 induced bradyarrhythmia and relative bradycardia: An overview.

Novel coronavirus 2019 (COVID-19) has been the focus of the medical community since its emergence in December 2019 and has already infected more than 100 million patients globally. Primarily described to cause a respiratory illness, COVID-19 has been found to affect almost every organ system. Bradycardia is a newly recognized ramification of COVID-19 that still has unknown prognostic value. Studies have shown an increase in the incidence of arrhythmias, cardiomyopathies, myocarditis, acute coronary syndromes, and coagulopathies in infected patients as well as an increased risk of mortality in patients with preexisting cardiovascular disease. While the pathogenesis of bradycardia in COVID-19 may be multifactorial, clinicians should be aware of the mechanism by which COVID-19 affects the cardiovascular system and the medication side effects which are used in the treatment algorithm of this deadly virus. There has yet to be a comprehensive review analyzing bradyarrhythmia and relative bradycardia in COVID-19 infected patients. We aim to provide a literature review including the epidemiology, pathogenesis, and management of COVID-19 induced bradyarrhythmia.

Surgery by a minimally invasive approach is associated with improved textbook outcomes in oesophageal and gastric cancer.

INTRODUCTION: Textbook outcome (TBO) is a composite measure of a number of peri-operative and clinical outcomes in oesophagogastric malignancy. It has previously been shown that TBOs are associated with improved overall survival in both oesophageal and gastric cancer. The influence of a minimally invasive approach (MIA) on TBO is not well defined. The purpose of this study is to validate TBO in our population, examine the influence of a MIA on achieving a TBO, and the impact of TBO on long-term survival. METHODS: 269 patients undergoing oesophagectomy and 258 patients undergoing subtotal or total gastrectomy were included in this study. Demographic, clinical and pathological differences between patients with and without a TBO were compared using univariable and multivariable analysis. Overall survival for those with and without a TBO was examined. The influence of MIA on overall survival and TBO was determined using Cox proportional hazard models. RESULTS: Patients undergoing oesophagectomy and gastrectomy were significantly more likely to achieve a TBO when MIA was used (p = 0.01 and 0.001 respectively). When MIA is included as an outcome measure patients achieving a TBO show improved overall survival in both oesophageal and gastric cancer. MIA, clear resection margins and no unplanned admission to critical care are the strongest predictors of overall survival from the putative bundle of TBO parameters. CONCLUSION: Minimally invasive surgery is associated with improved TBO. Completion of a minimally invasive approach should be considered for inclusion as a textbook parameter.

Naloxone-Induced Acute Pulmonary Edema is Dose-Dependent: A Case Series.

BACKGROUND Naloxone remains the mainstay for the treatment of opioids overdose both in the clinical and public settings. Naloxone has been showing relative safety, leading to trivial adverdse effects which are mostly due to acute withdrawal effects, but when used in patients with known long-term addiction, it usually requires additional dosing or rapid infusion to achieve detoxification effects in a timely manner or to sustain the effects after they fade away. In some patients this has resulted in fatal adverse effects, including non-cardiogenic pulmonary edema (NCPE), which may require intensive care for those patients. Whether the higher dose is the cause has been debatable and not enough studies have looked into this subject. CASE REPORT Here, we report a series of 2 cases where 2 young patients were given naloxone following opioid overdose. Both our patients required frequent dosing due to insufficient response or owing to the washout of the naloxone effect shortly after, given its short half-life. Although the administered doses were different, both patients developed the adverse effect of NCPE and required ventilator support. CONCLUSIONS Evidence suggests that such a catastrophic adverse effect following the administration of such a critical medication, which is known to be relatively safe and is being publicized for saving lives, might limit its use and would require more attention and further studies to standardize a safe dose, limiting these life-threatening events and decreasing the need for unnecessary invasive respiratory support as well as admissions to intensive care units, which might create an additional burden on the health care system.

Spontaneous Subcutaneous Emphysema and Pneumomediastinum in COVID-19 Patients: An Indicator of Poor Prognosis?

BACKGROUND Novel Coronavirus 2019 (COVID-19) has been in the spotlight since the first cases were reported in December 2019. COVID-19 has been found to cause severe acute respiratory distress syndrome and, more uncommonly, subcutaneous emphysema and pneumomediastinum. We present a case series of 3 patients with COVID-19 infection managed in the Intensive Care Unit and found to have subcutaneous emphysema and pneumomediastinum on chest imaging. CASE REPORT We present a case series of 3 men, ages 36, 47, and 78 years, diagnosed with COVID-19 via RT-PCR, found to have severe acute respiratory distress syndrome, and managed in the Intensive Care Unit. Two patients described in this case series were mechanically ventilated on low positive end-expiratory pressures and developed subcutaneous emphysema and pneumomediastinum on chest imaging, and 1 patient developed subcutaneous emphysema prior to intubation. Each of these patients had a more eventful hospital course and worse outcomes than most COVID-19 infected patients. CONCLUSIONS Subcutaneous emphysema and pneumomediastinum in COVID-19 patients have been rarely reported and is poorly understood. In our institution, we have found the diagnosis of subcutaneous emphysema and pneumomediastinum in COVID-19 patients is associated with unfavorable outcomes and worse prognosis.

Simulation training for lobectomy: a review of current literature and future directions†.

With growing work-time restrictions and public expectations, the Halstedian educational model of 'see one, do one, teach one' is unfit for the modern training of thoracic residents. With the cardiothoracic surgical workforce set to decline by 50% over the next 10 years, new models are desperately needed to help trainees bypass the early error-prone phase of the lobectomy learning curve. In this review, we detail the development and validation of numerous simulators designed to teach trainees an array of skills ranging from basic technical skills to more complex non-technical skills. Given the recent increases in minimally invasive lobectomies, we critique both open and thoracoscopic simulators. We elucidate that whilst there are a growing number of thoracic simulators of varying fidelity available, fundamentally, there is currently a significant lack of well-designed trials validating various simulators for teaching lobectomy despite an awareness of their potential to improve surgical education. Furthermore, there is a void in the simulation training of non-technical skills within thoracic surgery. Encouragingly, there is a definite awareness of the ability of simulation to aid with the training of future thoracic surgical trainees.

eHALOPH a Database of Salt-Tolerant Plants: Helping put Halophytes to Work.

eHALOPH (http://www.sussex.ac.uk/affiliates/halophytes/) is a database of salt-tolerant plants-halophytes. Records of plant species tolerant of salt concentrations of around 80 mM sodium chloride or more have been collected, along with data on plant type, life form, ecotypes, maximum salinity tolerated, the presence or absence of salt glands, photosynthetic pathway, antioxidants, secondary metabolites, compatible solutes, habitat, economic use and whether there are publications on germination, microbial interactions and mycorrhizal status, bioremediation and of molecular data. The database eHALOPH can be used in the analysis of traits associated with tolerance and for informing choice of species that might be used for saline agriculture, bioremediation or ecological restoration and rehabilitation of degraded wetlands or other areas.

A new screening technique for salinity resistance in rice (Oryza sativa L.) seedlings using bypass flow.

A lack of screening techniques delays progress in research on salinity resistance in rice. In this study, we report our test of the hypothesis that an apoplastic pathway (the so-called bypass flow) causes a difference in salt resistance between rice genotypes and can be used in screening for salinity resistance. Fourteen-day-old seedlings of low- and high-Na(+) -transporting recombinant inbred lines (10 of each) of rice IR55178 were treated with 50 mm NaCl and 0.2 mm trisodium-8-hydroxy-1,3,6-pyrenetrisulphonic acid (PTS), a bypass flow tracer, for short (4 d) and long (90 d) periods of time. The results showed that the average shoot Na(+) concentration and bypass flow for high-Na(+) -transporting lines were 1.4 and 2.4 times higher than those of low-Na(+) -transporting lines, respectively. There was a positive linear correlation between the percentage of bypass flow and Na(+) concentrations in the shoots, suggesting that the difference in Na(+) transport in rice is a consequence of different degrees of bypass flow. Moreover, a high correlation was found between bypass flow and seedling survival after prolonged salt stress: the lower the magnitude of bypass flow, the greater the seedling survival. We conclude that bypass flow could be used as a new screening technique for salt resistance in rice.

The role of lateral roots in bypass flow in rice (Oryza sativa L.).

Although an apoplastic pathway (the so-called bypass flow) is implicated in the uptake of Na(+) by rice growing in saline conditions, the point of entry of this flow into roots remains to be elucidated. We investigated the role of lateral roots in bypass flow using the tracer trisodium-8-hydroxy-1,3,6-pyrenetrisulphonic acid (PTS) and the rice cv. IR36. PTS was identified in the vascular tissue of lateral roots using both epifluorescence microscopy and confocal laser scanning microscopy. Cryo-scanning electron microscopy and epifluorescence microscopy of sections stained with berberine-aniline blue revealed that the exodermis is absent in the lateral roots. We conclude that PTS can move freely through the cortical layers of lateral roots, enter the stele and be transported to the shoot via the transpiration stream.

Studies on sodium bypass flow in lateral rootless mutants lrt1 and lrt2, and crown rootless mutant crl1 of rice (Oryza sativa L.).

An apoplastic pathway, the so-called bypass flow, is important for Na+ uptake in rice (Oryza sativa L.) under saline conditions; however, the precise site of entry is not yet known. We report the results of our test of the hypothesis that bypass flow of Na+ in rice occurs at the site where lateral roots emerge from the main roots. We investigated Na+ uptake and bypass flow in lateral rootless mutants (lrt1, lrt2), a crown rootless mutant (crl1), their wild types (Oochikara, Nipponbare and Taichung 65, respectively) and in seedlings of rice cv. IR36. The results showed that shoot Na+ concentration in lrt1, lrt2 and crl1 was lower (by 20-23%) than that of their wild types. In contrast, the bypass flow quantified using trisodium-8-hydroxy-1,3,6-pyrenetrisulphonic acid (PTS) was significantly increased in the mutants, from an average of 1.1% in the wild types to 3.2% in the mutants. Similarly, bypass flow in shoots of IR36 where the number of lateral and crown roots had been reduced through physical and hormonal manipulations was dramatically increased (from 5.6 to 12.5%) as compared to the controls. The results suggest that the path of bypass flow in rice is not at the sites of lateral root emergence.