Correction of nasal tip deformity using an island flap of nasal dorsum

Bifid nose is a rare congenital malformation, and few cases have been reported due to its low incidence. Herein, we report a new surgical procedure to treat patients with excess dorsal nasal tissue and an underfilled tip. A total of 22 patients with bifid nose deformities underwent surgery at our institution between 2012 and 2022. They were characterized by a broad nasal dorsum and a missing or underdeveloped nasal tip. We designed an innovative island flap of nasal dorsum as a new surgical method for treating this bifid nose deformity. Nasal length, tip projection, and photographs of nose morphology were obtained before and after the surgery. Outcomes, complications, indications, and patient satisfaction were analyzed and interviewed. The follow-up time ranges from 6 to 33 months (8.7 ± 5.5 months). The deformity was successfully corrected with an improved nasal appearance. Nasal length increased from initially 4.2 ± 0.3 mm to 4.6 ± 0.3 mm. Tip projection reached 19.9 ± 4.0 mm, which was 15.7 ± 2.9 mm before surgery. No severe complications were observed except poor venous reflux within postoperative 72 hours in four cases. Six patients (27.3%) got moderate healing and acceptable scars, and 14 patients (63.6%) got good healing. Most patients were very satisfied with the outcome (93.9%). The newly designed nasal dorsum island flap is a safe and effective technical approach to correct nose deformity featured by broad nasal dorsum and a missing or underdeveloped nasal tip.

Risk Factors for Locoregional Recurrence and Distant Metastasis in 143 Patients with Adenoid Cystic Carcinoma of the External Auditory Canal

AIMS

Adenoid cystic carcinoma (ACC) grows slowly and is characterised by potential recurrence and metastasis to distant organs. This study aimed to evaluate the risk factors for locoregional recurrence (LRR) and distant metastasis in patients with ACC of the external auditory canal (EAC).

MATERIALS AND METHODS

Demographic, pathological, therapeutic and survival data of 143 patients with EAC ACC were reviewed in this study. Univariate and multivariate Cox proportional hazard regression analyses were carried out to determine the risk factors for LRR and distant metastasis. Factors associated with overall survival after LRR and distant metastasis were also analysed.

RESULTS

During a median follow-up of 49 months, 31 of 143 patients were observed with LRR and 34 developed distant metastasis. Bone invasion and histological subtype were independent risk factors for locoregional recurrence-free survival. T stage and LRR were independent risk factors for distant metastasis-free survival. Salvage surgery and adjuvant radiotherapy or chemoradiotherapy for LRR resulted in better survival, whereas extrapulmonary metastasis and LRR were associated with a higher risk of poor survival after distant metastasis.

CONCLUSION

Patients with distant metastases, especially those with LRR, are at significant risk of poor prognosis. Our findings emphasise the importance of long-term regular follow-up and recommend surgical intervention with radiotherapy for recurrent EAC ACC.

Two novel mutations within FREM1 gene in patients with bifid nose

BACKGROUND

Bifid nose is a rare congenital deformity and the etiology is unknown. The purpose of this study was to report genetic variation in family of patients with bifid nose.

METHODS

Twenty-three consecutive patients who were diagnosed with mild bifid nose were operated with z-plasty from 2009 to 2021. Three underage patients (a pair of twins and a girl) from two family lines, who came to our hospital for surgical treatment, were enrolled. Whole exome sequencing and Sanger sequencing were conducted. Z-shaped flaps were created and the cartilago alaris major were re-stitched. Photographs and CT scan before and after surgery were obtained. Clinical outcomes, complications and patients' satisfaction were evaluated and analyzed. The follow-up time ranges from 2 to 3 years (2.4 ± 1.2 years).

RESULTS

Most patients were satisfied with the outcome (96.2%). The nasal deformities were corrected successfully with z-plasty technique in one-stage. FREM1 c.870_876del and c.2 T > C were detected with Whole exome sequencing, which have not been reported before. The results of Sanger sequencing were consistent with those of Whole exome sequencing.

CONCLUSIONS

The newly detected mutations of FREM1 have a certain heritability, and are helpful to make an accurate diagnosis and provide a better understanding of bifid nose mechanism. Z-plasty technique can be an effective technical approach for correcting mild bifid nose deformity.

Lateral Osteotomy for the Surgical Treatment of the Asian Wide Nose

OBJECTIVE

Narrowing of the nasal dorsum allows for a more pleasing moderate width. We here introduce a lateral osteotomy technique that is less traumatic and easier to perform than commonly used procedures in Asian and share our experiences in the application.

METHODS

After a blunt dissection of the periosteum at the mucosal side of the nasal bone, all patients who underwent treatment using nasal osteotomy at the level of the maxillary nasal process were retrospectively analyzed. The bony nasal width, height, and the nasal lateral wall slope of bone before and after surgery were measured. The postoperative outcomes, complications, and patient satisfaction were analyzed and evaluated.

RESULTS

From January 2008 to January 2018, nasal dorsum narrowing was implemented in 106 patients. On average, nasal width was significantly decreased and no change in nose height after the nasal osteotomy. The nasal width was significantly reduced by 8.51 ± 2.16 mm compared with before surgery. The slope of the nasal lateral wall was reduced from the mean of 155.0 ± 7.63-degree preoperation to the mean of 135.25 ± 7.50-degree postoperation. The follow-up period ranged from 6 months to 4 years, with an average of 10.3 months.

CONCLUSIONS

This type of nasal bone base osteotomy is a simple and feasible method for the treatment of wide Asian noses with a high patient acceptance and stable postoperative results.

LEVEL OF EVIDENCE

Level IV.

Bioengineered human tissue regeneration and repair using endogenous stem cells

We describe a general approach to produce bone and cartilaginous structures utilizing the self-regenerative capacity of the intercostal rib space to treat a deformed metacarpophalangeal joint and microtia. Anatomically precise 3D molds were positioned on the perichondro-periosteal or perichondral flap of the intercostal rib without any other exogenous elements. We find anatomically precise metacarpal head and auricle constructs within the implanted molds after 6 months. The regenerated metacarpal head was used successfully to surgically repair the deformed metacarpophalangeal joint. Auricle reconstructive surgery in five unilateral microtia patients yielded good aesthetic and functional results. Long-term follow-up revealed the auricle constructs were safe and stable. Single-cell RNA sequencing analysis reveal early infiltration of a cell population consistent with mesenchymal stem cells, followed by IL-8-stimulated differentiation into chondrocytes. Our results demonstrate the repair and regeneration of tissues using only endogenous factors and a viable treatment strategy for bone and tissue structural defects.

Reconstruction of the shortened columella in mild bifid nose using a propeller flap based on the nasal columella artery

Bifid nose generally appears short columellar and lacks the nasal tip. Here, we describe a surgical correction technique for correcting the short columellar and nasal tip of bifid nose using a local flap to discuss outcomes, patient selection, and complications based on 11 years of experience. Thirty-two patients with mild wide bifid nose and shortened columella were included in this retrospective study. All patients underwent nasal rhinoplasty using a propeller flap based on the nasal columella artery. Nasal columella length, horizontal distance of tip-defining point, and angle of facial convexity were evaluated based on three-dimensional simulation technology. Complications including possible underlying reasons were analyzed. Patient satisfaction was evaluated using a self-assessment survey. Nasal esthetics and function were considerably improved. Follow-up examinations during a period of 9 months on average demonstrated stable results. The columella length was 9.7 ± 4.6 mm preoperatively and 19.9 ± 3.2 mm postoperatively (P < 0.05). The horizontal distance of tip-defining point (mm) decreased to 18.9 ± 5.5 mm postoperatively from a preoperative 23.3 ± 5.4 mm (P < 0.05). There were no severe postoperative complications. Complications were scar, temporary hematoma, and mild infection of nasal skin. The majority of patients (97%) rated their outcome as improved and much improved. Surgical correction using a nasal columella artery propeller flap is an effective therapeutic approach for patients with mild bifid nose. The use of a local flap along with minimal donor-site morbidity and reliable outcomes contributes to the high patient acceptance. Meticulous surgical technique and careful patient selection are prerequisites for successful results.

[Correction model of the sampling time error on the blood trough concentration of tacrolimus in non-sustained-release dosage form for renal transplant recipients]

Objective: To establish correction model of the sampling time error on the blood trough concentration of tacrolimus in non-sustained-release dosage form for renal transplant recipient and improve the accuracy of drug dose assessment and clinical adjustment in renal transplant recipients. Methods: Visit records of 206 outpatients in the Department of Transplantation, Nanfang Hospital, Southern Medical University were retrospectively collected from October 15, 2022 to October 30, 2022. The distribution of sampling time of tacrolimus blood drug concentration was described and the time range of correction was determined. Twenty inpatients after renal transplantation in the Department of Transplantation, Nanfang Hospital, Southern Medical University from October 1, 2022 to November 30, 2022 were prospectively included, and their demography data, laboratory test results during follow-ups, and CYP3A5 genotype were collected. The patients took tacrolimus in non-sustained-release dosage form every 12 h starting from 19∶30 on the day of admission. Peripheral blood samples were collected from the patients on the second day of admission at 7∶30 and on the third day at 6∶00-10∶00 every 30 minutes to test the blood concentration of tacrolimus. Using the collection time as the independent variable and the blood tacrolimus concentration as the dependent variable, a simple linear regression was performed to fitting a linear model of tacrolimus blood concentration-sampling time. Multiple linear regression was performed to analyze the influencing factors of the tacrolimus metabolic rate within a specific period and generate the regression equation. Results: The 206 outpatients aged (46±13) years, including 131 males (63.6%). The time gap [M (Q₁, Q₃)] between the sampling time of the follow-up outpatients and standard C₁₂ was 24 (13.0, 46.5) min, and the maximum time gap was 135 min. The 20 enrolled inpatients aged (45±12) years, including 15 males (75.0%). There was no significant difference in the blood concentration of tacrolimus collected at 7∶30 on the second (7.87±2.21)ng/ml and third days (7.84±2.33)ng/ml after admission of the enrolled inpatients (P=0.917), and the blood tacrolimus concentration rhythm was stable in the trial. The plasma concentration of C_10.5-C_14.5 was linearly related to the time, with R² [M (Q₁, Q₃)] 0.88 (0.85, 0.92) and all P<0.05. The metabolic rate of tacrolimus during C_10.5-C_14.5=0.984+0.090×basic concentration of tacrolimus (ng/ml)-0.036×body mass index+0.489×CYP3A5 genotype-0.007×hemolobin(g/L)-0.035×alanine aminotransferase (U/L)+0.143×total cholesterol (mmol/L)+0.027×total bilirubin (μmol/L), with R²=0.85. Conclusion: This study propose a correction model for tacrolimus (non-sustained-release dosage form) trough concentration around C₁₂, which is helpful for clinicians to easily and accurately assess renal transplant recipients' tacrolimus exposure.

Repair of Scars and Tissue Deficiency With Free Grafts of Full-thickness Scalp in Secondary Unilateral Cleft Lip Deformity

Although surgical techniques have developed, the incidence of secondary cleft lip deformities after the primary repair is still high. Asymmetry of Cupid's bow and philtrum is a common presentation and a technical challenge to reconstruct the upper lip. The authors introduce a technique to use the free grafts of the full-thickness scalp for the correction of scars and tissue deficiency in secondary unilateral cleft lip deformity. Thirty-seven patients with a prominent scar, tight upper lip, deformed Cupid's bow and philtrum, and irregular vermillion border were included in this study. The specific points of interest were assessed before and after surgery by independent examiners with both subjective and objective methods. All surgeries were successfully completed, and the assessment results were satisfactory. The rating scores of philtrum improvement was 1.6±0.4, the POSAS result of patient scales was 13.48±3.21, and the observer scale result was 11.98±3.88. The asymmetry of Cupid's bow was corrected (P=0.004), the central tubercle of vermilion was more natural (P=0.001), and the irregular vermillion border was improved (P=0.015). The results presented significant differences before and after surgery. This method could be an optional treatment for repairing scars and tissue deficiency in secondary unilateral cleft lip deformity.

Differential Expression of Autophagy-Related Long Non-Coding RNA in Melanoma

To explore the role of autophagy-related differential long non-coding RNA (lncRNA) in the pathogenesis of melanoma, we established a prognostic prediction model for patients with melanoma based on the expression profiles of autophagy-related gene. Based on The Cancer Genome Atlas and GeneCard database, we used single-sample gene set enrichment analysis (ssGSEA), weighted gene co-expression network analysis (WGCNA), uniCOX in R software for COX proportional hazard regression analysis, and enrichment analysis to get an idea of biological processes with autophagy-related genes, which evaluates the relationship between autophagy-related genes and immune cell infiltration in patients with melanoma. The roles of identified lncRNA were evaluated by the risk score based on the results of single factor regression analysis for each lncRNA and on the prognosis for patients obtained from the database. Then, the whole sample was divided into high- and low-risk groups. Survival curve analysis showed that low-risk group had a better prognosis. Enrichment analysis revealed multiple key pathways enriched with lncRNA-associated genes. Analysis of immune cell infiltration revealed differences between high- and low-risk groups. Finally, 3 datasets verified the effect of our model on prognosis. There are important autophagy-related lncRNA in patients with melanoma. Top 6 lncRNA are significantly related to the overall survival rate of patients with melanoma and provide the basis for predicting the prognostic survival of patients.

Surgical Correction of a Bifid Nose Deformity with a Split M-Shaped Flap

Background: Bifid nose is a representative indicator of a facial cleft in patients with frontonasal dysplasia. There is no consensus on effective methods to correct bifid nose deformities due to their varied expressions and limited reports of surgical treatments. In this article, we propose using a split M-shaped flap to treat severe dorsal and alar deformities in patients with a bifid nose. Methods: From 2012 to 2021, a total of 26 bifid nose patients underwent surgical correction of their nasal deformities, which were characterized by cleft and board dorsum, alar defects, shortened nose, and shortened or absent nasal tip. These surgeries were performed with the transposition of an M-shaped split flap. Nasal length and nasolabial angle were assessed before and after surgery. Indications, outcomes, and complications were analyzed. Patient satisfaction was evaluated using a self-assessment survey. Results: Postoperative evaluation showed stable results with increased nasal length and improved nasal appearance. Complications were seen in difficulty breathing through the nose and persistent nostril deformities. The majority of patients (92.3%) were satisfied with their surgical outcome. Conclusion: Split M-shaped flap for bifid nose treatment provides improved nasal appearance with a high patient acceptance and stable postoperative results. Clinical Trial registration: chictr.org identifier ChiCTR2000039275.

Progress of Periosteal Osteogenesis: The Prospect of In Vivo Bioreactor

Repairing large segment bone defects is still a clinical challenge. Bone tissue prefabrication shows great translational potentials and has been gradually accepted clinically. Existing bone reconstruction strategies, including autologous periosteal graft, allogeneic periosteal transplantation, xenogeneic periosteal transplantation, and periosteal cell tissue engineering, are all clinically valuable treatments and have made significant progress in research. Herein, we reviewed the research progress of these techniques and briefly explained the relationship among in vivo microenvironment, mechanical force, and periosteum osteogenesis. Moreover, we also highlighted the importance of the critical role of periosteum in osteogenesis and explained current challenges and future perspective.

P–568 Homozygous Pathogenic Variants in ACTL9 Cause Fertilization Failure and Male Infertility in Human and Mouse

Study question

What are the other male factors that cause total fertilization failure (TFF) excepting for variants in PLCZ1?

Summary answer

Homozygous variants in ACTL9 (actin like 9) cause abnormal localization of PLCζ in a loosened perinuclear theca (PT) structure and leads to TFF.

What is known already

In previous studies, investigators have reported that the female factors in TFF after intracytoplasmic sperm injection (ICSI) include pathogenic variants in WEE2, TLE6, and TUBB8, whereas for male factors, pathogenic variants in PLCZ1 were reported to be the primary cause of TFF, which account for approximately 30% of couples with male factors in TFF excluding globozoospermia. Most recently, it was reported that pathogenic variants in ACTL7A led to reduced expression and abnormal localization of PLCζ, thereby identifying this genetic variant as a potential cause of TFF.

Study design, size, duration

Fifty-four infertile couples with TFF or poor fertilization (fertilization rate of &lt; 20%) at the Reproductive and Genetic Hospital of CITIC-Xiangya during January 2014 to June 2020 were recruited into this study.

Participants/materials, setting, methods

Male factors were identified in (MOAT). WES analysis was used to analyze the genetic factors of individuals with male factors. Sperm morphological study was conducted by H&E staining and TEM. Immunostaining of PLCζ was used to analyze the status of sperm-borne activation factor. A knock-in mouse model was generated by CRISPER-Cas9 technology. Sperm from homozygous Actl9 variant mice were analyzed by TEM and ICSI. ICSI with AOA was performed in couples with ACTL9 variants.

Main results and the role of chance

A total of 54 couples with TFF or poor fertilization were screened, with 21 couples determined to have a male infertility factor by MOAT. Whole-exome sequencing of these 21 male individuals identified three homozygous pathogenic variants in ACTL9 in three individuals. ACTL9 variations led to abnormal ultrastructure of the PT, with PLCζ absent in the head and present in the neck of the mutant sperm, which contributed to failed normal calcium oscillations in oocytes and subsequent TFF. The key roles of ACTL9 in the PT structure and TFF after ICSI were further confirmed in Actl9-mutated mouse model. Furthermore, assisted oocyte activation by calcium ionophore exposure successfully overcame TFF and achieved live births in a couple with an ACTL9 variant.

Limitations, reasons for caution

The mechanism of how ACTL9 regulate PLCζ remains unknown.

Wider implications of the findings: It provided a genetic marker and a therapeutic option for individuals who have undergone ICSI without successful fertilization.

Trial registration number

not applioable

EUS-guided gastroenterostomy with a lumen apposing self-expandable metallic stent relieves gastric outlet obstruction - a Scandinavian case series

BACKGROUND

EUS-guided gastroenterostomy (EUS-GE) with lumen-apposing metallic stents (LAMS) in patients with gastric outlet obstruction (GOO) has proven to be an alternative to luminal stenting in the duodenum and surgical gastroenterostomy. In severely ill patients, the method can provide improved quality of life (QoL) and symptom relief by restoration of the luminal passage of fluid and nutrients to the small intestine.

AIM

To assess the technical and clinical success and safety of EUS-GE.

MATERIAL AND METHODS

A dual center retrospective case series of 33 consecutive patients with GOO due to malignant (n = 28) or non-malignant conditions (n = 5). The patients were treated with EUS-GE using cautery enhanced LAMS. Procedures were performed guided by EUS and fluoroscopy in general anesthesia or conscious sedation.

RESULTS

Technical success was achieved in all patients. The median procedure time was 71 min and the median hospital stay was three days. Thirty (91%) patients were able to resume oral nutrition after the procedure. Ten patients (30%) experienced adverse events (AEs), including migration of the stent, bleeding, and infection. Four patients had fatal AEs (12%). All stent-related AEs were handled endoscopically. Five patients (15%) needed re-intervention. The median survival time for patients with malignant obstruction was 8.5 weeks (0.5-76), and 13 patients with obstructing malignancies lived 12 weeks or longer.

CONCLUSION

EUS-GE is a minimally invasive and efficient method for restoration of the gastrointestinal passage and may improve palliative care for patients with GOO. The method has potential hazards and should only be offered in expert centers that regularly perform the procedure.

A compact electron beam ion trap in support of high-temperature plasma diagnostics based on conduction-cooled superconducting coils

Spectroscopic diagnostics of future fusion reactor plasmas require information on impurity line emissions, especially for relevant high-Z metal elements (e.g., tungsten). These materials will be widely used as plasma facing components for their high heat tolerance and low sputtering yield. Based on an electron beam ion trap, a compact impurity spectra platform is developed to mimic the high-temperature environment of a fusion reactor. The proposed platform can deliver a focused e-beam at energies over 30 keV using a confining magnetic field of ∼1.0 T generated by two superconducting coils (NbTi). Cooled by a closed-loop cryocooler, the coils can avoid the usage of a complicated cryogenic system involving the handling of liquid helium. For spectroscopic studies of highly charged ions, a spherically curved crystal spectrometer is proposed to measure a wavelength range around 2-4 Å covering the typical wavelength range expected to be emitted by metal ions in a fusion plasma. This paper reports the design and development progress of the platform.

Assessing adaptation measures on agricultural water productivity under climate change: A case study of Huai River Basin, China

This study explored an integrated framework to assess the effectiveness of adaptation measures on the water productivity (WP) of the agricultural water management (AWM) system in the Huai river basin of China considering climate change impact. The adaptation measures include optimization of cropping pattern (OCP) and upgradation of irrigation techniques (UIT). The delta change method was used to downscale the climate variables from RCP4.5 and RCP8.5 of general circulation models (GCMs) during 2021-2050, the water footprint theory was used to estimate the spatial distribution of blue water to calculate the WP, and the nonlinear optimization model was used to seek optimal cropping pattern aiming at maximizing the system's WP. The changes in WP due to climate change and adaptation measures (e.g. combinations of OCP and UIT) were compared. Results indicated that WP under RCP4.5 and RCP8.5 would be 4.56% and 6.51% lower than those under the benchmark scenario, respectively. The mitigation rates to the negative impact of climate change on WP under RCP4.5 and RCP8.5 would be (1) 3.05% and 3.37% for the combination of spay irrigation technique and OCP, and (2) 4.34% and 4.59% for the combination of drip irrigation technique and OCP, respectively. It was revealed that the combination of drip irrigation and cropping pattern optimization could largely offset the adverse effect from climate change on WP under RCP4.5. Under such a scenario, the total plant areas of wheat and maize would reduce over the basin and so would the net export of crops in the basin; this would lead to a decrease in the crop trade benefit of 7.07 × 10⁹ $ and a relief of 7.50 × 10⁹ m³ of blue water loss. This study results could offer strategic decision support for long-term sustainable AWM of Huai river basin in a changing environment.

Short term results of philtrum reconstruction with an orbicularis oris muscle flap in cleft patients

PURPOSE

In the treatment of philtral ridge deficiency in cleft lip patients, optimal results are difficult to obtain due to visible scarring following surgery. The purpose of this article is to introduce a novel strategy for philtrum reconstruction along with an evaluation of postoperative outcomes of this technique.

METHOD

All patients with a deficiency of the philtrum underwent reconstruction of the philtral ridge and upper lip using an orbicularis oris muscle flap with a specific re-suturing technique in our study. The convexity of the philtral ridge was evaluated pre- and postoperatively at rest and while puckering using patient photography as well as three-dimensional simulation technology. Postoperative outcomes and complications were assessed during follow-up, including a patient satisfaction survey.

RESULTS

Thirty cleft lip patients underwent treatment in this study using a specific orbicularis oris muscle re-suturing technique. The average age of the 13 male and 17 female patients was 31.5 years. The follow-up period ranged from 6 months to 3.5 years with an average of 10.3 months. Postoperative results showed an aesthetic reconstructed philtral ridge with stable outcome. Complications included acute infection (1 case) and temporary stiffness of smile (3 cases). No systemic complications occurred. All patients were satisfied with their results, and none required further surgery.

CONCLUSION

We propose a simple, effective, and reproducible technique involving an orbicularis oris muscle flap for the creation of the philtral column in secondary cleft lip deformity. Our approach allowed aesthetically pleasing and stable outcomes. Although the short-term results of the philtrum reconstruction seem to be adequate there is no information on the long-term situation, and therefore no general recommendation to adopt this method can be given.

Manipulating topological transformations of polar structures through real-time observation of the dynamic polarization evolution

Topological structures based on controllable ferroelectric or ferromagnetic domain configurations offer the opportunity to develop microelectronic devices such as high-density memories. Despite the increasing experimental and theoretical insights into various domain structures (such as polar spirals, polar wave, polar vortex) over the past decade, manipulating the topological transformations of polar structures and comprehensively understanding its underlying mechanism remains lacking. By conducting an in-situ non-contact bias technique, here we systematically investigate the real-time topological transformations of polar structures in PbTiO₃/SrTiO₃ multilayers at an atomic level. The procedure of vortex pair splitting and the transformation from polar vortex to polar wave and out-of-plane polarization are observed step by step. Furthermore, the redistribution of charge in various topological structures has been demonstrated under an external bias. This provides new insights for the symbiosis of polar and charge and offers an opportunity for a new generation of microelectronic devices.

Direct observation of the dynamic evolution of polar domain structures at atomic level remains challenging. Here, the authors report the observation of real-time topological transformations of polar structures in PbTiO₃/SrTiO₃ multilayers.

Supermicrosurgical reconstruction of nasal tip defects using the preauricular reversed superficial temporal artery flap

BACKGROUND

Microsurgical reconstruction of nasal tip defects is difficult to achieve. The free composite auricular flap allows for repair in a one-stage procedure. However, anastomosis to the recipient facial artery is often complicated because of its variable anatomy and the need for a vessel graft. In this study, we describe our experience using the alar artery and angular vein as recipient vessels for direct super microsurgical anastomosis.

METHOD

From February 2004 to December 2015, thirty-two patients with different degrees of full-thickness multi-subunit nasal tip defects were included in this study. The superficial temporal vessels, alar artery, and angular vein were marked preoperatively by ultrasound detection. The preauricular reversed superficial temporal artery flap was harvested and transferred to the nasal tip defect region as a free flap using a supermicrosurgical technique. Patient pictures were taken before surgery and at 1, 3, and 6 months of follow-up. Outcomes and complications were recorded and analyzed. Moreover, a postoperative patient satisfaction survey was performed.

RESULTS

The reversed superficial temporal artery flap was used in a total of 32 patients for the reconstruction of nasal tip defects in a one-stage procedure. In all cases, the alar artery and angular vein showed no anatomical variations and were used as recipient vessels. The size of the harvested preauricular flap size was 2.5 × 2.0 to 4.0 × 3.6 cm², and the average flap size was 3.6 × 2.7 cm². The length of the arterial pedicle was 4.0 to 6.7 cm, 5.58 cm on average. The length of the venous pedicle was 5.0 to 6.8 cm, 6.21 cm on average. Direct anastomosis was achieved in all patients, and in none of the cases, a vascular graft was needed. Donor sites were all closed primarily. Flap survival was complete, except for one case of vascular thrombosis, resulting in a 10% flap necrosis. Temporary hematoma was noted in one patient. The postoperative outcome showed excellent functional coverage and improved esthetic appearance. The average follow-up period was 12 months. The majority of patients (98.5%) rated their postoperative outcome as highly improved and improved. No late recurrence or other complications were seen in any of the patients. Twenty-two patients underwent a secondary debulking procedure of the flap for fine adjustment.

CONCLUSION

Our results demonstrate that the alar artery and angular vein are suitable recipient vessels for the super microsurgical reconstruction of nasal tip defects. Surgical planning and procedure are facilitated by their reliable anatomy without the need for a vessel graft. This technique may offer wider applications by extension to other facial cutaneous defects.

Optical creation of a supercrystal with three-dimensional nanoscale periodicity

Stimulation with ultrafast light pulses can realize and manipulate states of matter with emergent structural, electronic and magnetic phenomena. However, these non-equilibrium phases are often transient and the challenge is to stabilize them as persistent states. Here, we show that atomic-scale PbTiO₃/SrTiO₃ superlattices, counterpoising strain and polarization states in alternate layers, are converted by sub-picosecond optical pulses to a supercrystal phase. This phase persists indefinitely under ambient conditions, has not been created via equilibrium routes, and can be erased by heating. X-ray scattering and microscopy show this unusual phase consists of a coherent three-dimensional structure with polar, strain and charge-ordering periodicities of up to 30 nm. By adjusting only dielectric properties, the phase-field model describes this emergent phase as a photo-induced charge-stabilized supercrystal formed from a two-phase equilibrium state. Our results demonstrate opportunities for light-activated pathways to thermally inaccessible and emergent metastable states.

Intracellular manipulation and measurement with multipole magnetic tweezers

The capability to directly interrogate intracellular structures inside a single cell for measurement and manipulation is important for understanding subcellular and suborganelle activities, diagnosing diseases, and developing new therapeutic approaches. Compared with measurements of single cells, physical measurement and manipulation of subcellular structures and organelles remain underexplored. To improve intracellular physical measurement and manipulation, we have developed a multipole magnetic tweezers system for micromanipulation involving submicrometer position control and piconewton force control of a submicrometer magnetic bead inside a single cell for measurement in different locations (spatial) and different time points (temporal). The bead was three-dimensionally positioned in the cell using a generalized predictive controller that addresses the control challenge caused by the low bandwidth of visual feedback from high-resolution confocal imaging. The average positioning error was quantified to be 0.4 μm, slightly larger than the Brownian motion–imposed constraint (0.31 μm). The system is also capable of applying a force up to 60 pN with a resolution of 4 pN for a period of time longer than 30 min. The measurement results revealed that significantly higher stiffness exists in the nucleus’ major axis than in the minor axis. This stiffness polarity is likely attributed to the aligned actin filament. We also showed that the nucleus stiffens upon the application of an intracellularly applied force, which can be attributed to the response of structural protein lamin A/C and the intracellular stress fiber actin filaments.

A simple technique for the correction of maxillonasal dysplasia using customized expanded polytetrafluoroethylene (ePTFE) implants

BACKGROUND

The treatment of maxillonasal dysplasia in Binder's syndrome using autologous costal bone and cartilage is well established, but postoperative results may be compromised by scarring, unpredictable absorption of transferred autologous tissue, and donor site morbidity. Here, we propose a simple surgical technique to improve maxillonasal dysplasia using an expanded polytetrafluoroethylene (ePTFE) implant.

MATERIALS AND METHODS

From February 1999 to May 2014, fifty-eight patients affected by maxillonasal dysplasia with different degrees of flattened nose and midfacial depression underwent surgical correction by augmentation of the nasal dorsum using an "L"-shaped ePTFE and subperiosteal implantation of an inverted "m"-shaped ePTFE at the base of the piriform aperture. The outcome was evaluated based on preoperative and postoperative patient pictures, 3D imaging technology for the assessment of nasolabial angle and facial convexity angle, and a postoperative patient satisfaction survey.

RESULTS

Postoperative results showed improved facial aesthetics with a significantly increased nasolabial angle from initially 74.1° ± 8.9° to 93.7° ± 6.1° at 6 months postoperatively (p < 0.05). Temporary discomfort involving upper lip numbness, foreign body sensation, and stiff smiling expression were complained during the first 3 months postoperatively, but spontaneously resolved within 6 months. Complications included infection (2 cases), implant migration (2 cases), and implant exposure (1 case). The vast majority of patients (95.7%) rated their postoperative outcome as highly improved and improved.

CONCLUSION

The present therapeutic strategy provides a simple and effective treatment for the correction of maxillonasal dysplasia with high patient acceptance in a single step approach. Further research is required to determine long-term outcomes.

Early diagnosis and outcome prediction of neonatal hypoxic-ischemic encephalopathy with color Doppler ultrasound

PURPOSE

To describe the ultrasound presentation of the brain and cerebral hemodynamics in neonates with hypoxic-ischemic encephalopathy (HIE) by comparison with control subjects.

MATERIAL AND METHODS

During June 2012 to April 2013, full term neonates who had clinical evidence of HIE were enrolled. Healthy newborns without HIE were used as a control group. Cerebral parenchyma, size of lateral ventricles and hemodynamic parameters of cerebral arteries were studied using two-dimensional duplex and color Doppler ultrasound. Neonates with moderate and severe HIE were followed-up with ultrasound for at least 3 months.

RESULTS

A total of 158 consecutive neonates (82 boys and 76 girls), including 54 with mild HIE, 60 with moderate HIE and 44 with severe HIE were included. One hundred and twenty healthy newborns were randomly selected as a control group. Abnormal ultrasound findings of brain parenchyma were found in 25/54 (46.3%) neonates with mild HIE whereas they were found in 58/60 (96.7%) neonates with moderate HIE and 44/44 (100%) neonates with severe HIE. Almost all neonates with severe HIE had decreased cerebral artery blood flow velocity and increased resistance index of cerebral arteries. Of the 104 neonates with moderate or severe HIE, follow-up ultrasound examination revealed cystic parenchymal lesions in 12/104 (11.5%), progressive ventricular dilatation and brain atrophy in 12/104 (11.5%), mild ventricular dilatation in 15/104 (14.4%) and leukoencephalomalacia in 2/104 (1.9%) neonates.

CONCLUSION

Ultrasound features such as the size of lateral ventricles, altered brain parenchymal echogenicity and cerebral blood flow parameters are useful for the early diagnosis of HIE and help predict outcome.

Autologous temporomandibular joint reconstruction independent of exogenous additives: a proof-of-concept study for guided self-generation

Joint defects are complex and difficult to reconstruct. By exploiting the body’s own regenerative capacity, we aimed to individually generate anatomically precise neo-tissue constructs for autologous joint reconstruction without using any exogenous additives. In a goat model, CT scans of the mandibular condyle including articular surface and a large portion of the ascending ramus were processed using computer-aided design and manufacturing. A corresponding hydroxylapatite negative mold was printed in 3D and temporarily embedded into the transition zone of costal periosteum and perichondrium. A demineralized bone matrix scaffold implanted on the contralateral side served as control. Neo-tissue constructs obtained by guided self-generation exhibited accurate configuration, robust vascularization, biomechanical stability, and function. After autologous replacement surgery, the constructs showed stable results with similar anatomical, histological, and functional findings compared to native controls. Further studies are required to assess long-term outcome and possible extensions to other further applications. The absence of exogenous cells, growth factors, and scaffolds may facilitate clinical translation of this approach.

Treatment of gummy smile: Nasal septum dysplasia as etiologic factor and therapeutic target

Various techniques to improve gummy smile exist. Depending on the individual etiology, previous approaches have focused on osseous, dental, and soft-tissue aspects. On the basis of the identification of nasal septum dysplasia as etiologic factor of gummy smile, we propose a novel strategy for the improvement in the treatment of excessive gingival exposure. In this prospective controlled study, 121 Asian patients with gummy smile and 150 volunteers were examined and compared with regard to the developmental status of the nasal septal cartilage reflected by the columella upward maximum movability (CUMM) as objective measurement parameter. A total of 46 patients with significantly increased CUMM underwent surgical treatment for excessive gingival exposure by septum cartilage reinforcement and, where required, additional extension using an autologous cartilage graft or an expanded polytetrafluoroethylene (ePTFE) implant. Gingival exposure at the fullest smile was photographed, measured, and analyzed before and 1, 3, and 6 months after surgery, and all possible complications were recorded. The results were evaluated in a patient satisfaction survey. CUMM showed a significant statistical difference between the patients desiring treatment for gummy smile (5.6 ± 0.92 mm) and volunteers (3.1 ± 0.76 mm), (p < 0.05). In the 46 patients who underwent surgical correction of gummy smile, the measured maximum gingival exposure at the fullest smile was 4.52 ± 1.7 mm preoperatively and significantly decreased to 1.79 ± 0.26 mm at 6 months postoperatively (p < 0.05). The overall complication rate was low, including transient stiffness of smile, implant deformation, and acute infection. The postoperative results were highly satisfactory in terms of aesthetic smile. This study proposes a novel strategy of reinforcement and extension of the nasal septum cartilage for the improvement of gummy smile confirming septal cartilage dysplasia as the etiologic factor.

Negative regulation of the p300-p53 interplay by DDX24

Numerous studies indicate that p300 acts as a key transcriptional cofactor in vivo, at least, in part, through modulating activities of p53 by acetylation. Nevertheless, the regulation of the p53-p300 interplay is not completely understood. Here, we have identified the DEAD box RNA helicase DDX24 as a novel regulator of the p300-p53 axis. We found that DDX24 interacts with p300, and this interaction leads to suppression of p300 mediated acetylation of p53. Notably, RNAi-mediated knockdown of endogenous DDX24 significantly increases the acetylation levels of endogenous p53 in human cancer cells and subsequently promotes p53-mediated activation of its transcriptional targets such as p21 and PUMA. In contrast, DDX24 expression inhibits the p300-p53 interaction and suppresses p300-mediated acetylation of p53. Moreover, DDX24 is overexpressed in human cancer cells and reduction of DDX24 protein levels by RNAi induces cell cycle arrest and senescence in a p53 dependent manner. These results reveal DDX24 as an important regulator of p300 and suggest that the modulation of the p53-p300 interplay by DDX24 is critical in controlling p53 activities in human cancer cells.

An integrated simulation and optimization approach for managing human health risks of atmospheric pollutants by coal-fired power plants

This research developed a simulation-aided nonlinear programming model (SNPM). This model incorporated the consideration of pollutant dispersion modeling, and the management of coal blending and the related human health risks within a general modeling framework In SNPM, the simulation effort (i.e., California puff [CALPUFF]) was used to forecast the fate of air pollutants for quantifying the health risk under various conditions, while the optimization studies were to identify the optimal coal blending strategies from a number of alternatives. To solve the model, a surrogate-based indirect search approach was proposed, where the support vector regression (SVR) was used to create a set of easy-to-use and rapid-response surrogates for identifying the function relationships between coal-blending operating conditions and health risks. Through replacing the CALPUFF and the corresponding hazard quotient equation with the surrogates, the computation efficiency could be improved. The developed SNPM was applied to minimize the human health risk associated with air pollutants discharged from Gaojing and Shijingshan power plants in the west of Beijing. Solution results indicated that it could be used for reducing the health risk of the public in the vicinity of the two power plants, identifying desired coal blending strategies for decision makers, and considering a proper balance between coal purchase cost and human health risk.

IMPLICATIONS

A simulation-aided nonlinear programming model (SNPM) is developed. It integrates the advantages of CALPUFF and nonlinear programming model. To solve the model, a surrogate-based indirect search approach based on the combination of support vector regression and genetic algorithm is proposed. SNPM is applied to reduce the health risk caused by air pollutants discharged from Gaojing and Shijingshan power plants in the west of Beijing. Solution results indicate that it is useful for generating coal blending schemes, reducing the health risk of the public, reflecting the trade-offbetween coal purchase cost and health risk.

Anti-TNF-α therapy for patients with sepsis: a systematic meta-analysis

OBJECTIVE

In humans, the role of anti-tumour necrosis factor (TNF)-α therapy in severe sepsis and septic shock is debatable. The aim of this meta-analysis was to determine the efficacy of anti-TNF-α therapies against placebo in patients with severe sepsis or septic shock.

METHODS

A structured literature search was undertaken to identify randomised controlled trials (RCTs) conducted in patients with severe sepsis or septic shock receiving anti-TNF-α therapy or placebo. A meta-analysis on relative risk (OR) with a 95% confidence interval (95% CI) was performed.

RESULTS

Seventeen studies with a total of 8971 patients were included. When all forms of anti-TNF-α therapy were pooled together, there was a significant reduction of 28-day all-cause mortality with respect to placebo (OR = 0.91, 95% CI: 0.83-0.99; p = 0.04). Subgroup analysis showed that anti-TNF-α antibodies (monoclonal and polyclonal) reduced mortality (OR = 0.90, 95% CI: 0.81-0.99; p = 0.04). Monoclonal antibodies enhanced survival (OR = 0.91, 95% CI: 0.82-1.00; p = 0.05), while polyclonal antibodies or receptor blockers did not enhance survival (OR = 0.71, 95% CI: 0.39-1.28, p = 0.25; OR = 0.95, 95% CI: 0.78-1.17, p = 0.65). There was a trend towards better survival in patients with high levels of IL-6 (> 1000 pg/ml) and patients with shock if they were treated with anti-TNF-α therapy (OR = 0.85, 95% CI: 0.72-1.00; OR = 0.80, 95% CI: 0.62-1.04). Publication bias and statistical heterogeneity (I(2)  < 50% and p > 0.1) were absent. Sensitivity analysis suggests that these results are highly stable.

CONCLUSIONS

This meta-analysis suggests that in patients with severe sepsis (before shock), immunotherapy with anti-TNF-α monoclonal antibodies reduces overall mortality. In patients with shock or high levels of IL-6 (> 1000 pg/ml), anti-TNF-α therapy may improve survival.