A Rare Case of Post-orchidectomy Arterial Injury With Rapidly Enlarging Scrotal Hematoma Treated With Coil Embolization.

Testicular cancer is the most common solid tumor in young adult males. Radical inguinal orchidectomy is the gold standard for the diagnosis and treatment of testicular cancer, which is confined to the scrotum and is generally well tolerated. An uncommon, but known, complication of radical orchidectomy is scrotal hematoma. Scrotal hematoma from radical orchidectomy is commonly self-limited and typically self-resolving. We present a rare case of metastatic testicular malignancy diagnosed with radical inguinal orchidectomy complicated by a rapidly enlarging scrotal hematoma, successfully treated with surgical evacuation and image-guided arterial embolization.

Fertility-Preserving Management of Uterine Arteriovenous Malformation in a 16-Year-Old Female.

Arteriovenous malformations (AVM) are abnormal connections between arteries and veins without a capillary bed, creating high- and low-flow areas that are prone to bleeding. Uterine AVMs can be congenital or acquired with an incidence of 0.1%. Acquired cases are usually caused by uterine instrumentation, trauma, infection, or gestational trophoblastic disease. Patients typically present with sudden onset of heavy vaginal bleeding. Diagnosis is made using angiography, ultrasound, computerized tomography, or magnetic resonance imaging. After patients are stabilized, management depends on their desire for future fertility and may include hysterectomy or endovascular embolization. We present the case of a 16-year-old G1P0010 female with recurrent vaginal bleeding caused by a uterine AVM. To preserve the patient's fertility, a selective embolization approach was employed using microcoils and gel foam. This case highlights a unique treatment option for uterine AVMs in patients who desire fertility preservation. Additionally, we review the diagnostic imaging and treatment options for uterine AVMs.

Are You In or Are You Out? The Importance of Group Saliency in Own-Group Biases in Face Recognition.

Previous research has demonstrated several own-group biases (OGBs) in face recognition, but why they occur is unclear. Social-cognitive accounts suggest they stem from differential attention and facial processing, following the categorisation of a face as belonging to an "in" or "out" group. Three studies explored whether OGBs can be produced by mere categorisation at encoding and investigated the role of in-group membership saliency on face recognition. Participants saw 40 facial images fictionally grouped according to in-/out-group status. Studies 1 and 2 used university membership as the grouping variable and found no evidence of an OGB, and no relationship between OGB magnitude and salience of group membership. Study 3 used the same design as Study 2, but with a highly salient group characteristic: participants' stance on the U.K. Referendum (i.e., whether they were "Leave" or "Remain" supporters). In this case, an asymmetrical OGB was found, with only Remain voters demonstrating an OGB. Furthermore, a relationship between OGB magnitude and attitude toward the Referendum result was found. Overall, our results suggest that social categorisation and membership saliency alone may not be enough to moderate in- and out-group face recognition. However, when sufficiently polarised groups are used as in-/out-group categories, OGBs may occur.

Telephone outreach by community workers to improve uptake of NHS Health Checks in more deprived localities and minority ethnic groups: a qualitative investigation of implementation.

BACKGROUND: NHS Health Checks is a national cardiovascular risk assessment and management programme in England. To improve equity of uptake in more deprived, and Black, Asian and minority ethnic (BAME) communities, a novel telephone outreach intervention was developed. The outreach call included an invitation to an NHS Health Check appointment, lifestyle questions, and signposting to lifestyle services. We examined the experiences of staff delivering the intervention. METHODS: Thematic analysis of semi-structured interviews with 10 community Telephone Outreach Workers (TOWs) making outreach calls, and 5 Primary Care Practice (PCP) staff they liaised with. Normalization Process Theory was used to examine intervention implementation. RESULTS: Telephone outreach was perceived as effective in engaging patients in NHS Health Checks and could reduce related administration burdens on PCPs. Successful implementation was dependent on support from participating PCPs, and tensions between the intervention and other PCP priorities were identified. Some PCP staff lacked clarity regarding the intervention aim and this could reduce the potential to capitalize on TOWs' specialist skills. CONCLUSIONS: To maximize the potential of telephone outreach to impact equity, purposeful recruitment and training of TOWs is vital, along with support and integration of TOWs, and the telephone outreach intervention, in participating PCPs.

Between a shock and a hard place: challenges and developments in HIV latency reversal.

Latently infected cells that persist in HIV-infected individuals on antiretroviral therapy (ART) are a major barrier to cure. One strategy to eliminate latency is by activating viral transcription, commonly called latency reversal. Several small non-randomised clinical trials of latency reversing agents (LRAs) in HIV-infected individuals on ART increased viral production, but disappointingly did not reduce the number of latently infected cells or delay time to viral rebound following cessation of ART. More recent approaches aimed at reversing latency include compounds that both activate virus and also modulate immunity to enhance clearance of infected cells. These immunomodulatory LRAs include toll-like receptor agonists, immune checkpoint inhibitors and some cytokines. Here, we provide a brief review of the rationale for transcription-activating and immunomodulatory LRAs, discuss recent clinical trials and some suggestions for combination approaches and research priorities for the future.

Enhanced skills in periodontology: evaluation of a pilot scheme for general dental practitioners and dental care professionals in London.

Background The need for periodontal management is great and increasing; thus, the oral and dental workforce should be suitably equipped to deliver contemporary care. Health Education London developed a training scheme to extend the skills of dentists and dental care professionals (DCPs).Aim To examine the feasibility of assessing a skill-mix initiative established to enhance skills in clinical periodontology involving the views of patients, clinicians and key stakeholders, together with clinical and patient outcomes in London.Methods This mixed methods feasibility and pilot study involved four parallel elements: a postal questionnaire survey of patients; analysis of clinical logbooks; self-completion questionnaire survey of clinicians; and semi-structured interviews of key stakeholders, including clinicians.Results Twelve of the 19 clinicians participated in the evaluation, returning completed questionnaires (63%) and providing access to log diaries and patients. Periodontal data from 42 log-diary cases (1,103 teeth) revealed significant improvement in clinical outcomes (P = 0.001 for all). Eighty-four percent (N = 99) of the 142 patients returning a questionnaire reported improved dental health; however, responses from hospital patients greatly exceeded those from dental practice. Interviews (N = 22) provided evidence that the programme contributed to professional healthcare across four key domains: 'service', 'quality care', 'professional' and 'educational'. Clinicians, while supportive of the concept, raised concerns regarding the mismatch of their expectations and its educational and service outcomes.Discussion The findings suggest that it is feasible to deliver and evaluate inter-professional extended skills training for dentists and dental care professionals, and this may be evaluated using mixed methods to examine outcomes including clinical log diaries, patient questionnaires and stakeholder interviews. This inter-professional course represents a positive development for patient care using the expertise of different members of the dental team; however, its formal integration to the health and educational sectors require further consideration.

Glargine co-administration with intravenous insulin in pediatric diabetic ketoacidosis is safe and facilitates transition to a subcutaneous regimen.

BACKGROUND: Diabetes ketoacidosis (DKA) is a common presentation and complication of type 1 diabetes (T1D). While intravenous insulin is typically used to treat acute metabolic abnormalities, the transition from intravenous to subcutaneous treatment can present a challenge. We hypothesize that co-administration of glargine, a subcutaneous long-acting insulin analog, during insulin infusion may facilitate a flexible and safe transition from intravenous to subcutaneous therapy. OBJECTIVE: To determine if the practice of administering subcutaneous glargine during intravenous insulin is associated with an increased risk of hypoglycemia, hypokalemia, or other complications in children with DKA. METHODS: Retrospective chart review of patients aged 2 to 21 years, presenting to our center with DKA between April 2012 and June 2014. Patients were divided into two groups: those co-administered subcutaneous glargine with intravenous insulin for over 4 hours (G+); and patients with less than 2 hours of overlap (G-). RESULTS: We reviewed 149 DKA admissions (55 G+, 94 G-) from 129 unique patients. There was a similar incidence of hypoglycemia between groups (25% G+ vs 20% G-, P = 0.46). Hypokalemia (<3.5 mmol/L) occurred more frequently in the G+ group (OR = 3.4, 95% CI 1.7-7.0, P = 0.001). Cerebral edema occurred in 2/55 (3.6%) of the G- group and none of the G+ subjects. CONCLUSION: Co-administration of glargine early in the course of DKA treatment is well tolerated and convenient for discharge planning; however, this approach is associated with an increased risk of hypokalemia.

Directional memory arises from long-lived cytoskeletal asymmetries in polarized chemotactic cells.

Chemotaxis, the directional migration of cells in a chemical gradient, is robust to fluctuations associated with low chemical concentrations and dynamically changing gradients as well as high saturating chemical concentrations. Although a number of reports have identified cellular behavior consistent with a directional memory that could account for behavior in these complex environments, the quantitative and molecular details of such a memory process remain unknown. Using microfluidics to confine cellular motion to a 1D channel and control chemoattractant exposure, we observed directional memory in chemotactic neutrophil-like cells. We modeled this directional memory as a long-lived intracellular asymmetry that decays slower than observed membrane phospholipid signaling. Measurements of intracellular dynamics revealed that moesin at the cell rear is a long-lived element that when inhibited, results in a reduction of memory. Inhibition of ROCK (Rho-associated protein kinase), downstream of RhoA (Ras homolog gene family, member A), stabilized moesin and directional memory while depolymerization of microtubules (MTs) disoriented moesin deposition and also reduced directional memory. Our study reveals that long-lived polarized cytoskeletal structures, specifically moesin, actomyosin, and MTs, provide a directional memory in neutrophil-like cells even as they respond on short time scales to external chemical cues.

Biased migration of confined neutrophil-like cells in asymmetric hydraulic environments.

Cells integrate multiple measurement modalities to navigate their environment. Soluble and substrate-bound chemical gradients and physical cues have all been shown to influence cell orientation and migration. Here we investigate the role of asymmetric hydraulic pressure in directional sensing. Cells confined in microchannels identified and chose a path of lower hydraulic resistance in the absence of chemical cues. In a bifurcating channel with asymmetric hydraulic resistances, this choice was preceded by the elaboration of two leading edges with a faster extension rate along the lower resistance channel. Retraction of the "losing" edge appeared to precipitate a final choice of direction. The pressure differences altering leading edge protrusion rates were small, suggesting weak force generation by leading edges. The response to the physical asymmetry was able to override a dynamically generated chemical cue. Motile cells may use this bias as a result of hydraulic resistance, or "barotaxis," in concert with chemotaxis to navigate complex environments.

An evaluation of the recording of folic acid use in the South West Congenital Anomaly Register.

OBJECTIVE: Some congenital anomaly registers are collecting data on risk factors for pregnancies affected by anomalies; yet the quality of that information is rarely assessed. We assessed the quality of the risk factor data in the South West Congenital Anomaly Register (SWCAR) through a review of the data held on folic acid use, in cases of neural tube defect (NTD). METHODS: We reviewed all cases of NTD reported to SWCAR over 2 years and compared information held in the register with that in handwritten and computerised prenatal records, where available. RESULTS: Data on folic acid use was recorded in only 41 (36.9%) of the prenatal records of the 111 cases of NTDs reviewed. Information on any folic acid use in the prenatal records was transferred to the register in all instances where it existed. Information on the time of taking folic acid or not taking folic acid was rarely recorded in prenatal records. CONCLUSION: Incomplete recording of folic acid use and timing in prenatal records has limited the ability of SWCAR to collect accurate information on folic acid use in cases of NTDs. Minimal recording information on folic acid use in prenatal records is suggested.

Malaria-specific antibody responses and parasite persistence after infection of mice with Plasmodium chabaudi chabaudi.

While it is known that antibodies are critical for clearance of malaria infections, it is not clear whether adequate antibody responses are maintained and what effect chronic infection has on this response. Here we show that mice with low-grade chronic primary infections of Plasmodium chabaudi or infections very recently eliminated have reduced second infections when compared with the second infection of parasite-free mice. We also show that parasite-specific antibody responses induced by infection of mice with Plasmodium chabaudi contain both short- and long-lived components as well as memory B cells responsible for a faster antibody response during re-infection. Furthermore, parasite-specific antibodies to the C-terminal fragment of merozoite surface protein-1 (MSP-1) undergo avidity maturation. However, antibodies with both low and high avidity persist throughout infection and after re-infection, suggesting repeated rounds of activation and maturation of memory B cells. Neither the avidity profile of the antibody response, nor its maintenance is affected by persisting live parasites. Therefore, differences in parasitemia in re-infection cannot be explained solely by higher levels of antibody or greater affinity maturation of malaria-specific antibodies. These data suggest that there may be an antibody-independent component to the early control of secondary infections in mice that are chronically infected.

Magnesium supplementation and perinatal hypoxia: outcome of a parallel group randomised trial in pregnancy.

OBJECTIVE: To determine the effects of magnesium supplementation in pregnancy on the incidence of hypoxic-ischaemic encephalopathy (HIE). DESIGN: A randomised double-blind placebo-controlled study. SETTING: A Midwife Obstetric Unit and its two referral hospitals in Cape Town, South Africa. POPULATION: A group of 4494 black pregnant women of low socio-economic status. METHOD: Mothers, from the time of booking until delivery, were randomised to receive two identical tablets daily, containing either 128 mg slow-release magnesium stearate or lactose sugar. MAIN OUTCOME MEASURES: Primary: The incidence of HIE. Secondary: The incidence of fetal heart rate decelerations, term Stillbirths, Low Apgar Scores, Meconium Aspiration Pneumonia. RESULTS: The incidence of HIE (0.9%) was considerably less than anticipated (2%). There were 22 infants in the placebo group and 15 infants in the supplemented group (P = 0.279). The difference was not significant. Secondary outcomes such as late fetal heart rate decelerations (P = 0.002) and term stillbirths (P = 0.016) were reduced significantly in the supplemented group, but this finding needs further substantiation. CONCLUSIONS: Magnesium supplementation did not reduce the incidence of HIE significantly, probably because the study was underpowered and compliance was relatively poor.

The cognitive and social development of the child.

The social and psychological development of children from birth to adolescence is described using the framework of Jean Piaget's theory of cognitive development. This theory proposes that children's understanding of the world proceeds through four broad stages, with each stage demonstrating an increasingly sophisticated understanding of concepts and how they can be used. The relevance of this development for children's understanding of oral health, disease and dental care is discussed.

Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial.

BACKGROUND: Patients with asthma are interested in the use of breathing exercises but their role is uncertain. The effects of the Buteyko breathing technique, a device which mimics pranayama (a yoga breathing technique), and a dummy pranayama device on bronchial responsiveness and symptoms were compared over 6 months in a parallel group study. METHODS: Ninety patients with asthma taking an inhaled corticosteroid were randomised after a 2 week run in period to Eucapnic Buteyko breathing, use of a Pink City Lung Exerciser (PCLE) to mimic pranayama, or a PCLE placebo device. Subjects practised the techniques at home twice daily for 6 months followed by an optional steroid reduction phase. Primary outcome measures were symptom scores and change in the dose of methacholine provoking a 20% fall in FEV(1) (PD(20)) during the first 6 months. RESULTS: Sixty nine patients (78%) completed the study. There was no significant difference in PD(20) between the three groups at 3 or 6 months. Symptoms remained relatively stable in the PCLE and placebo groups but were reduced in the Buteyko group. Median change in symptom scores at 6 months was 0 (interquartile range -1 to 1) in the placebo group, -1 (-2 to 0.75) in the PCLE group, and -3 (-4 to 0) in the Buteyko group (p=0.003 for difference between groups). Bronchodilator use was reduced in the Buteyko group by two puffs/day at 6 months; there was no change in the other two groups (p=0.005). No difference was seen between the groups in FEV(1), exacerbations, or ability to reduce inhaled corticosteroids. CONCLUSION: The Buteyko breathing technique can improve symptoms and reduce bronchodilator use but does not appear to change bronchial responsiveness or lung function in patients with asthma. No benefit was shown for the Pink City Lung Exerciser.

Relationship between soluble intracellular endothelin-converting enzyme and endothelin-1 synthesis: effect of inhibitors of the secretory pathway.

The relationship between soluble and membrane-bound endothelin-converting enzyme (ECE) activity with the level of endothelin-1 (ET-1) synthesis was investigated in cultured endothelial cells. Escherichia coli lipopolysaccharide (LPS) was used to stimulate ET-1 synthesis, and brefeldin A, monensin, colchicine or cytochalasin B, which disrupt peptide biosynthetic pathways in a variety of ways, were tested for their ability to modify changes in ET-1 synthesis and ECE levels. LPS increased ET-1 secretion by more than twofold. Levels of soluble ECE activity, but not those of membrane-bound ECE activity, correlated with ET-1 synthesis. These results suggest the soluble ECE activity is likely to play a role in ET-1 biosynthesis.