Anesthesia-Analgesia

Prolapse of Aortic Right Coronary Cusp Causing Right Ventricular Outflow Tract Obstruction in a Child With Large Ventricular Septal Defect No abstract available

Delayed Neuromuscular Blockade Reversal With Sugammadex After Vecuronium, Desflurane, and Magnesium Administration: A Case Report A variety of factors are known to prolong neuromuscular blockade, including several medications commonly used in anesthetic practice. We present a patient who underwent general anesthesia using desflurane, vecuronium, and magnesium infusion with delayed neuromuscular blockade reversal after sugammadex administration. A higher than anticipated total dose of sugammadex was required for adequate reversal, and quantitative neuromuscular monitoring was essential to ensuring complete neuromuscular recovery before extubation in this case. Accepted for publication May 23, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Stuart Grant, MBChB, Department of Anesthesiology, Duke University Medical Center, DUMC Box 3094, Durham, NC 27710. Address e-mail to stuartgrant1@me.com. © 2019 International Anesthesia Research Society

Decreasing Frontal Electroencephalogram Alpha Power and Increasing Sensitivity to Volatile Anesthetics Over 3 Surgeries Within 7 Months: A Case Report Depth of anesthesia (DoA) monitors are widely used during general anesthesia to guide individualized dosing of hypnotics. Other than age and specific drugs, there are few reports on which comorbidities may influence the brain and the resultant electroencephalogram (EEG) of patients undergoing general anesthesia. We present a case of a patient undergoing 3 cardiac operations within 7 months with severe illness and comorbidity, leading to pronounced physical frailty and significant changes of frontal alpha power in the EEG and increased sensitivity to volatile anesthetics. These findings may have important clinical implications and should trigger further investigations on this topic. Accepted for publication May 1, 2019. Funding: This work received funding from Bangerter-Rhyner Foundation Grant and Clinical Trials Unit grant of the University Hospital of Bern, Inselspital, Bern, Switzerland. The authors declare no conflicts of interest. Clinical trial number: ClinicalTrials.gov; Identifier: NCT02976584. Address correspondence to, Heiko A. Kaiser, MD, Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland., Address e-mail to heiko.kaiser@insel.ch. © 2019 International Anesthesia Research Society

Postpartum Thyroid Storm in Poorly Controlled Graves' Disease: A Case Report Hyperthyroidism during pregnancy is a relatively rare event, but poor control of hyperthyroidism during pregnancy is associated with a host of issues. These include intrauterine fetal demise, hypertensive disorders of pregnancy, preterm delivery, low birth weight, intrauterine growth restriction, and maternal congestive heart failure. One of the most feared sequelae of hyperthyroidism is thyroid storm, which has a mortality rate >10%. Patients who develop thyroid storm present several challenges to anesthesiologists including hemodynamic instability and medication management. Here, we present the anesthetic management for a parturient whose delivery was complicated by signs and symptoms consistent with thyroid storm. Accepted for publication May 23, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Jack M. Peace, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron F5-704, Chicago, IL 60611. Address e-mail to jack.peace@northwestern.edu. © 2019 International Anesthesia Research Society

Analgesic Rescue With Opioid-Only Thoracic Epidural After Surgical Infiltration of Liposomal Bupivacaine: A Case Report We present the case of a 51-year-old man with a history of recurrent lung cancer after left upper lobectomy who presented for an elective completion pneumonectomy via a bilateral anterior thoracotomy incision. At the completion of surgery, bilateral multilevel intercostal infiltration was performed with liposomal bupivacaine. Due to poorly controlled postoperative pain after extubation, a thoracic epidural was placed in the intensive care unit. An opioid-only infusion was started and transitioned to a local anesthetic–based infusion on postoperative day 2. This case report represents a novel stepwise approach of thoracic epidural management after surgical infiltration of liposomal bupivacaine. Accepted for publication May 16, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Matthew W. Swisher, MD, Department of Anesthesiology, University of California San Diego, 9500 Gilman Dr MC 0898, La Jolla, CA 92093. Address e-mail to mwswisher@ucsd.edu. © 2019 International Anesthesia Research Society

Lung Isolation for Whole Lung Lavage in a Pediatric Patient With Atypical Airway Anatomy due to Short Stature: A Case Report This case demonstrates the airway management of a pediatric patient with short stature due to STAT5b deficiency, a rare genetic immunodeficiency associated with lung disease and endocrinopathy. The patient had recurrent pulmonary infections and pulmonary alveolar proteinosis (PAP) for which whole lung lavage (WLL) was recommended. Due to short stature and overall body habitus, the patient's airway would not accommodate a traditional double-lumen tube (DLT). Therefore, we placed 2 single-lumen breathing tubes: 1 endobronchial and 1 endotracheal, to mimic a DLT and facilitate WLL, demonstrating a viable option for lung isolation in the absence of purpose-built equipment. Accepted for publication April 30, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Susan E. Eklund, MD, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, 300 Longwood Ave, Bader 3, Boston, MA 02115. Address e-mail to susan.eklund@childrens.harvard.edu. © 2019 International Anesthesia Research Society

Comparison of Twitter Use of the American Society of Anesthesiologists and the American Association of Nurse Anesthetists Twitter has become a powerful tool for dissemination of information. The objective of this study was to evaluate Twitter usage of the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA). All tweets from ASA ("@ASALifeline") and AANA ("@aanawebupdates") were collected over a 1-year time period. The content of each tweet was categorized using a rubric. ASA generated more original tweets than AANA. Twitter use was highest in October for ASA and September for AANA. Both societies are actively using Twitter. Future work should evaluate the impact of societal Twitter use. Accepted for publication May 7, 2019. Funding: None. The authors declare no conflicts of interest. Address correspondence to Elizabeth M. S. Lange, MD, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E Huron St, F5-704, Chicago, IL 60611. Address e-mail to elizabeth.lange@northwestern.edu. © 2019 International Anesthesia Research Society

Having a Conscious Patient During Cardiopulmonary Resuscitation: Is It Not Time to Consider Sedation Protocol?: A Case Report A middle-aged man with acute inferior wall myocardial infarction was admitted in cardiac arrest and in an unresponsive state to the hospital. Cardiopulmonary resuscitation (CPR) was initiated. Patient showed signs of consciousness throughout the CPR. The impact of awareness during CPR on the neuropsychological status of a patient with a favorable neurological outcome is yet to be studied on a large scale. Sedation protocol without compromising hemodynamic status may prove a fair choice in such cases. Accepted for publication April 9, 2019. Funding: None. The author declares no conflicts of interest. Address correspondence to Vasanth Sukumar, DA, DNB, Royal Care Super Specialty Hospitals, Neelambur, Coimbatore 641062, Tamil Nadu, India. Address e-mail to vasnt.dr@gmail.com. © 2019 International Anesthesia Research Society

Bilateral Sciatic Neuropathies as a Complication of Positioning During Neuraxial Anesthesia for Cesarean Delivery: A Case Report Neurologic complications following neuraxial anesthesia for cesarean delivery are rare. We present a 33-year-old parturient who developed prolonged lower extremity weakness following a single-shot subarachnoid block for cesarean delivery. After neurologic evaluation, she was diagnosed with bilateral sciatic neuropathies due to prolonged positioning for the anesthetic. We review the incidence of nerve injury associated with neuraxial anesthesia and risk factors for developing peripheral nerve injury in this context. We offer a solution to prevent this complication from occurring. Accepted for publication March 18, 2019. Funding: None. The authors declare no conflicts of interest. The views expressed are those of the authors and do not reflect the official views or policy of the Department of Defense or its components. Address correspondence to Bradley A. Reel, MD, Department of Anesthesia, Brooke Army Medical Center, 3551 Roger Brooke Dr, San Antonio, TX 78234. Address e-mail to bradley.a.reel2.mil@mail.mil. © 2019 International Anesthesia Research Society

Andexanet Alfa for Urgent Reversal of Apixaban Before Aortic Surgery Requiring Cardiopulmonary Bypass: A Case Report Andexanet alfa is a recombinant factor Xa decoy molecule capable of reversing direct and indirect factor Xa–inhibiting anticoagulants. We present an adult patient on apixaban for nonvalvular atrial fibrillation who required urgent reoperative aortic surgery for an aortic root pseudoaneurysm. Apixaban was reversed with andexanet alfa. A second dose of andexanet alfa was required before surgical incision for persistently elevated antifactor Xa levels. Intraoperative management required use of cardiopulmonary bypass (CPB). No major adverse cardiovascular, cerebrovascular, hemorrhagic, or thromboembolic events were observed. Accepted for publication May 13, 2019. The authors declare no conflicts of interest. Funding: None. Address correspondence to Devon Flaherty, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. Address e-mail to flaherdc@gmail.com. © 2019 International Anesthesia Research Society

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Radiation and Environmental Biophysics

Selenium does not affect radiosensitivity of breast cancer cell lines Abstract Supplementation with the antioxidant selenium is frequently performed in breast cancer patients to protect the normal tissue from radiation-induced side effects. However, concerns exist whether selenium also protects tumor cells from radiation-induced cell kill and thereby reduces the efficacy of radiotherapy. In this work, the effect of selenium administration on the radiosensitivity of breast cancer cells was evaluated in vitro. Physiological relevant selenium concentrations (70 and 140 µg/l) did not affect DNA double-strand breaks (γH2AX foci) after 4-Gy X-ray irradiation. Also apoptosis (caspase 3/7) after irradiation with 10 Gy was not influenced by selenium treatment in MDA-MB-231 and MCF7 cells. Most importantly, selenium supplementation did not impair the clonogenic survival of the breast cancer cell lines after irradiation (0, 2, 4, 6, 8 Gy). The data suggest that physiological relevant selenium concentrations administered in combination with radiation therapy do not deteriorate the efficacy of radiotherapy in breast cancer patients. However, randomized clinical trials comparing the effectiveness of radiotherapy and the associated side effects in patients with and without selenium supplementation are recommended.

Dose to the interventional radiologist in CTF-guided procedures Abstract The aim of this work was to assess the occupational dose received by an interventional radiologist (IR) during computed tomography fluoroscopy (CTF)-guided procedures; to identify the most exposed areas of the body including the hands and fingers; to suggest recommendations for individual monitoring; and to improve radiation safety of the practice. A total of 53 CTF-guided procedures were studied. Twelve whole-body dosimeters were worn by the IR in each procedure for the assessment of the personal dose equivalent, Hp(10), on the chest, waist, and back, both over and under the lead apron, as well as the personal dose equivalent, Hp(0.07), on both arms, knees, and feet. Special gloves with casings to fit extremity dosimeters were prepared to assess Hp(0.07) to the fingers. The measured chest dose values were higher than those on the waist and back; the dominant hand or the left side was the most exposed. In general, the ring, middle, and index fingers of the dominant hand were the most exposed (maximum in the 36–39 mSv range), while wrist dose was negligible compared to finger doses. Based on the results obtained the following recommendations are suggested: protective devices (lead aprons, thyroid shield, and goggles) should be worn; Hp(10) should be assessed at the chest level both above and below the lead apron; finger doses can be measured on the basis of each middle finger; the arm closer to the beam should be monitored; and finally, a wrist dosimeter will not provide useful information.

Impact of dimethyl sulfoxide on irradiation-related DNA double-strand-break induction, -repair and cell survival Abstract Dimethyl sulfoxide (DMSO) is an effective radical scavenger and, when added to cells, reduces the initial number of radiation-induced DNA double-strand breaks (DSB). The aim of this study was to investigate modification by DMSO of both DSB induction and DSB repair by means of pulsed-field gel electrophoresis (PFGE) as well as gamma-H2AX immunofluorescence staining. WiDr cells (human colon carcinoma provided by DKFZ) were incubated with 2% DMSO for 2 h (or mock-treated) prior to irradiation with varying X-ray doses and subsequent incubation for repair. Sample processing for PFGE analysis or counting of γ-H2AX foci was performed according to standard protocols. Effects on apoptosis induction and cell survival were investigated additionally by standard protocols. DMSO reduced DSB yield after 20–80 Gy measured by PFGE. A qualitatively similar result was found after low-dose irradiation (1 Gy) using γ-H2AX immunofluorescence staining. During incubation for repair, both DNA fragment rejoining (PFGE) as well as γ-H2AX foci removal occurred at a reduced rate when cells had been pre-treated with DMSO. But this effect was clearly more pronounced for the PFGE-analyzed double-strand breakage, particularly at early repair times. WiDr cells treated with DMSO (2%) showed a significantly increased clonogenic survival after irradiation doses above 8 Gy. Apoptosis rates were not changed by DMSO. The radio-protective effect of DMSO, well known from other PFGE studies, could be confirmed for the formation of γ-H2AX foci. DSB generated in the presence of DMSO were less rapidly repaired. DMSO showed radio-protective effects on clonogenic survival but not on apoptosis.

Comparison of results from indoor radon measurements using active and passive methods with those from mathematical modeling Abstract Computational fluid dynamics (CFD) has been used to simulate the distribution of indoor radon concentration in a naturally ventilated room. Finite volume method was employed in CFD code for the simulation of indoor radon. The simulation results were validated at 34 points in a matrix of two horizontal planes (y = 1.3 m and y = 2.1 m) using passive pinhole dosimeters and at six points using an active scintillation radon monitor. The CFD results were found to exhibit an excellent correlation with the measured values. It is concluded that CFD analysis is a powerful tool to visualize indoor radon distribution.

The effect of lycopene supplementation on radiation-induced micronuclei in mice reticulocytes in vivo Abstract Lycopene (LYC) is a natural pigment present in tomatoes and other red fruits and vegetables including red carrots, red peppers, watermelons, pink grapefruits, apricots, pink guavas, and papaya. There is some evidence that LYC may provide protection against mutations induced by ionizing radiation. The study aimed to investigate whether the genetic material of reticulocytes (RET) could be protected from radiation-induced damage by LYC. Mice were treated with LYC [0.15 mg/kg bodyweight (bw), 0.30 mg/kg bw], acute and fractionated irradiation (0.5 Gy, 1 Gy applied daily), or with both agents (0.5 Gy + 0.15 mg/kg bw LYC, 0.5 Gy + 0.30 mg/kg bw LYC, 1 Gy + 0.15 mg/kg bw LYC, 1 Gy + 0.30 mg/kg LYC). LYC supplementation was started at 24 h or 1 week after the first irradiation. Irradiation significantly enhanced the frequency of micronuclei (MN) in RET. LYC treatment at a dose of 0.15 mg/kg bw 24 h after starting fractionated radiation at 1 Gy significantly decreased (41–68%, p < 0.0125) the level of MN in peripheral blood and bone marrow RET. LYC supplementation at 0.30 mg/kg bw did not significantly alter the frequency of MN in peripheral blood, but significantly increased the frequency of bone marrow RET MN. LYC treatment on day 8 following the first radiation exposure showed results similar (92–117%, p > 0.24) to those obtained with irradiation alone. Lycopene may act as a radiomitigator but must be administered at low doses and as soon as possible after irradiation. Contrary, combined exposure with high doses of irradiation and LYC may enhance the mutagenic effect of irradiation.

Monte Carlo single-cell dosimetry using Geant4-DNA: the effects of cell nucleus displacement and rotation on cellular S values Abstract Investigation of biological effects of low-dose ionizing radiation at the (sub-) cellular level, which is referred to as microdosimetry, remains a major challenge of today's radiobiology research. Monte Carlo simulation of radiation tracks can provide a detailed description of the physical processes involved in dimensions as small as the critical substructures of the cell. Hereby, in the present study, microdosimetric calculations of cellular S values for mono-energetic electrons and six Auger-emitting radionuclides were performed in single-cell models of liquid water using Geant4-DNA. The effects of displacement and rotation of the nucleus within the cell on the cellular S values were studied in spherical and ellipsoidal geometries. It was found that for the examined electron energies and radionuclides, in the case of nucleus cross-absorption where the radioactivity is either localized in the cytoplasm of the cell or distributed on the cell surface, rotation of the nucleus within the cell affects cellular S values less than displacement of the nucleus. Especially, the considerable differences observed in S(nucleus ← cell surface) values between an eccentric and a concentric cell–nucleus configuration in spherical and ellipsoidal geometries (up to 63% and up to 44%, respectively) suggests that the approximation of concentricity should be used with caution, at least for localized irradiation of the cell membrane by an Auger-emitter in targeted radionuclide cancer therapy. The obtained results, which are based on a more realistic modeling of the cell than was done before, provide more accurate information about nuclear dose. This can be useful for theranostic applications.

Toxicity of high uranium doses in broilers and protection with mineral adsorbents Abstract The aim of this study was to determine the uranium distribution and histopathological changes in broiler organs (kidney, liver, and brain) and muscle after 7 days of contamination with high doses of uranyl nitrate hexahydrate (UN), and the protective efficiency of three different mineral adsorbents (organobentonite, organozeolite, and sepiolite). During the 7 days, the UN administration was 50 mg per day, and administration of adsorbents was 2 g per day immediately after UN. In control group where broilers received only UN, histopathological changes such as necrosis of intestinal villi, oedema, vacuolisation and abruption of epithelial cells in renal tubules, oedema and vacuolisation of the cytoplasm of hepatocytes, and dystrophic changes in the neurons of the medulla oblongata were observed. In contrast, when the adsorbents organobentonite, organozeolite, and sepiolite were administered, no histopathological changes were observed in liver and brain. The investigated adsorbents showed the highest protective effects in liver (80–92%), compared to the kidney (77–86%), brain (37–64%), and meat (31–63%).

Hypoxia inducible factor-1α/B-cell lymphoma 2 signaling impacts radiosensitivity of H1299 non-small cell lung cancer cells in a normoxic environment Abstract Hypoxia inducible factor-1α (HIF-1α) is a critical transcriptional factor for the response of cells to hypoxic microenvironment and its expression induces resistance of hypoxic non-small-cell lung cancer (NSCLC) cells to radiotherapy. This study investigated how the activation of HIF-1α/B-cell lymphoma 2 (BCL-2) signaling under normoxic conditions impacted radiosensitivity of NSCLC cells. The recombinant pcDNA3.0-EGFP plasmids with wild-type or mutant HIF-1α complementary DNA (cDNA) were transfected into H1299 cells, an NSCLC cell line, establishing two H1299 sublines with high expression of HIF-1α. Compared with the levels of HIF-1α and BCL-2 proteins in non-transfected cells, increased levels of both proteins were found in transfected cells. Moreover, the expression of HIF-1α in non-transfected cells induced by chloride cobalt (CoCl2), a commonly used mimetic hypoxia reagent, was concomitant with the enhancement of BCL-2 expression. Conversely, reduction of HIF-1α expression by an inhibitor decreased the levels of BCL-2 proteins. The results revealed that the stabilization and expression of HIF-1α promoted the accumulation of BCL-2 proteins in H1299 cells. Subsequent experiments showed that intracellular HIF-1α/BCL-2 signaling was triggered in a normoxic environment after H1299 cells were exposed to irradiation, causing an elevated radioresistance. In contrast, blockage of HIF-1α/BCL-2 signaling leads to an elevated radiosensitivity. Proliferation of cells assay showed that, under normoxic conditions, population doubling times (PDTs) of irradiated cells were prolonged by suppression of HIF-1α/BCL-2 signaling. It is, therefore, indicated that HIF-1α/BCL-2 signaling activated by ionizing radiation reduces the radiosensitivity of H1299 cells independent of the hypoxic environment.

99m Tc activity concentrations in room air and resulting internal contamination of medical personnel during ventilation–perfusion lung scans Abstract This paper presents the results of measurements of 99mTc activity concentrations in indoor air in a nuclear medicine department and resulting estimated 99mTc intake by medical personnel. 99mTc air activity measurements were conducted at the Nuclear Medicine Department, John Paul II Hospital, Krakow, Poland, during ventilation–perfusion SPECT lung scans. Technetium from the air was collected by means of a mobile aerosol sampler with a Petryanov filter operating at an average flow rate of 10 dm3 min−1. Measured activities ranged from 99 ± 11 to 6.1 ± 0.5 kBq m−3. The resulting daily average intake of 99mTc by medical staff was estimated to be 5.4 kBq, 4.4 kBq, 3.0 kBq and 2.5 kBq, respectively, for male technicians, female technicians, male nurses and female nurses. Corresponding annual effective doses were 1.6 µSv for technicians and 1 µSv for nurses. The highest equivalent dose values were determined for extrathoracic (ET) airways: 5 µSv and 10 µSv for nurses and technicians, respectively. It is concluded that estimated annual absorbed doses are over three orders of magnitude lower than the dose limit established in the Polish Atomic Law Act and in recommendations of the International Commission on Radiological Protection for medical staff.

Nuclear medicine: workplace monitoring and internal occupational exposure during a ventilation/perfusion single-photon emission tomography Abstract The administration of 99mTc-HDP to diagnose pulmonary thromboembolisms leads to the presence of 99mTc in the environment of a nuclear medicine department, which could pose a potential risk of internal contamination to medical staff. Therefore, air samples from the administration room, gamma camera room and corridor of such a department were taken for the purpose of performing a workplace monitoring program of the medical centre under study, with maximum activity values of 640 ± 30 kBq/m3, 1.5 ± 0.1 kBq/m3 and 54 ± 3 kBq/m3, respectively, being obtained. These results correspond to committed effective doses received by exposed employees, via inhalation, when one ventilation/perfusion single-photon emission tomography study was performed, of 0.7 μSv, 0.004 μSv and 0.2 μSv, respectively. As inhalation is the employees' main exposure pathway to radio-aerosols, the internal dose of the nuclear medicine department's medical staff was also evaluated via urine bioassay measurements. Nuclear medicine nurses showed the highest 99mTc activity in 24-h urine samples (2100 ± 130 Bq/day), resulting in a committed effective dose of 21 μSv for each diagnostic study performed. Even so, the performance of ventilation/perfusion diagnostic studies did not constitute a substantial radiological risk since the annual dose limit for exposed employees was not exceeded.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Food Security

Inclusive malt barley business and household food security in Lay Gayint district of northern Ethiopia Abstract Food security has become a major problem in Ethiopia. To reverse the situation, inclusive businesses, such as malt barley production, are being promoted. However, the determinants of inclusion in the malt barley industry and the food security impacts of inclusion have not been studied systematically. Thus, the objectives of the present research were twofold, namely to investigate the reason for inclusion in, or exclusion from, the malt barley industry, and to examine the food security impacts of inclusion in three villages in Lay Gayint district, northern Ethiopia. The research used a mixed method approach. Survey data were collected from 140 non-included and 103 included farm households. In addition, focus group discussions were held with 18 included and 18 non-included households, as well as with six officials. Three multiple dimensions of food security were considered: food availability, measured by months per year during which households reported having an adequate food supply; food access, indicated by coping strategies employed by the households to secure sufficient food; and food utilisation, measured by food calorie intake, food variety and diet diversity scores, and three anthropometric measures for children under 5 years of age. Quantitative data were analysed using a two stage least square regression model, while qualitative data were analysed using thematic analysis. The results indicate that inclusion in the malt barley industry is determined by higher economic status. Older farmers and farmers living far from the main town of the district were excluded. We also show that inclusion in the malt barley industry results in higher incomes, better food access and higher diet diversity scores, but has less impact in terms of food availability, food variety score, per capita kilocalorie consumption and child growth. Based on these findings, we suggest that, in the context of inclusive business for those at the 'bottom of the pyramid', one needs to re-frame the targeting process of chain governance and integrate other actors who work on food and nutrition components of rural livelihoods.

An assessment of the global food security index Abstract Several measures of food insecurity, whether at the household or at the national level, have been introduced during the past two or three decades. Some concentrate on the determinants of food security while other emphasize more the consequences of food insecurity. The main focus of this paper is on the food security indicators introduced by the Economist Intelligence Unit (EIU), the Global Food Security Index (GFSI). The paper has two goals. It first checks whether the set of weights selected by the panel of experts of the EIU plays a crucial role in the ranking of countries by level of food security. Then it examines to what extent the ranking of countries given by the GFSI is sensitive to the list of indicators selected. The empirical analysis conducted, based on statistical techniques such as principal components and efficiency analysis, led us to conclude that both the weights selected and the choice of indicators give a reasonable ranking of countries by level of their food security.

The threat of alien invasive insect and mite species to food security in Africa and the need for a continent-wide response Abstract Alien invasive insect and mite species (AIS) represent a major challenge for agriculture, food production, and biodiversity in Africa. However, the lack of awareness and appreciation of AIS threats continues to hinder the development of appropriate policies and practices for their management in sub-Saharan Africa. The objectives of this review are to (1) provide a synthesis of current and future threats to food production and the economic impacts of AIS, (2) identify challenges to their management at national and regional levels, and (3) propose a strategy for a concerted pan-African response. The review identifies a total of 16 alien invasive insect and mite pests, affecting all categories of food crops, causing combined losses in excess of US$ 1 billion annually across Africa. Various models predict that AIS threats will continue to increase due to expansion of the geographic distribution and host range of existing invasions, thus threatening the already tenuous food situation on the continent. The review also reveals that only 16.7% of the countries have adequate border control procedures, while over 66.7% do not have comprehensive AIS management strategies. Therefore, we propose development of a pan-African strategy for effectively responding to AIS threats, and achieving the continental visions of free trade and collective food security. We recommend that biosecurity be considered as a food security intervention complementing yield improvement technologies, and implemented as a core element of national and regional strategies.

In this issue

Shashidhara Kolavalli and Marcella Vigneri: The Cocoa Coast: The Board-Managed Cocoa Sector in Ghana

Fabien Girard and Christine Frison (eds): The commons, plant breeding and agricultural research: challenges for food security and agrobiodiversity

Research on agro-food sustainability transitions: where are food security and nutrition? Abstract The main outcome of sustainable agro-food systems is food and nutrition security. Nevertheless, about half of the global population is affected by food insecurity and malnutrition, a symptom of the dysfunctions of the current food system. This paper provides a review of the state of research on the sustainability of agro-food transitions, and the extent to which and in what ways such research examines food and nutrition security. A search carried out on Scopus in January 2018 yielded 771 documents; 120 of these were included in the systematic review. Agro-food represents a small share of the sustainability transitions research field. Most of the available research focuses on crops and the production stage. In general, it is assumed that a transition to sustainability in the agro-food arena would lead to increased food availability, improved food access, better food utilisation and increased food system stability and resilience. However, scholars also point out that the quest for food security (especially through intensification) may undermine transition towards sustainable agriculture and food systems. Likewise, it is assumed that a transition towards sustainable food systems implies changes in dietary patterns and nutrition habits. Nevertheless, food security and nutrition are still marginal topics in the literature on agro-food sustainability transitions. Furthermore, transformation of food systems, which should guide agro-food sustainability transitions, is the exception rather than the rule in the research field. This systematic review represents a useful contribution to research on transitions towards sustainability in agriculture and food sectors, and provides insights into how such research can contribute to addressing the grand challenges of food insecurity and malnutrition. The paper suggests the need to move beyond silos by fostering cross-sectoral collaboration and the integration of the agro-food sustainability transitions and food security research fields.

Food security and the Food Insecurity Experience Scale (FIES): ensuring progress by 2030

Food insecurity as a determinant of international migration: evidence from Sub-Saharan Africa Abstract In this paper, we examined how food insecurity can affect international migration aspirations and subsequent actions taken in preparation to move internationally from Sub-Saharan Africa. Drawing on a conceptual framework of the determinants of migration, we developed a three-stage regression model and tested it using data from the 2014 Gallup World Poll. The results indicate that multiple determinants play different roles in the migration decision process, which is characterized by aspirations, planning and final decision to migrate. Specifically, food insecurity is an important determinant of both the desire and the decision to migrate: food insecurity raises the probability of desiring to migrate internationally, with the probability of the desire increasing along with the severity of food insecurity. However, the probability of actually deciding to migrate internationally decreased as food insecurity worsened. These findings are in line with migration literature stating that the very poor, despite wishing to migrate, face tremendous constraints in transforming this desire into concrete decisions. Our results suggest that removing or reducing constraints to migration will benefit the poorest/most food insecure and highlight the need for an increased and effective coordination between food security and international migration policy agendas.

Heterogeneous factors predict food insecurity among the elderly in developed countries: insights from a multi-national analysis of 48 countries Abstract This study aimed to estimate the prevalence of food insecurity and its association with demographic and socioeconomic factors that characterized elderly survey respondents in 48 developed countries. Cross-sectional data came from the Gallup World Poll for the years 2014 to 2017 based on respondents aged ≥60 years (n = 53,556). Food insecurity was assessed using the Food Insecurity Experience Scale, a direct measure of experience-based food insecurity. Descriptive statistics of target populations and the prevalence of food insecurity were produced. Demographic variables included age, gender, marital status, household size, education level, social support, and wellbeing. For socioeconomic variables, income, employment status, urbanicity, and the Community Basics Index were evaluated. A binary logistic regression model was used and the level of statistical significance was set at 5%. Respondents aged 60 to 69 years were the most food insecure. Food insecure individuals were more likely to live alone, not have a partner, and tended to have poorer scores for social support and wellbeing. Also, poor community infrastructure was associated with food insecurity of elderly people, and there were more food insecure elderly people in urban areas. At the multinational level, results indicated wide and statistically significant disparities among continents. The study concluded that not only personal factors but also social conditions could prevent the elderly from achieving full food security status.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Psychiatry

Suicidal Risk Following Hospital Discharge: A Review Learning objectives After participating in this activity, learners should be better able to: • Evaluate risk of suicide and suicide attempts following psychiatric hospitalization • Assess the relationship between suicide attempts and completed suicides Background Suicidal risks among psychiatric patients appear to be especially high soon after hospitalization. Given the importance of such outcomes, and the lack of recent reviews of post-discharge suicide attempt risks, we evaluated reported findings on the risk of suicide and attempts following psychiatric hospitalization. Methods With systematic, computerized searching, we identified 48 studies (1964–2017) involving 1,700,785 subjects. Follow-up was limited to ≥12 months after discharge from psychiatric hospitalization to avoid inflation of annualized rates due to shorter exposure times. Results The overall observed pooled, annualized rate of completed suicide was 241 (confidence interval, 238–243) per 100,000 person-exposure years in 41 studies, and for attempts, 722 (698–746) in 13 studies. In six studies (64,848 subjects) reporting on both suicides and attempts, the ratio of annualized rates for attempts/completed suicides was 8.79 (6.63–12.0). Among all 48 studies, cumulative distribution of suicidal events included 26.4% (25.9–26.9) within the initial month, 40.8% (40.2–41.4) within 3 months, and 73.2% (72.7–73.7) within 12 months of discharge. Conclusions Among patients recently discharged from psychiatric hospitalization, rates of suicide deaths and attempts were far higher than in the general population or even in unselected clinical samples of comparable patients, with a strong inverse association with time post-discharge. Improved monitoring and care of patients discharged from psychiatric hospitalization are needed, ideally with detailed planning and implementation of aftercare prior to discharge.

A Meta-analysis and Systematic Review of Emotion-Regulation Strategies in Borderline Personality Disorder Emotion dysregulation is often considered a core characteristic of individuals with borderline personality disorder (BPD). With the development and strength of a contemporary affective-science model that encompasses both healthy emotion regulation (ER) and emotion dysregulation, this model has increasingly been used to understand the affective experiences of people with BPD. In this meta-analysis and review, we systematically review six of the most commonly studied ER strategies and determine their relative endorsement in individuals with elevated symptoms of BPD compared to individuals with low symptoms of BPD and healthy controls, as well as to individuals with other mental disorders. Results from 93 unique studies and 213 different effect-size estimates indicated that symptoms of BPD were associated with less frequent use of ER strategies that would be considered more effective at reducing negative affect (i.e., cognitive reappraisal, problem solving, and acceptance) and more frequent use of ER strategies considered less effective at reducing negative affect (i.e., suppression, rumination, and avoidance). When compared to individuals with other mental disorders, people with BPD endorsed higher rates of rumination and avoidance, and lower rates of problem solving and acceptance. We also review important contributions from studies of ER in BPD that we were unable to incorporate into our meta-analysis. We conclude by discussing how the pattern of using ER strategies in BPD contributes to emotion dysregulation and also the potential reasons for this pattern, integrating both Gross's extended process model of ER and Linehan's updated theoretical account on the development of emotion dysregulation.

Competitive Bodybuilding: Fitness, Pathology, or Both? The sport of competitive bodybuilding requires an intense regimen of weightlifting and dieting, often aided with muscle-building or fat-burning drugs, and culminating in an on-stage posing competition. Despite these rigorous demands, competitive bodybuilding is popular, with thousands of competitions performed annually around the world. Although many studies have addressed the psychological features of various sports and the athletes who compete in them, few have examined the psychological aspects of bodybuilding. Even fewer studies have specifically examined competitive bodybuilders, as opposed to the much larger group of "recreational" bodybuilders who do not compete. The limited available literature suggests that competitive bodybuilders may show an increased risk for four categories of psychopathology: muscle dysmorphia, eating disorders, abuse of appearance- and performance-enhancing drugs, and exercise dependence. However, in each of these categories, one must carefully distinguish between the planned and dedicated behaviors required for success in the sport, as opposed to frankly pathological behaviors that impair social or occupational function, cause subjective distress, or lead to adverse health consequences. Future work should attempt to better assess the nature and prevalence of these conditions among competitive bodybuilders, with perhaps greatest attention to the issue of drug use.

The Association Between Parental Depression and Child Psychosocial Intervention Outcomes: Directions for Future Research Recent studies suggest that parental depressive symptoms may affect a child's ability to benefit from interventions for anxiety and depression. This article reviews the current literature, suggesting that, when parents experience current depressive symptoms, children are less likely to benefit from psychosocial interventions for anxiety and depression. Opportunities for future research are discussed, including moderators and mechanisms of the association between parental depressive symptoms and child intervention outcomes.

Globus Pharyngeus: Etiology, Taxonomy, and Response to Electroconvulsive Therapy No abstract available

A Brief History of Death and American Psychiatry No abstract available

Considering the Therapeutic Alliance in Digital Mental Health Interventions No abstract available

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Obstetrics and Gynecology

Editorial introductions No abstract available

Impact of obesity on male and female reproductive outcomes Purpose of review The association between obesity and infertility has gained increasing provider and public awareness. The purpose of this review is to outline the recent research into the pathophysiology regarding obesity and its impact of reproductive function in both women and men. Recent findings A BMI more than 25 has a detrimental impact on the hypothalamus-pituitary-gonadal (HPG) axis in both men and women, leading to alterations of HPG hormones, gametogenesis, as well as an increase in inflammation and lipotoxicity from excessive adipose tissue. Additionally, BMI likely impacts assisted reproductive technology (ART) outcomes, with a greater influence on women than men. Studies regarding weight loss interventions are heterogenous in methods and outcomes, and it is difficult to extrapolate from current data if weight loss truly leads to improved outcomes. Summary Elevated BMI induces changes in the HPG axis, hormone levels, gametogenesis, and adverse ART outcomes. Inconsistencies regarding weight loss interventions make it difficult to assess the impact on outcomes after weight loss interventions.

New insights into human prolactin pathophysiology: genomics and beyond Purpose of review To briefly summarize what is known regarding hyperprolactinemia and prolactin-secreting tumors, and review recent findings. Recent findings Prolactin was previously thought to inhibit secretion of gonadotropin-releasing hormone (GnRH) by directly inhibiting the firing of GnRH neurons, resulting in hypogonadotropic hypogonadism and infertility. However, kisspeptin has recently been implicated as the mediator of hyperprolactinemia-induced infertility, by acting upstream of the GnRH neurons as an integrator of endocrine signals. Macroprolactin is generally considered to be inactive and clinically insignificant, but new studies have suggested that patients with macroprolactinemia may have reproductive manifestations as well as sexual dysfunction. Several mutations and polymorphisms in the prolactin receptor have been described, which could describe a genetic cause for prolactinomas and characterize cases of isolated familial hyperprolactinemia. Kisspeptin and tyrosine kinase inhibitors have emerged as potential new therapeutic targets for the treatment of hyperprolactinemia and dopamine-resistant prolactinomas. Summary Molecular studies are shedding light on the pathophysiology of hyperprolactinemia and the effects of excess prolactin production on the reproductive system. Similarly, genetic studies have begun to reveal how differences in prolactin receptor function may account for some of the previously 'idiopathic' cases of hyperprolactinemia and bring to light new causes of prolactinomas. Further elucidation of the transcriptional pathways affected by these genetic changes may help to create new therapeutic targets.

A critical review of recent advances in the diagnosis, classification, and management of uterine adenomyosis Purpose of review The purpose of this review is to summarize and highlight recent critical advances in the diagnosis, classification, and management of adenomyosis. Recent findings Recent studies have clarified the specific mechanism through which adenomyotic lesions invade the underlying myometrium by epithelial–mesenchymal transition. Correlation studies using diagnostic MRI also strongly support the hypothesis of a different pathogenesis between the inner and outer myometrium forms of adenomyosis. Given advances in diagnostic imaging, several international organizations have also highlighted the importance of classification systems for adenomyosis. Finally, selective progesterone receptor modulators and gonadotropin-releasing hormone antagonists have demonstrated significant promise for treating pelvic pain and bleeding associated with adenomyosis, whereas novel fertility-preserving surgical techniques have been introduced to excise diffuse adenomyotic pathology while maintaining adequate uterine integrity. Summary Recent attempts at a uniform and reproducible classification system likely represent the first step for the development of a staging system for adenomyosis that can be correlated with the severity of clinical symptoms and promote an individualized therapeutic approach. Simultaneously, further insights into the etiology and pathogenesis as outlined in this review may also help in the development of targeted medical therapies.

Sleep and female reproduction Purpose of review Sleep disturbances are increasing in prevalence in North America. There is growing evidence that poor sleep quality and short sleep duration may adversely affect circadian rhythms, which in turn may affect female reproduction. The objective of this review is to evaluate recent literature on the association between sleep disturbances and female reproduction. Recent findings There is accumulating evidence that sleep quality and duration are important for female reproduction, but epidemiologic research is limited. Recent studies provide suggestive evidence that sleep disorders are associated with increased menstrual irregularity, subfertility/infertility, and poor pregnancy and birth outcomes. Mechanisms underlying these associations are likely to be multifactorial and complex. In addition to genetics, circadian disruption may impact reproductive outcomes through dysregulation of the hypothalamic-pituitary-adrenal axis, insulin resistance, oxidative stress, and systemic inflammation. Recommendations for future studies include: use of prospective study designs; assessment of populations not already experiencing reproductive disorders; more detailed and accurate assessments of sleep such as validated self-reported measures or objective sleep measures (e.g. actigraphy); comprehensive assessment of potential confounders and mediators; and elucidation of biologic mechanisms. Summary There is a growing body of literature showing evidence that sleep disturbances influence female reproduction, although further epidemiologic research is needed.

Surgical management and gynecologic care of the transgender patient Purpose of review Over 1.4 million adults are identified as transgender in 2014. Many of these individuals have undergone, or plan to undergo, gender-affirming surgery. This review summarizes the medical and surgical options available for the transgender population and reviews screening guidelines and fertility preservation options. In addition, it highlights the role gynecologists have in caring for this population. Recent findings Gynecologists perform certain gender-affirming surgeries, such as hysterectomies and bilateral salpingooophorectomies. They also can play an important role in providing hormone therapy, anatomy specific cancer screening, and discussion of and/or referral for fertility preservation. Summary Gynecologists are skilled to perform certain gender-affirming surgeries and play an important role in gender-affirming care.

Applications of Tranexamic acid in benign gynecology Purpose of review Bleeding at the time of benign gynecologic surgery, as well as from benign gynecologic conditions, is a major source of morbidity for many women. Few nonhormonal medical options exist for the treatment of heavy menstrual bleeding, and to reduce surgical bleeding during major gynecologic surgery. Interest in Tranexamic acid (TXA) as a means to reduce surgical blood loss has been growing across many surgical specialties. This review focuses on applications for TXA as a means to reduce heavy menstrual bleeding (HMB) as well as to reduce surgical bleeding during benign gynecologic surgery. Recent findings Tranexamic acid is an effective treatment to reduce the volume of bleeding during menstruation. Tranexamic acid was found to be superior to both placebo and oral progestins, and as good as combined oral contraceptives at reducing menstrual blood volume. Tranexamic acid has also been show to reduce the volume of bleeding during abdominal myomectomy as well as hysterectomy. There is a major need for prospective studies evaluating the utility of TXA for reducing blood loss during benign gynecologic surgery. Summary Tranexamic acid has been found to be an excellent affordable nonhormonal treatment option for women with HMB and should be considered during major gynecologic surgery.

Informed consent in gynecologic surgery Purpose of review Informed consent is frequently used interchangeably with obtaining a signature on a form. This oversimplification shifts the value from the process of informed consent to the documentation. This review focuses on the recommended components of the consent process, barriers encountered, factors influencing patient satisfaction, attempts to improve the consent practice, and considerations in special populations. Recent findings The process of informed consent is key to promoting shared decision-making and patient autonomy. Several barriers exist to providing optimal consent including time constraints as well as educational, cultural, and language barriers. Innovative approaches such as audiovisual aids show promise in overcoming barriers and improving the consent process. Summary Patients seek expertise and knowledge to aid in making decisions that align with their care goals. Providers have an obligation to provide individualized and accessible counseling. Ongoing research is needed to optimize this process.

Prevention and management of bowel injury during gynecologic laparoscopy: an update Purpose of review The current article aims to briefly review recent literature on bowel injury in gynecologic surgery with a focus on minimally invasive techniques, strategies for prevention, and management of injury. Recent findings Recent reviews describe a low incidence of bowel injury that is likely affected by low rates of reporting and inconsistent definitions. The major risk factor for bowel injury is adhesive disease, and assessment and prevention techniques for the presence of adhesive disease are evolving. When bowel injury occurs, prompt diagnosis and intraoperative repair yields more favorable outcomes than delayed diagnosis. Repair can be performed by a gynecologic surgeon, with or without the help of a consultant depending on the extent of the injury and surgeon comfort. Summary Bowel injury is a potentially catastrophic complication in gynecologic surgery, but its rarity presents a challenge in research. A high index of suspicion and meticulous surgical technique are the cornerstones of managing a bowel injury.

Optimizing surgical management of patients who decline blood transfusion Purpose of review This review highlights the complexity of caring for gynecologic patients who refuse blood transfusion and discusses the importance of early, targeted perioperative and intraoperative medical optimization. We review alternative interventions and the importance of medical management to minimize blood loss and maximize hematopoiesis, particularly in gynecologic patients who may have significant uterine bleeding. The review also focuses on intraoperative interventions and surgical techniques to prevent and control surgical blood loss. Recent findings With improvements in surgical technique, greater availability of minimally invasive surgery, and increased use of preop UAE and cell salvage, definitive surgical management can be safely performed. New technologies have been developed that allow for safer surgeries or alternatives to traditional surgical procedures. Many medical therapies have been shown to decrease blood loss and improve surgical outcomes. Nonsurgical interventions have also been developed for use as adjuncts or alternatives to surgery. Summary The care of a patient who declines blood transfusion may be complex, but gynecologic surgeons can safely and successfully offer a wide variety of therapies depending on the patient's goals and needs. Medical management should be implemented early. A multidisciplinary team should be mobilized to provide comprehensive and patient-centered care.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Otolaryngology & Head and Neck Surgery

Editorial introductions No abstract available

Editorial: The changing face of adult surgical education: a positive 'disruption' for more than just millennials No abstract available

Facial reanimation: an update on nerve transfers in facial paralysis Purpose of review The aim of this article is to review the recent literature on nerve transfers in facial paralysis. The discussion focuses on direct nerve repair and three types of nerve transfers, cross facial nerve graft, hypoglossal, and masseter nerve transfers. Recent findings Masseteric nerve transfers have a high probability of creating significant movement, although tone is poor. The hypoglossal to facial nerve transfer is reliable in affording facial tone and has been updated to involve a transposition technique that offers good results with minimal morbidity. Combination nerve transfer techniques using multiple cranial nerves or cross-face nerves are increasingly described. Summary Reinnervation of the facial nerve and neural regeneration in general are areas of intense research and novel surgical approaches continue to be explored. Although direct nerve repair is the most ideal, other nerve transfers can be performed with good results. More specifically, the masseteric nerve transfer can provide excellent movement and the hypoglossal transfer good tone. Combination transfers may afford the benefits of multiple nerves.

Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies Purpose of review To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS. Recent findings Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials. Summary The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.

An update in facial gender confirming surgery Purpose of review To summarize current surgical and nonsurgical approaches to facial gender confirming surgery (FGCS) and highlight standards of care and areas of future research. Recent findings Gender nonconforming individuals may encounter considerable internal coping and external social stressors that may contribute to gender-associated dysphoria. FGCS provides patients the ability to align facial appearance with gender identity, using recently described advances in surgical and nonsurgical techniques. The majority of FGCS is performed on transwomen (individuals identifying as female), yielding the more common term of facial feminization surgery (FFS). Although no set protocols or standards are in place, certain procedures are commonly performed to alter sex-determining characteristics of the face, and further research may help define guidelines. As many training programs have minimal exposure to FGCS, promotion of transgender health awareness is paramount for diverse and inclusive surgical training. Summary Although demand for FGCS is increasing, there remains a need for improving surgical approaches, developing evidence-based care guidelines, and implementing education and awareness in training programs.

Contemporary management of frontal sinus fractures Purpose of review Frontal sinus fracture management is evolving. This article will highlight recent literature and provide an evidence-based algorithm in the contemporary management of frontal sinus fractures. Recent findings The role of transnasal endoscopic treatment of frontal sinus fractures has expanded to include fracture reduction and posterior table reconstruction. Evidence continues to support the safety of nonoperative management in select frontal sinus outflow tract fractures. Summary The management of frontal sinus fractures with frontal sinus outflow tract injury continues to evolve with a trend toward observation and minimally invasive approaches. Restoration of the frontal sinus outflow tracts with transnasal endoscopic techniques is being used increasingly in the acute and delayed setting. For severe fractures, the role of conservative treatment paradigms requires further research.

Rib cartilage in Asian rhinoplasty: new trends Purpose of review Costal cartilage has many advantages over other grafting materials because of its large quantity and high biocompatibility. As a result, it has been considered as a good option for Asian rhinoplasty. However, costal cartilage is difficult to use and is associated with a high complication rate. To avoid the disadvantages and complications of costal cartilage graft, several techniques have been proposed in the literature. This review addresses the conventional uses of costal cartilage in Asian rhinoplasty and recent updates. Recent findings Different techniques have been reported for Asian rhinoplasty using costal cartilage. Solid-block costal cartilage and diced cartilage with or without wrapping materials are widely used for dorsal augmentation. Many different grafting techniques for the tip and septal reconstruction have been reported by numerous surgeons. When using costal cartilage graft, surgeons should pay attention to both graft complications, such as warping or infection, and donor-site morbidity. Several strategies have recently been developed to avoid these complications. Summary This article summarises grafting options for Asian rhinoplasty using costal cartilage and possible complications. This information may assist with proper selection of appropriate techniques for harvesting, carving and grafting costal cartilage.

The evolving roles of computer-based technology and smartphone applications in facial plastic surgery Purpose of review This article aims to provide a comprehensive review of the established and emerging applications of various computer-based technologies and smartphone applications in the field of facial plastic surgery. Recent findings Computer-based technologies and smartphone applications have widespread utility across various domains of facial plastic surgery; these include preoperative consultation, surgical planning, intraoperative navigation, custom implant creation, postoperative assessment, physician productivity, communication, and education. Smartphone applications are being utilized for assessment of patients such as those with facial paralysis. Three-dimensional (3D) imaging and 3D printing has influenced preoperative counseling, surgical planning, and execution. The incorporation of intraoperative navigation has the potential to improve the accuracy and precision of facial reconstruction. Summary Current advances in computer-based technology have made a significant impact on the practice of facial plastic and reconstructive surgery. These technological advances have influenced how we counsel patients, perform procedures, assess outcomes, and learn new techniques.

Update on the management of craniomaxillofacial trauma in low-resource settings Purpose of review Craniomaxillofacial (CMF) trauma is a common cause of global morbidity and mortality. Although in high resource settings the management of CMF trauma has improved substantially over the past several decades with internal rigid fixation technology; these advancements have remained economically unviable and have not yet reached low and middle-income countries (LMICs) en masse. The purpose of this review is to discuss the current management of CMF injuries in low-resource settings. Recent findings Trauma injuries remain a global epidemic with head and neck injuries among the most common. CMF trauma injuries largely occur in LMICs, with motor vehicle trauma being a common cause. Patients present in a delayed fashion which increases complications. Diagnostic methods are often limited to plain radiographs as computed tomography is not always available. In low-resource settings, CMF trauma continues to be treated primarily by closed reduction, maxillomandibular fixation, and transosseous wiring, yielding acceptable results through affordable methods. With the advent of less expensive plating systems, internal fixation with plates and screws are gradually finding their place in the management of facial trauma in low-resource settings. A shortage of CMF surgeons in LMICs is a recognized problem and is being addressed by targeted curricula. Summary CMF trauma is a major cause of morbidity and mortality globally that remains poorly addressed. Currently, conventional methods of treating CMF trauma in low-resource settings have evolved to meet resource constraints. The education of CMF surgeons remains a key leverage point in improving CMF trauma care globally.

Rhinoplasty outcomes and trends Purpose of review This article reviewed studies that support the use of implants for nasal valve surgery and augmentation rhinoplasty. Recent findings For nasal valve collapse, there is a trend for rhinoplasty surgeons to use Monarch nasal implant, absorbable valve implant and titanium butterfly implant rather than traditional cartilaginous grafts. For augmentation rhinoplasty, it is still a gold standard to use autologous cartilage. However, alloplastic implants are still very popular for Asian rhinoplasty. A combination of implant materials for augmentation rhinoplasty can improve outcomes while minimizing complications. Summary Application of implants and newer techniques in nasal valve surgery and augmentation rhinoplasty are important to enhance the outcome in rhinoplasty.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Cardiovascular Pharmacology

In-Hospital Initiation of Sacubitril/Valsartan: A New PARADIGM for Acute Decompensated Heart Failure? No abstract available

Bioactive Lipids as Mediators of the Beneficial Actions of Statins No abstract available

Translational Implications for Targeting Ischemia-Induced Cardiac Inflammation by Ticagrelor: One Fits All or Dose Matters? No abstract available

Ticagrelor Reduces Ischemia-Reperfusion Injury Through the NF-κB–Dependent Pathway in Rats Abstract: We recently showed that ticagrelor reduced myocardial ischemia-reperfusion injury (IRI) and downregulated galectin-3 in the ischemic myocardium. This study tested the hypothesis that ticagrelor could reduce IRI through the NF-κB pathway. Rats were randomly divided into sham-operated group, placebo group (gastric administration of saline after IRI), ticagrelor group (gastric administration of ticagrelor after left anterior descending artery ligation), dextran sodium sulfate (DSS) group (DSS was added to drinking water 7 days before IRI), and DSS + ticagrelor group (DSS was added to drinking water 7 days before IRI and gastric administration of ticagrelor after left anterior descending artery ligation). Ticagrelor significantly reduced the infarct size and plasma cTnI at 3 and 7 days after IRI, significantly downregulated protein and mRNA expressions of NF-κB and galectin-3, and mRNA expressions of IL-6 and TNF-α in the ischemic area at 24 hours, 3 and 7 days after IRI. Ticagrelor also significantly decreased plasma high-sensitivity C-reactive protein and NT-proBNP levels at 24 hours and 3 days after IRI. Furthermore, pretreatment with DSS blocked the beneficial effects of ticagrelor. Our study indicates that the cardioprotective effect of ticagrelor might be partly mediated by inhibiting the NF-κB pathway in this rat model of IRI.

Melatonin-Mediated Pak2 Activation Reduces Cardiomyocyte Death Through Suppressing Hypoxia Reoxygenation Injury–Induced Endoplasmic Reticulum Stress Abstract: Cardiac reperfusion injury has been found to be associated with endoplasmic reticulum (ER) stress. Recently, p21-activated kinase 2 (Pak2) has been identified as a primary mediator of ER stress in chronic myocardial injury. Melatonin, a biological clock–related hormone, has been demonstrated to attenuate heart reperfusion burden by modulating ER stress and mitochondrial function. The aim of our study was to explore whether reperfusion-induced ER stress is modulated by melatonin through Pak2. Hypoxia reoxygenation (HR) was used in vitro to mimic reperfusion injury in cardiomyocytes. ER stress, oxidative stress, calcium overload, and cell death were measured through Western blotting, enzyme-linked immunosorbent assay, quantitative polymerase chain reaction, and immunofluorescence with the assistance of siRNA transfection and pathway blocker treatment. The results of our study demonstrated that HR decreased the levels of Pak2 in cardiomyocytes in vitro, and inactivation of Pak2 was associated with ER stress, oxidative stress, calcium overload, caspase-12 activation, and cardiomyocytes apoptosis in vitro. Interestingly, melatonin treatment attenuated HR-mediated ER stress, redox imbalance, calcium overload, and caspase-12–related cardiomyocytes apoptosis, and these protective effects were dependent on Pak2 upregulation. Knockdown of Pak2 abolished the beneficial actions exerted by melatonin on HR-treated cardiomyocytes in vitro. Finally, we found that melatonin reversed Pak2 expression by activating the AMPK pathway and blockade of the AMPK pathway suppressed Pak2 upregulation and cardiomyocytes survival induced by melatonin in the presence of HR stress. Overall, our study reports that the AMPK-Pak2 axis, a novel signaling pathway modulated by melatonin, sends prosurvival signals for cardiomyocytes reperfusion injury through attenuation of ER stress in vitro.

Cinnamaldehyde Ameliorates High-Glucose–Induced Oxidative Stress and Cardiomyocyte Injury Through Transient Receptor Potential Ankyrin 1 Abstract: Oxidative stress plays a critical role in diabetic cardiomyopathy. Transient receptor potential ankyrin subtype 1 (TRPA1) has antioxidative property. In this study, we tested whether activation of TRPA1 with cinnamaldehyde protects against high-glucose–induced cardiomyocyte injury. Cinnamaldehyde remarkably decreased high-glucose–induced mitochondrial superoxide overproduction, upregulation of nitrotyrosine, P22phox, and P47phox, and apoptosis in cultured H9C2 cardiomyocytes (P < 0.01), which were abolished by a TRPA1 antagonist HC030031 (P < 0.01). Nrf2 and its induced genes heme oxygenase-1 (HO-1), glutathione peroxidase-1 (GPx-1), and quinone oxidoreductase-1 (NQO-1) were slightly increased by high glucose (P < 0.01) and further upregulated by cinnamaldehyde (P < 0.05 or P < 0.01). Feeding with cinnamaldehyde (0.02%)-containing diet for 12 weeks significantly decreased cardiac nitrotyrosine levels (P < 0.01), fibrosis, and cardiomyocyte hypertrophy (P < 0.05), while increased expression of antioxidative enzymes (HO-1, GPx-1, NQO-1, and catalase) (P < 0.01) in the myocardial tissue of db/db diabetic mice. These results suggest that cinnamaldehyde protects against high-glucose–induced oxidative damage of cardiomyocytes likely through the TRPA1/Nrf2 pathway.

Low-Dose Adrenaline Reduces Blood Pressure Acutely in Anesthetized Pigs Through a β2-Adrenergic Pathway Abstract: Adrenaline (epinephrine) is one of the prime messengers of the fight-or-flight response, favoring the activation of β-adrenergic receptors. Although general vasoconstriction to nonessential tissues is imperative, the vasodilatory effect of β-adrenergic receptor activation contends with this. We aimed to determine the dose-dependent effects of adrenaline on hemodynamics and to test whether adrenaline could lower blood pressure (BP) through a β2-adrenergic pathway. Nineteen Danish landrace pigs were used to pharmacologically probe the hemodynamic effect of adrenaline. Pigs were anesthetized, intubated, and electrocardiogram, systolic BP (SBP), diastolic BP (DBP), and left ventricular pressure (LVP) were monitored continuously. First, we tested the dose-dependent effects of adrenaline (0.01–10 µg/kg). Second, we determined the response to adrenaline (0.3 µg/kg) after atropine, prazosin, and propranolol pretreatment. Finally, we tested the hemodynamic effect of salbutamol in a subset of pigs. All doses of adrenaline increased heart rate, while BP showed a biphasic response: At low doses, adrenaline decreased SBP from 118 ± 3 to 106 ± 4 mm Hg (n = 15; P < 0.05) and DBP from 86 ± 3 to 71 ± 3 (n = 15; P < 0.05), while at high doses, SBP and DBP increased. LVP showed a similar pattern, with a tendency of decreased pressure at low doses, and an increased pressure at high doses (P < 0.05). Pretreatment with autonomic blockers revealed that the increase in BP was due to α-adrenergic activity, while the decrease was due to β-adrenergic activity. In confirmation, β-adrenergic activation through salbutamol showed a similar decrease in SBP, DBP, and LVP. We conclude that adrenaline dose-dependently increases heart rate, while producing a biphasic response in BP with a decrease at low doses and an increase at high doses in an anesthetized, large-animal model.

Vascular Protection and Decongestion Without Renin–Angiotensin–Aldosterone System Stimulation Mediated by a Novel Dual-Acting Vasopressin V1a/V2 Receptor Antagonist Abstract: Increased plasma vasopressin levels have been shown to be associated with the progression of congestive heart failure. Vasopressin mediates water retention by renal tubular V2 receptor activation as well as vasoconstriction, cardiac hypertrophy, and fibrosis through V1a receptor activation. Therefore, we developed a novel, dual-acting vasopressin receptor antagonist, BAY 1753011, with almost identical Ki-values of 0.5 nM at the human V1a receptor and 0.6 nM at the human V2 receptor as determined in radioactive binding assays. Renal V2 antagonism by BAY 1753011 was compared with the loop diuretic furosemide in acute diuresis experiments in conscious rats. Similar diuretic efficacy was found with 300-mg/kg furosemide (maximal diuretic response) and 0.1-mg/kg BAY 1753011. Furosemide dose-dependently induced plasma renin and angiotensin I levels, while an equiefficient diuretic BAY 1753011 dose did not activate the renin–angiotensin system. BAY 1753011 dose-dependently decreased the vasopressin-induced expression of the profibrotic/hypertrophic marker plasminogen activator inhibitor-1 and osteopontin in rat cardiomyocytes, while the selective V2 antagonist satavaptan was without any effect. The combined vascular V1a-mediated and renal V2-mediated properties as well as the antihypertrophic/antifibrotic activity enable BAY 1753011 to become a viable treatment option for oral chronic treatment of congestive heart failure.

Physcion 8-O-β-Glucopyranoside Alleviates Oxidized Low-Density Lipoprotein-Induced Human Umbilical Vein Endothelial Cell Injury by Inducing Autophagy Through AMPK/SIRT1 Signaling Aim: Vascular endothelial cell dysfunction plays a crucial role in the initiation and development of atherosclerosis. Physcion 8-O-β-glucopyranoside (PG), an anthraquinone extracted from Polygonum cuspidatum, has a number of pharmacological functions. The aim of this study was to elucidate the protective effects of PG against oxidized low-density lipoprotein (ox-LDL) in VECs. Methods and Materials: Human umbilical vein endothelial cells (HUVECs) were used as the in vitro model. Cell viability and apoptosis were, respectively, assessed by CCK-8 assay and Annexin-V/PI staining. Formation of autophagosomes was visualized by acridine orange staining, and the autophagy flux was tracked after infecting the cells with the mRFP-GFP-LC3 adenovirus. The expression levels of various apoptosis and autophagy-associated marker proteins were detected by Western blotting. Results: Pretreatment with PG protected the HUVECs from ox-LDL–induced apoptosis. In addition, PG promoted autophagy in HUVECs, which was responsible for its antiapoptotic effects. Finally, activation of AMPK/SIRT1 signaling was upstream of PG-induced autophagy. Conclusions: PG has potential pharmacological effects against oxidative damage–induced HUVEC injury through inducing AMPK/SIRT1-mediated autophagy.

miR-3188 (rs7247237-C>T) Single-Nucleotide Polymorphism Is Associated With the Incidence of Vascular Complications in Chinese Patients With Type 2 Diabetes Abstract: miR-3188, one of the earliest discovered microRNAs, is involved in regulating the mTOR-p-PI3K/AKT pathway, thus affecting the progression of diabetic complications. In this study, we observed that the miR-3188 (rs7247237-C>T) polymorphism not only affected the production of nitric oxide (NO) production in endothelial cells, but also significantly associated with the incidence of vascular complications in Chinese patients with type 2 diabetes. Mechanistic analyses indicate that miR-3188 (rs7247237-T) polymorphism inhibited its own expression and upregulated the expression of gstm1 and trib3, which impairs NO production in human endothelial cells through inactivating AKT/eNOS signal transduction pathway. In addition, our clinical retrospective study indicated that, compared with patients with the CC genotype (n = 351), patients with rs7247237 TT + CT genotypes (n = 580) exhibited an increased risk of major vascular events during intensive glucose control treatment (hazard ratio = 1.560; 95% CI: 1.055–2.307, P = 0.025). Simultaneously, the risk of major vascular events was marginally decreased in patients with the CC genotype during intensive glucose control treatment compared with standard treatment (hazard ratio = 0.666; 95% CI: 0.433–1.016, P = 0.053). Our findings indicate that the miR-3188 (rs7247237-C>T) polymorphism is associated with the incidence of vascular complications in Chinese patients with type 2 diabetes, likely due to its remarkable effect on miR-3188 expression.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com