Enhancing clayey soil performance with lime and waste rubber tyre powder: Mechanical, microstructural, and statistical analysis.

Nowadays, for soil stabilisation and cleaner production of geo-composites, the possibility of utilizing waste rubber is in vogue. The present paper deals with experimentally investigating the mechanical and micro-structural characteristics of weak Indian clayey soil partially substituted with lime (0-3.5%) and waste rubber tyre powder (0-15%). It was observed that, with increasing lime and rubber powder content, the plasticity index of the soil decreases. The shear strength and compaction testing results reveal that adding lime and rubber tyre powder (RTP) enhances the geotechnical performance of clayey soil up to an optimum dosage value. Also, the tri-axial shear testing was performed to obtain stress-strain curves for all considered soil mixes. For modified clayey soil containing 3% lime and 12.5% rubber powder, the cohesion values and bearing capacities improved phenomenally by 36.1% and 88.6% respectively, when compared to clayey soil. Further for this mix, SEM analysis reveals a compacted microstructure which improves dry-density and California's bearing ratio among all modified mixes. The novel co-relations upon regression analysis are found able to predict plasticity index, dry density, bearing capacity and shear strength with higher confidence levels. Overall, the cost-benefit analysis worked out to obtain the optimum cost of construction of footings and flexible pavement shows cost deductions up to 19% and 39% respectively while utilizing modified clay soil mixes containing 3% lime and 12.5% rubber powder in subgrade, ultimately making production stronger, cheaper and environment friendly.

Mandibular Fracture in a Hemifacial Microsomia Patient following Implant Failure and Hardware Infection: A Case Report.

Hemifacial microsomia (HFM) is a complex congenital condition with heterogeneous malformations of the facial skeleton that almost always involves mandibular hypoplasia. Here we introduce a unique case in which a patient with HFM had initially successful optimization of facial symmetry using a polyetheretherketone implant for mandibular augmentation. However, multiple factors associated with the intraoperative and postoperative course, including hardware failure and infection, led to diminished mechanical strength of the mandible, ultimately resulting in a mandibular fracture. In this unique case presentation of HFM, we discuss the various factors that contributed to mandibular weakness and increased susceptibility to fracture.

Treatment Outcomes of Manual Lymphatic Drainage in Pediatric Lymphedema.

BACKGROUND: Pediatric lymphedema can result in irreversible, debilitating limb swelling, tissue fibrosis, skin ulcers, infection, and impaired limb function in children at an early age. Manual lymphatic drainage (MLD) is a noninvasive technique, which is a part of intensive decongestive therapy to reroute lymphatic flow to healthy channels used to manage lymphedema. Outcomes of this treatment option in children have not been studied. We evaluated the effect of decongestive therapy involving MLD in pediatric patients with complex lymphatic anomalies by measuring treatment progress and functional outcomes via changes in limb circumference, limb functionality, dexterity, skin quality, and pain. METHODS: A single-institution retrospective study on a cohort of 8 pediatric patients with lymphatic anomalies who completed a course of MLD was conducted from 2015 to 2017 to investigate the role MLD plays in their lymphedema reduction. Pain scores were measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. The functional performance was measured by the Canadian Occupational Performance Measurement questionnaire. RESULTS: Among all patients, there were 4 cases affecting the upper extremities, 4 affecting the lower extremities, and 3 affecting the truncal region. Five of 8 patients demonstrated a reduction in lymphedema with an average girth reduction of 8.2% in the lower extremities, 3.0% in the upper extremities, and 7.4% in the truncal regions. In unilateral cases, the difference in limb circumference between the affected and normal extremity decreased by an average of 25.6%. Four patients completed the Canadian Occupational Performance Measurement questionnaire with an average improvement of 30% in daily task performance. Three patients reported complete resolution of pain. CONCLUSIONS: MLD can be used as a reliable noninvasive method for decongestion and analgesia to delay the onset of lymphedema-associated fibrosis and long-term disability in children with complex lymphatic malformations.

Revision Peripheral Nerve Surgery of the Upper Extremity.

Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.

Online Resources in Plastic Surgery Education: A Toolbox for Modern Trainees and Plastic Surgeons.

Plastic surgery is a rapidly evolving field that requires novel approaches in providing continuous and dynamic educational resources to address the increasing time and skill demands from residents. Online resources in their various forms, such as books, journals, simulators, and applications, are increasingly used by residents, notably over traditional print and in-person counterparts. In this digital era, it is imperative to understand the scope and utility of online resources that have the potential to revolutionize plastic surgery education. In this review article, we first discuss the current model of plastic surgery education and the challenges of meeting its goals and then suggest reasons by which online resources close this gap. We also offer an exposition on the benefits of distinct types of resources and current trends regarding their use. Our goal is to create a framework within which learners and educators are able to organize online resources in plastic surgery.

Algorithm for Temple Reconstruction With Consideration of Anatomic and Defect Characteristics.

The temple is an intriguing region of the face with unique anatomic features, such as the temporal hairline, concave contour, and close proximity to vital structures like the frontal branch of the facial nerve. However, cancerous skin lesions can plague this sun-exposed region and, when excised, it can result in large and significant defects. Reconstruction in this area is a formidable challenge for surgeons, as it requires comprehensive knowledge of temple morphology and the use of creative techniques in order to minimize disruption of surrounding functional and aesthetic structures. In this study, we describe our experience with temple reconstruction in patients of varying defect size and depth. Based on these defect characteristics, anatomic and aesthetic principles of the temple, we propose a surgical algorithm for temple reconstruction to aid surgeons in achieving optimal results.

Fat Grafting for Hand Rejuvenation.

The hands are one of the most visible parts of the body, and prominent dorsal veins and extensor tendons are the most readily recognized signs of the aging process. Fat grafting has been demonstrated to be a safe and effective method of hand rejuvenation by restoration of subcutaneous fat. Despite some variability in the technical approach, fat grafting techniques are consistent in their use of low-pressure injection with standard cannula sizes, small aliquots of graft, and a total volume of graft greater than or equal to 15 mL per hand. While distribution of the fat is an area of debate and a topic of active research, published studies have shown high patient satisfaction rates, suggesting that perhaps the restoration of volume alone is paramount. In this article, we will review the applications of fat grafting to the hand, focusing primarily on its role in hand rejuvenation.

Approach to Reconstruction of Nasal Defects.

The nose is the most central and anterior projecting facial feature. Therefore, the presence of a defect is easily noticeable to the untrained eye. Return of the defect to the original form is an achievable end goal of reconstruction, necessitating appropriate reformation of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures. Regarding its physiological importance, disruption of the normal function may cause respiratory obstruction and contribute to patient distress. To achieve successful repair, preoperative preparation must consider the location, the layers involved, and the size of the defect. Prompt and well-organized repair minimizes the occurrence of progressive necrosis and severe late-stage deformity. Here the authors provide a framework to approach various nasal defects and provide a review of the novel ideologies and techniques. The workhorse of nasal repair, the forehead flap, is discussed independently due to the breadth of innovation.

A Randomized Controlled Trial for Abdominal Binder Use after Laparoendoscopic Single-Site Surgery.

STUDY OBJECTIVE: To compare postoperative pain in patients using an abdominal binder with a control group after laparoendoscopic single-site (LESS) surgery. DESIGN: A randomized controlled trial (Canadian Task Force classification level 1). SETTING: An academic gynecologic surgeon's practice. PATIENTS: Private patients undergoing surgery performed by a fellowship-trained minimally invasive gynecologic surgeon between April 2016 and April 2017. INTERVENTIONS: Ninety total patients were selected for this study, with 60 randomized to receive an abdominal binder after surgery and 30 patients randomized to the control group without a binder. MEASUREMENTS AND MAIN RESULTS: Using a 10-point verbal analog scale, patients recorded pain levels for 3 weeks postoperatively on a variety of measures, including overall and incisional pain. They recorded results on postoperative days 0, 1, 2, 3, 4, 7, 14, and 21. On average, the association between time and the overall pain score did not differ with binder use (p = .37). The overall pain decreases significantly over time (p < .001). After adjusting for time, the overall pain score differed significantly by binder status (p = .04). Those without a binder reported an average pain score that was 1.13 (standard deviation = 0.55) points higher than those with a binder across the first week. CONCLUSION: The results suggest that abdominal binder use after LESS surgery may be beneficial in reducing postoperative pain in the first week. Results from this study can provide feasibility data for future studies.

Postoperative Pain After Single-Site Versus Multiport Hysterectomy.

BACKGROUND AND OBJECTIVES: With advances in laparoscopic surgery, the goal of surgeons and patients is to minimize pain to allow for faster recovery and return to normal daily activities. One of these advances is single-site surgery. In this study, we compared postoperative pain in laparoendoscopic single-site surgery (LESS) to that in traditional multiple-incision hysterectomy. METHODS: Seventy patients were selected for this prospective cohort study, with 35 undergoing multiple-incision and 35 undergoing LESS hysterectomy. All patients were included who were undergoing hysterectomy with the primary surgeon. All multiport hysterectomies were performed laparoscopically. Six patients underwent LESS hysterectomy and 29 underwent robotic single-site surgery (rLESS). Patients recorded pain levels for 3 weeks after surgery on a variety of measures, including overall and incisional pain. Linear mixed effects models for repeated measures were used for all multivariate analyses, with an unstructured covariance matrix accounting for correlation between time points. RESULTS: Overall, across all time points, there was an average reduction in pain by 1.26 (SD 0.69) points in the single-site group (P = .06). Days 3 and 14 had a marginally significant reduction in pain (P = .06 and 0.058, respectively). On days 4 and 7 there was a significant reduction in overall pain (P = .04 and .04, respectively). CONCLUSION: Based on the results, it is likely that single-site hysterectomy leads to less postoperative pain and achieves a lower pain score faster than multiport surgery. A randomized control trial is necessary to confirm these results before accepting them in clinical practice.

Otologic and Audiology Concerns of Microtia Repair.

Microtia is a congenital auricular deformity that commonly presents with associated congenital aural atresia. The most acute concern in these patients is concomitant hearing loss at birth. A team-based approach by plastic surgeons and otologists is necessary to address both the otologic and audiologic concerns of microtia and atresia. Hearing rehabilitation is imperative; yet it should not compromise the aesthetic components of reconstruction and vice versa. Here, the authors propose a framework to evaluate and manage patients with microtia and atresia with the goal of optimizing functional and cosmetic outcomes.

The Protruding Ear: Cosmetic and Reconstruction.

Ear prominence is a relatively common cosmetic deformity with no associated functional deficits, but with profound psychosocial impact, especially in young patients. Protruding ears in children have propagated surgical advances that incorporate reconstructive techniques. Here we outline a systematic framework to evaluate the protruding ear and present various reconstructive surgical options for correction. Both cosmetic and reconstructive perspectives should be entertained when addressing this anatomical deformity.

Total Ear Reconstruction Using Porous Polyethylene.

Total ear reconstruction has been approached by several techniques involving autologous graft, prosthetic implant, and alloplastic implant options. Recent studies have shown the superiority of porous polyethylene (Medpor, Porex Surgical) reconstruction over autologous reconstruction based on improved aesthetic results, earlier age of intervention, shorter surgery times, fewer number of required procedures, and a simpler postoperative recovery process. A durable and permanent option for total ear reconstruction, like Medpor, can help alleviate the cosmetic concerns that patients with auricular deformities may be burdened with on a daily basis. In this article, the authors discuss the advantages of Medpor-based ear reconstruction and discuss recent advances in the surgical techniques involved, such as harvesting a temporoparietal fascia flap and full-thickness skin graft to adequately cover the Medpor framework and decrease extrusion rates.

Management of Panfacial Fracture.

Traumatic panfacial fracture repair is one of the most complex and challenging reconstructive procedures to perform. Several principles permeate throughout literature regarding the repair of panfacial injuries in a stepwise fashion. The primary goal of management in most of these approaches is to restore the occlusal relationship at the beginning of sequential repair so that other structures can fall into alignment. Through proper positioning of the occlusion and the mandibular-maxillary unit with the skull base, the spatial relationships and stability of midface buttresses and pillars can then be re-established. Here, the authors outline the sequencing of panfacial fracture repair for the restoration of anatomical relationships and the optimization of functional and structural outcomes.

Host S-nitrosylation inhibits clostridial small molecule-activated glucosylating toxins.

The global prevalence of severe Clostridium difficile infection highlights the profound clinical significance of clostridial glucosylating toxins. Virulence is dependent on the autoactivation of a toxin cysteine protease, which is promoted by the allosteric cofactor inositol hexakisphosphate (InsP(6)). Host mechanisms that protect against such exotoxins are poorly understood. It is increasingly appreciated that the pleiotropic functions attributed to nitric oxide (NO), including host immunity, are in large part mediated by S-nitrosylation of proteins. Here we show that C. difficile toxins are S-nitrosylated by the infected host and that S-nitrosylation attenuates virulence by inhibiting toxin self-cleavage and cell entry. Notably, InsP(6)- and inositol pyrophosphate (InsP(7))-induced conformational changes in the toxin enabled host S-nitrosothiols to transnitrosylate the toxin catalytic cysteine, which forms part of a structurally conserved nitrosylation motif. Moreover, treatment with exogenous InsP(6) enhanced the therapeutic actions of oral S-nitrosothiols in mouse models of C. difficile infection. Allostery in bacterial proteins has thus been successfully exploited in the evolutionary development of nitrosothiol-based innate immunity and may provide an avenue to new therapeutic approaches.

The incidence of peripheral arterial embolism in association with a patent foramen ovale (right-to-left shunt).

OBJECTIVES: The aim of this study was to examine a cohort of patients who had suffered an arterial embolism to see whether a patent foramen ovale (PFO) was an identifiable cause. DESIGN: This study was conducted in two parts; a retrospective limb involving an audit of patient records over a period of 10 years, and a prospective limb including selected patients from that audit to search for a PFO using an agitated saline test with transcranial Doppler ultrasound monitoring of the anterior cerebral artery. Data on patients with peripheral vascular disease were collected using a structured questionnaire. SETTING: A clinical vascular department. All patients were seen in the vascular outpatients clinic. PARTICIPANTS: Patients who had been identified from a retrospective search based on the headline diagnosis of arterial embolus. Collected data on the 71 patients revealed that 75% had predisposing factors for DVT, 70% were male smokers, and 84.4% had a significant past history of vascular symptoms. MAIN OUTCOME MEASURES: Whether or not patients identified as having a possible PFO actually had one on objective testing with transcranial Doppler assessment of the cerebral circulation with an agitated saline solution. RESULTS: Fifteen patients who were suspected of having a PFO were selected from these 71 patients; 12 of these were found to have no PFO on testing, and three had already undergone a percutaneous PFO closure. CONCLUSION: The incidence of a PFO in this small study group is no higher than that found in the general population (3/15, 20%). There was high prevalence of male smokers with associated predisposing factors leading to a DVT.