A functional vesicostomy for six decades: A case report.

Vesicostomy is a temporary solution for patients with bladder outlet challenger who are not eligible for catheterization. A 73 year-old man who has successfully managed his bladder using a vesicostomy for 59 years. Complications of prolapse and dermatitis led to vesicostomy closure and cystostomy placement at age 73. Vesicostomy can be safely used to preserve bladder and upper urinary tract health for a lifetime.

The superior vesical artery: A review of conflicting definitions and how these could affect invasive procedures.

Since the superior umbilical artery is the only functioning branch of the patent umbilical artery, some anatomical and surgical books/atlases fail to clarify that it is a branch of the umbilical artery and not a direct branch of the anterior division of the internal iliac artery and so specifically state that it is a direct branch of the internal iliac artery. This discrepancy in nomenclature can obviously affect invasive procedures and communication between physicians. Therefore, the present review is intended to highlight this issue. The term "superior vesical artery" was searched using standard search engines, for example, PubMed and Google Scholar. Several standard and specialized anatomy textbooks were also examined to ascertain how the superior vesical artery was described. Thirty-two articles were identified that used the terms "superior vesical artery" or "superior vesical arteries." After applying exclusion criteria, in 28 papers, the definition of the superior vesical artery was undetermined in eight, described as a direct branch of the internal iliac artery in 13, described as a branch of the umbilical artery in six, and defined as being equivalent to the umbilical artery in one. Of the sampled textbooks, some defined the superior vesicle artery as a branch of the umbilical artery, some as a direct branch of the internal iliac artery and some as both. Taken all together, most define the superior vesical artery as a branch of the umbilical artery. As the superior vesical artery is described as a branch of the umbilical artery in the internationally accepted terminology (Terminologia Anatomica), we recommend that this definition be used by anatomists and physicians alike so that communication is clear.

History of Bone Grafts in Spine Surgery.

Bone grafting replaces damaged or missing bone with new bone and is used for surgical arthrodesis. Patients benefit from a huge variety of bone graft techniques and options for spinal fusions. This article reviews the rich history of bone grafts in surgery with particular emphasis on spinal fusion. During the early years of bone grafting in spine surgery, bone grafts were used on tuberculosis patients, and the structural support of the graft was most the important consideration. Between 1960 and 2000, many advances were made, specifically in the use of bone graft substitutes. The field of bone grafts in spine surgery has evolved rapidly since first described.

Cervicovaginal microbiome in twin vs singleton gestations.

BACKGROUND: The vaginal microbiome diversity profile varies by race and ethnicity and changes considerably from the nonpregnant state to the pregnant state, specifically with a shift to Lactobacillus predominance in singleton gestations. There is a paucity of data that evaluate the cervicovaginal microbiome in women with twin gestations as a distinct population from those with singleton gestations. OBJECTIVE: We sought to characterize the cervicovaginal microbiome diversity profiles among twin gestations in the second trimester of pregnancy. STUDY DESIGN: In this prospective cross-sectional cohort study, women with twin gestations were matched to singleton controls without a history of a short cervix or preterm birth by gestational age ±2 weeks and race. Cervicovaginal lavage samples were collected from 14 to 24 weeks of gestation during prenatal visits followed by a cervical length measurement. Cervicovaginal microbiota were analyzed with 16S RNA gene sequencing and classified into community state types based on Lactobacillus species predominance. Microbiome alpha and beta diversities were compared between twin and singleton gestations. RESULTS: A total of 19 twin gestations and 19 singleton gestations underwent second-trimester cervicovaginal microbiome analysis. The groups were similar in gestational age at sample collection, maternal age, parity, body mass index, preterm birth history, and comorbidity. The cohort was predominantly of Black race (79%). Of twin gestations, 79% were dichorionic and diamniotic and 21% monochorionic and diamniotic. Of note, 3 twin gestations and 1 singleton gestation were complicated by a short cervix (P=.6). The vaginal microbiome of twin gestations had decreased alpha and beta diversities compared with singleton gestations. Twin gestations had lower taxon abundance and decreased variability in taxon abundance than singleton gestations. Overall, there was decreased diversity of community state type groups among twin gestations compared with singleton gestations. Community state types I and III were more prevalent among twin gestations, whereas community state types II and IV were similar among these 2 groups. Community state type IV, which is defined by a lack of Lactobacillus species and the presence of diverse strict anaerobes, was the predominant type among microbiota profiles of twin gestations (55%) and singleton gestations (64%). Community state type V was more prevalent in singleton gestations. When stratified by race, we found similar alpha diversity in Black and non-Black patients with twin gestations. CONCLUSION: In our predominantly Black population of pregnant women, the second-trimester vaginal microbiome in twin gestations showed decreased alpha and beta diversities compared with singleton controls. Our findings increased the understanding of the content of microbial communities in the second trimester of pregnancy in twin gestations and suggested a potential mechanism for preterm birth in twin gestations.

National Landscape of Human Immunodeficiency Virus-Positive Deceased Organ Donors in the United States.

BACKGROUND: Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety. METHODS: We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors. RESULTS: Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL <400 copies/mL. The median CD4 T-cell count (interquartile range) was 194/µL (77-331/µL), and the median CD4 T-cell percentage was 27.0% (16.8%-36.1%). Major HIV DRMs were detected in 42%, including nonnucleoside reverse-transcriptase inhibitors (33%), integrase strand transfer inhibitors (4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history. CONCLUSION: The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor-based regimens is rare, which is reassuring regarding safety.

Fetal overgrowth in pregnancies complicated by diabetes: validation of a predictive index in an external cohort.

PURPOSE: To assess validity of a fetal overgrowth index in an external cohort of women with diabetes in pregnancy METHODS: We performed a retrospective analysis of data derived from women with singleton gestations complicated by diabetes who delivered January 2015-June 2018. The following index variables were used to calculate risk of fetal overgrowth as defined by a customized birthweight ≥ 90th centile: age, history of fetal overgrowth in a prior pregnancy, gestational weight gain, fetal abdominal circumference measurement and fasting glucose between 24 and 30 weeks. RESULTS: In our validation cohort, 21% of 477 pregnancies were complicated by fetal overgrowth. The predictive index had a bias-corrected bootstrapped area under receiver operating characteristic curve of 0.90 (95% CI 0.86-0.93). 55% of the cohort had a low-risk index (≤ 3) which had a negative predictive value of 97% (95% CI 94-98%), while 18% had a high-risk index (≥ 8) that had a positive predictive value of 74% (95% CI 66-81%). CONCLUSION: The fetal overgrowth index incorporates five factors that are widely available in daily clinical practice prior to the period of maximum fetal growth velocity in the third trimester. Despite substantial differences between our cohort and the one studied for model development, we found the performance of the index was strong. This finding lends support for the general use of this tool that may aid counseling and allow for targeted allocation of healthcare resources among women with pregnancies complicated by diabetes.

Activity Patterns in the Neuropil of Striatal Cholinergic Interneurons in Freely Moving Mice Represent Their Collective Spiking Dynamics.

Cholinergic interneurons (CINs) are believed to form synchronous cell assemblies that modulate the striatal microcircuitry and possibly orchestrate local dopamine release. We expressed GCaMP6s, a genetically encoded calcium indicator (GECIs), selectively in CINs, and used microendoscopes to visualize the putative CIN assemblies in the dorsal striatum of freely moving mice. The GECI fluorescence signal from the dorsal striatum was composed of signals from individual CIN somata that were engulfed by a widespread fluorescent neuropil. Bouts of synchronous activation of the cholinergic neuropil revealed patterns of activity that preceded the signal from individual somata. To investigate the nature of the neuropil signal and why it precedes the somatic signal, we target-patched GECI-expressing CINs in acute striatal slices in conjunction with multiphoton imaging or wide-field imaging that emulates the microendoscopes' specifications. The ability to detect fluorescent transients associated with individual action potential was constrained by the long decay constant of GECIs (relative to common inorganic dyes) to slowly firing (<2 spikes/s) CINs. The microendoscopes' resolving power and sampling rate further diminished this ability. Additionally, we found that only back-propagating action potentials but not synchronous optogenetic activation of thalamic inputs elicited observable calcium transients in CIN dendrites. Our data suggest that only bursts of CIN activity (but not their tonic firing) are visible using endoscopic imaging, and that the neuropil patterns are a physiological measure of the collective recurrent CIN network spiking activity.

Encoding of Conditioned Taste Aversion in Cortico-Amygdala Circuits.

Avoidance of potentially toxic food by means of conditioned taste aversion is critical for survival of many animals. However, the underlying neuronal mechanisms are poorly understood. Here, using two-photon calcium imaging of defined gustatory cortex neurons in vivo, we show that conditioned taste aversion dynamically shifts neuronal population coding by stimulus-specific recruitment of neurons that project to the basolateral amygdala.

Organs from deceased donors with false-positive HIV screening tests: An unexpected benefit of the HOPE act.

Organs from deceased donors with suspected false-positive HIV screening tests were generally discarded due to the chance that the test was truly positive. However, the HIV Organ Policy Equity (HOPE) Act now facilitates use of such organs for transplantation to HIV-infected (HIV+) individuals. In the HOPE in Action trial, donors without a known HIV infection who unexpectedly tested positive for anti-HIV antibody (Ab) or HIV nucleic acid test (NAT) were classified as suspected false-positive donors. Between March 2016 and March 2018, 10 suspected false-positive donors had organs recovered for transplant for 21 HIV + recipients (14 single-kidney, 1 double-kidney, 5 liver, 1 simultaneous liver-kidney). Median donor age was 24 years; cause of death was trauma (n = 5), stroke (n = 4), and anoxia (n = 1); three donors were labeled Public Health Service increased infectious risk. Median kidney donor profile index was 30.5 (IQR 22-58). Eight donors were HIV Ab+/NAT-; two were HIV Ab-/NAT+. All 10 suspected false-positive donors were confirmed to be HIV-noninfected. Given the false-positive rates of approved assays used to screen > 20 000 deceased donors annually, we estimate 50-100 HIV false-positive donors per year. Organ transplantation from suspected HIV false-positive donors is an unexpected benefit of the HOPE Act that provides another novel organ source.

Experience-Dependent Plasticity of Odor Representations in the Telencephalon of Zebrafish.

Sensory systems balance stability and plasticity to optimize stimulus representations in dynamic environments. We studied these processes in the olfactory system of adult zebrafish. Activity patterns evoked by repeated odor stimulation were measured by multiphoton calcium imaging in the olfactory bulb (OB) and in telencephalic area Dp, the homolog of olfactory cortex. Whereas odor responses in the OB were highly reproducible, responses of Dp neurons adapted over trials and exhibited substantial variability that could be attributed to ongoing activity and to systematic changes in neuronal representations following each stimulus. An NMDA receptor antagonist did not affect the magnitude of odor responses but strongly reduced the variability and experience-dependent modification of odor responses in Dp. As a consequence, odor representations became stable over trials. These results demonstrate that odor representations in higher brain areas are continuously modified by experience, supporting the view that olfactory processing is inseparable from memory, even in the absence of reinforcement.

Tension compared to no tension on a Foley transcervical catheter for cervical ripening: a randomized controlled trial.

BACKGROUND: Cervical ripening of an unfavorable cervix can be achieved by placement of a transcervical catheter. Advantages of this method include both lower cost and lower risk of tachysystole than other methods. Despite widespread use with varying degrees of applied tension, an unanswered question is whether there is an advantage to placing the transcervical catheter to tension compared with placement without tension. OBJECTIVE: The purpose of this study was to determine whether tension placed on a transcervical balloon catheter that is inserted for cervical ripening results in a faster time to delivery. STUDY DESIGN: This was a prospective, randomized controlled trial; 140 women who underwent cervical ripening (Bishop score, ≤6) were assigned randomly to a balloon catheter with applied tension vs no tension. Tension was created when the catheter was taped to the patient's thigh and tension was reapplied in 30-minute increments. There were 67 patients in the tension group and 73 patients in the no tension group. Low-dose oxytocin (maximum, 6 mU/min) was administered after catheter placement. The primary outcome was time from catheter insertion to delivery. A secondary outcome was time from insertion to catheter expulsion. The Kolmogorov-Smirnov test was used to determine whether the data were distributed normally. Survival curves that used lifetables were constructed from time of catheter insertion to delivery and from time of catheter insertion to catheter expulsion and were compared with the use of the Wilcoxon (Gehan) Breslow statistic. A probability value of <.05 was set to denote statistical significance. RESULTS: Baseline characteristics were similar between groups. The median time from catheter insertion to delivery was not significantly different between the tension group and the no tension group (16.2 vs 16.9 hours; P=.814). The median time from catheter insertion to expulsion, however, was significantly less in the tension group vs the no tension group (2.6 vs 4.6 hours; P<.001), respectively. Vaginal delivery within 24 hours was not significantly different between the tension and no tension groups (41/52 [79%] vs 37/52 [71%]; P=.365) nor were there significant differences in cesarean delivery rates between the tension and no tension groups (17/67 [25%] vs 27/73 [37%]; P=.139). CONCLUSION: Application of tension did not result in faster delivery times but did result in faster times to catheter expulsion.

Standard External Doppler Fetal Heart Tracings versus External Fetal Electrocardiogram in Very Preterm Gestation: A Pilot Study.

Introduction Very preterm babies can be difficult to monitor using standard external Doppler fetal heart tracings (eFHR). External fetal electrocardiogram (fECG) is a potential alternative. Methods This was a prospective observational pilot study of hospitalized patients at 24 to 28 weeks' gestation. A total of 30 women were traced for up to 2 hours using eFHR followed by up to 2 hours using fECG. The percentage of time the fetal heart rate was traced during the 2-hour window for each modality was calculated. Differences of ≥ 60, ≥ 80, and ≥ 90% total time traced were compared between modalities using McNemar's test. Differences were also assessed for each method between nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2) women using chi-square and Fisher's exact tests. Results Superior performance was found with eFHR at ≥ 60% (93.3 vs. 46.7%, p < 0.001), ≥ 80% (80.0 vs. 30.0%, p < 0.001), and ≥ 90% (60.0 vs. 23.3%, p < 0.01) total time traced. There was a statistically significant finding favoring nonobese women at ≥ 80% total time traced using fECG (7.1 vs. 50.0%, p = 0.017). Conclusion With current technology fECG performance in very preterm gestation was worse than conventional eFHR, although fECG may have a role in nonobese patients.

Orthopedic Injury in Pregnancy.

There are many reasons why a woman's pregnancy can put her at risk for orthopedic pain and injury. Given the high percentage of pregnant patients experiencing some degree of musculoskeletal pain, it is surprising that this is not an area of wider study. This chapter takes an evidence based approach to help the reader understand the implications of the numerous anatomic and physiologic changes associated with the gravid state, and how they act to promote both discomfort and injury. One-third of pregnant women in America are obese, further increasing risk. Exercise in most pregnancies is recommended and regarded as safe and thus obstetric care providers need to understand risk, diagnostic techniques and treatments.

The Effect of Clinical Chorioamnionitis on Cesarean Delivery in the United States.

OBJECTIVE: To examine the association of clinical chorioamnionitis on cesarean delivery in a national sample of hospital discharges. DATA SOURCE: Hospital discharge data from the 1998-2010 Nationwide Inpatient Sample. STUDY DESIGN: We performed a cross-sectional study and general linear modeling was used to determine the association of clinical chorioamnionitis on risk of cesarean delivery. PRINCIPAL FINDINGS: A total of 10,843,682 deliveries and 51,799,431 nationally weighted deliveries were identified. Clinical chorioamnionitis was present in 2.9 percent of cesarean and 1.3 percent of vaginal deliveries (p < .001). In multivariate analysis, clinical chorioamnionitis was associated with a 1.39-fold increased risk of cesarean delivery. Compared with women without clinical chorioamnionitis at an urban/teaching hospital, women with clinical chorioamnionitis at an urban/teaching, urban/nonteaching, and rural hospital were 1.4-1.5 times more likely to have cesarean delivery. Compared with women without clinical chorioamnionitis in the Midwest, the relative risk for cesarean in women with clinical chorioamnionitis was 1.54 for women in the South, 1.47 in the Northeast, 1.39 in the Midwest, and 1.34 in the West. CONCLUSIONS: Women with clinical chorioamnionitis were more likely to have cesarean delivery than those without clinical chorioamnionitis, and the risk of cesarean delivery varied significantly by hospital location, teaching status, and U.S. region.

A barrier retractor to reduce surgical site infections and wound disruptions in obese patients undergoing cesarean delivery: a randomized controlled trial.

BACKGROUND: Surgical site infections (SSIs) are an important cause of morbidity following cesarean delivery, particularly in obese patients. Methods to reduce SSIs after cesarean delivery would have an important impact in obese obstetric patients. OBJECTIVE: The purpose of this study was to determine whether the Alexis O cesarean delivery retractor, a barrier self-retaining retractor, reduces SSIs and wound disruptions in obese patients undergoing cesarean delivery. STUDY DESIGN: This was a randomized controlled trial of obese women (body mass index ≥ 30 kg/m(2)) undergoing nonemergent cesarean delivery. Patients were randomized to the treatment group (using the Alexis O cesarean delivery retractor) or to the control group (using conventional handheld retractors). The primary outcome was SSI or wound disruption during the 30 day postoperative period. Secondary outcomes included operative time, estimated blood loss, change in hemoglobin, antiemetic use, length of postoperative hospital stay, hospital readmission, and other postoperative complications. RESULTS: A total of 301 patients were enrolled in the study. One hundred forty-four patients were randomized to the treatment group and 157 to the control group. Baseline characteristics and indications for cesarean delivery were similar between the 2 groups. Median body mass index was 40.1 kg/m(2). There were no significant differences between the treatment and the control group in the primary outcome of SSI or wound disruption rates at the 30 day assessment (20.6% vs 17.6%, P = .62), during the postoperative inpatient hospitalization or at the 1-2 week postoperative visit. There were also no differences in the primary outcome when adjusting for obesity class or thickness of the subcuticular layer. Patients in the treatment group had lower rates of uterine exteriorization (54.3% vs 87.3%, P < .001), but there were no differences in all other outcomes. CONCLUSION: Use of the Alexis retractor in cesarean delivery deliveries did not decrease SSI or wound disruption rates in an obese population. Its use as a retractor should be left to the discretion of the surgeon and clinical circumstances.

Laparoscopic uterosacral ligament suspension and sacral colpopexy: results and complications.

INTRODUCTION AND HYPOTHESIS: We describe our techniques, outcomes, and complications with laparoscopic procedures for correcting pelvic organ prolapse (POP). We hypothesized that laparoscopic abdominal sacrocolpopexy (ASC) gives better anatomic results than laparoscopic uterosacral ligament suspension (USLS), without increased complications. METHODS: This was a retrospective cohort study of 290 patients who underwent laparoscopic suspensions in a 2-year period. Anatomic measurements using the Pelvic Organ Prolapse Quantification (POP-Q) system were collected. Subjective data were obtained from the Pelvic Floor Distress Inventory Short-Form 20 (PFDI) questionnaire. The anatomic improvement for each stage and complication rates were analyzed. The difference in the risk of mesh erosion between patients undergoing concomitant total hysterectomy and those who had a prior hysterectomy was determined. In 102 patients with stage 2 prolapse, a comparison between ASC and USLS in anatomic and subjective results and complication rates was performed. RESULTS: Anatomic success rates ranged between 86 % and 95 %. Overall mesh erosion rate was 1.2 %, showing no difference between concomitant total laparoscopic hysterectomy (0 %) and prior hysterectomy (2.1 %, p = 0.155). ASC resulted in statistically significantly better anterior-compartment support than USLS (p = 0.043). There was no difference in apex or posterior compartment position or in PFDI scores. CONCLUSION: Laparoscopic ASC may be better than USLS for correcting anterior-compartment prolapse, with only a minor risk of mesh erosion.

Amygdala interneuron subtypes control fear learning through disinhibition.

Learning is mediated by experience-dependent plasticity in neuronal circuits. Activity in neuronal circuits is tightly regulated by different subtypes of inhibitory interneurons, yet their role in learning is poorly understood. Using a combination of in vivo single-unit recordings and optogenetic manipulations, we show that in the mouse basolateral amygdala, interneurons expressing parvalbumin (PV) and somatostatin (SOM) bidirectionally control the acquisition of fear conditioning--a simple form of associative learning--through two distinct disinhibitory mechanisms. During an auditory cue, PV(+) interneurons are excited and indirectly disinhibit the dendrites of basolateral amygdala principal neurons via SOM(+) interneurons, thereby enhancing auditory responses and promoting cue-shock associations. During an aversive footshock, however, both PV(+) and SOM(+) interneurons are inhibited, which boosts postsynaptic footshock responses and gates learning. These results demonstrate that associative learning is dynamically regulated by the stimulus-specific activation of distinct disinhibitory microcircuits through precise interactions between different subtypes of local interneurons.

Neural circuits: random design of a higher-order olfactory projection.

A recent study in Drosophila has found that the connectivity between the first olfactory processing center, the antennal lobe, and one of its targets, the mushroom body, is apparently random. This supports the idea that the mushroom body is designed for learning arbitrary odor features.

A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy.

OBJECTIVE: Women commonly experience low back pain during pregnancy. We examined whether a multimodal approach of musculoskeletal and obstetric management (MOM) was superior to standard obstetric care to reduce pain, impairment, and disability in the antepartum period. STUDY DESIGN: A prospective, randomized trial of 169 women was conducted. Baseline evaluation occurred at 24-28 weeks' gestation, with follow-up at 33 weeks' gestation. Primary outcomes were the Numerical Rating Scale (NRS) for pain and the Quebec Disability Questionnaire (QDQ). Both groups received routine obstetric care. Chiropractic specialists provided manual therapy, stabilization exercises, and patient education to MOM participants. RESULTS: The MOM group demonstrated significant mean reductions in Numerical Rating Scale scores (5.8 ± 2.2 vs 2.9 ± 2.5; P < .001) and Quebec Disability Questionnaire scores (4.9 ± 2.2 vs 3.9 ± 2.4; P < .001) from baseline to follow-up evaluation. The group that received standard obstetric care demonstrated no significant improvements. CONCLUSION: A multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.

Retroperitoneal duplication cyst with a fistulous tract to the vagina: a case report.

OBJECTIVES: To describe a rare case of a retroperitoneal duplication cyst that fistulized to the vagina. METHODS: Case description and discussion of a patient found to have an intestinal duplication cyst. RESULTS: A patient presented for a laparoscopic hysterectomy because of menorrhagia and a fibroid uterus. She also complained of recurrent urinary tract infections (UTIs) and a vaginal discharge. A retroperitoneal intestinal duplication cyst that fistulized to the vagina and caused her recurrent UTIs was identified. Surgical resection of the cyst resolved her complaint of recurrent UTIs. CONCLUSIONS: Retroperitoneal intestinal duplication cysts are rare congenital anomalies with vague clinical manifestations. The finding of a fistulous communication to the vagina originating from such a structure can be associated with recurrent UTIs.