A Subdural Hygroma Necessitating a Subdural-Peritoneal Shunt in a Pediatric Patient Following Total Cranial Vault Remodeling Surgery.

Sagittal synostosis is a common non-syndromic synostosis treated with open or endoscopic cranial vault remodeling. Early intervention is recommended to avoid restricted brain growth, increased intracranial pressure, and resultant developmental delay. Common complications such as failure or reconstruction, cerebrospinal fluid leak, blood loss, and stroke are well-reported in the literature. Here, we present a rare case of the development of a subdural hygroma following cranial vault remodeling in a seven-month-old male, necessitating the insertion of a subdural-peritoneal shunt.

Automated iterative Csp3-C bond formation.

Fully automated synthetic chemistry would substantially change the field by providing broad on-demand access to small molecules. However, the reactions that can be run autonomously are still limited. Automating the stereospecific assembly of Csp3-C bonds would expand access to many important types of functional organic molecules1. Previously, methyliminodiacetic acid (MIDA) boronates were used to orchestrate the formation of Csp2-Csp2 bonds and were effective building blocks for automating the synthesis of many small molecules2, but they are incompatible with stereospecific Csp3-Csp2 and Csp3-Csp3 bond-forming reactions3-10. Here we report that hyperconjugative and steric tuning provide a new class of tetramethyl N-methyliminodiacetic acid (TIDA) boronates that are stable to these conditions. Charge density analysis11-13 revealed that redistribution of electron density increases covalency of the N-B bond and thereby attenuates its hydrolysis. Complementary steric shielding of carbonyl π-faces decreases reactivity towards nucleophilic reagents. The unique features of the iminodiacetic acid cage2, which are essential for generalized automated synthesis, are retained by TIDA boronates. This enabled Csp3 boronate building blocks to be assembled using automated synthesis, including the preparation of natural products through automated stereospecific Csp3-Csp2 and Csp3-Csp3 bond formation. These findings will enable increasingly complex Csp3-rich small molecules to be accessed via automated assembly.

Projecting species' vulnerability to climate change: Which uncertainty sources matter most and extrapolate best?

Species distribution models (SDMs) are commonly used to assess potential climate change impacts on biodiversity, but several critical methodological decisions are often made arbitrarily. We compare variability arising from these decisions to the uncertainty in future climate change itself. We also test whether certain choices offer improved skill for extrapolating to a changed climate and whether internal cross-validation skill indicates extrapolative skill. We compared projected vulnerability for 29 wetland-dependent bird species breeding in the climatically dynamic Prairie Pothole Region, USA. For each species we built 1,080 SDMs to represent a unique combination of: future climate, class of climate covariates, collinearity level, and thresholding procedure. We examined the variation in projected vulnerability attributed to each uncertainty source. To assess extrapolation skill under a changed climate, we compared model predictions with observations from historic drought years. Uncertainty in projected vulnerability was substantial, and the largest source was that of future climate change. Large uncertainty was also attributed to climate covariate class with hydrological covariates projecting half the range loss of bioclimatic covariates or other summaries of temperature and precipitation. We found that choices based on performance in cross-validation improved skill in extrapolation. Qualitative rankings were also highly uncertain. Given uncertainty in projected vulnerability and resulting uncertainty in rankings used for conservation prioritization, a number of considerations appear critical for using bioclimatic SDMs to inform climate change mitigation strategies. Our results emphasize explicitly selecting climate summaries that most closely represent processes likely to underlie ecological response to climate change. For example, hydrological covariates projected substantially reduced vulnerability, highlighting the importance of considering whether water availability may be a more proximal driver than precipitation. However, because cross-validation results were correlated with extrapolation results, the use of cross-validation performance metrics to guide modeling choices where knowledge is limited was supported.

Fibrous dysplasia: an overview of disease process, indications for surgical management, and a case report.

INTRODUCTION: First described by Von Recklinghausen in 1891, fibrous dysplasia is a developmental defect of osseous tissue such that bone is produced with an abnormally thin cortex and marrow is replaced with fibrous tissue that demonstrates characteristic ground-glass appearance on x-ray examination. The underlying defect in fibrous dysplasia is a mutation of the GNAS1 gene, which leads to constitutive activation of gene products that preclude the maturation of osteoprogenitor cells and lead to development of abnormal bone matrix, trabeculae, and collagen, produced by undifferentiated mesenchymal cells. There exists a mainly self-limiting form of fibrous dysplasia classified as monostotic, which is characterized by dysplastic bone in a single location that remains relatively stable throughout life and a polyostotic form, which can exhibit aggressive growth placing adjacent structures at risk for compressive sequelae. METHODS: We present the surgical management of an unusual case of monostotic fibrous dysplasia, which exhibited aggressive growth with mass effect, and late presentation, both uncharacteristic features for the monostotic form. The authors also performed a comprehensive review of the literature and discuss the disease process, management options, and indications for surgical treatment. RESULTS: An overview of the disease process and management options is presented. The authors also present details of reconstruction in an unusual form of symptomatic monostotic fibrous dysplasia. CONCLUSION: Conservative management is usually the mainstay of therapy in asymptomatic cases of fibrous dysplasia. In patients fulfilling criteria for surgical management, craniofacial reconstruction offers a viable option in the surgeon's armamentarium, providing good functional and cosmetic outcomes.

Persistent and transient Listeria monocytogenes strains from retail deli environments vary in their ability to adhere and form biofilms and rarely have inlA premature stop codons.

Based on recent risk assessments, up to 83% of listeriosis cases from deli meat in the United States are predicted to be from ready-to-eat deli meats contaminated during processing at retail grocery stores. Listeria monocytogenes is known to use sanitizer tolerance and biofilm formation to survive, but interplay of these mechanisms along with virulence potential and persistence mechanisms specific to deli environments had yet to be elucidated. In this study, 442 isolates from food and nonfood contact surfaces in 30 retail delis over 9 months were tested for inlA premature stop codons (PMSCs); inlA encodes InlA, which is necessary to cause listeriosis. A total of 96 isolates, composed of 23 persistent and 73 transient strains, were tested for adhesion and biofilm-forming ability and sanitizer tolerance. Only 10/442 isolates had inlA PMSCs (p<0.001). Strains with PMSCs were not persistent, even in delis with other persistent strains. Most (7/10) PMSC-containing isolates were collected from food contact surfaces (p<0.001); 6/10 PMSC-containing isolates were found in moderate prevalence delis (p<0.05). Persistent strains had enhanced adhesion on day 1 of a 5-day adhesion-biofilm formation assay. However, there was no significant difference in sanitizer tolerance between persistent and transient strains. Results suggest that foods contaminated with persistent L. monocytogenes strains from the retail environment are (1) likely to have wild-type virulence potential and (2) may persist due to increased adhesion and biofilm formation capacity rather than sanitizer tolerance, thus posing a significant public health risk.

Analgesic effectiveness of acetaminophen for primary cleft palate repair in young children: a randomized placebo controlled trial.

BACKGROUND: Clefting of the lip, palate, or both is a common congenital abnormality. Inadequate treatment for pain in children may result from concerns over opioid-related adverse effects. Providing adequate pain control with minimal adverse effects remains challenging in children. OBJECTIVES: To assess opioid-sparing effects of oral or intravenous acetaminophen following primary cleft palate repair in children. METHODS: Prospective randomized controlled trial in 45 healthy children, ages 5 months to 5 years, using standardized general anesthesia and lidocaine infiltration of the operative field. Patients were allocated to groups: intravenous acetaminophen/oral placebo (intravenous), oral acetaminophen/intravenous placebo (oral), or intravenous/oral placebo (control). Groups were compared for differences in opioid administration during the 24-h study period (morphine equivalents µg·kg(-1) ; 95% confidence interval). RESULTS: Intravenous acetaminophen decreased opioid requirement after surgery (P = 0.003). Patients in the intravenous group received less opioid (272.9; 202.9-342.8 µg·kg(-1) ) than control patients (454.2; 384.3-524.2 µg·kg(-1) ; P < 0.002). Opioid requirement in oral patients (376.5; 304.1-448.9 µg·kg(-1) ) was intermediate and not significantly different from either intravenous (P = 0.11) or control (P = 0.27). During the ward phase of care, intravenous had better analgesia than control (P = 0.002), and both intravenous and oral group patients received less opioid than control (P = 0.01). CONCLUSION: Intravenous acetaminophen given to young children undergoing primary cleft palate repair was associated with opioid-sparing effects compared to placebo. The fewer morphine doses during ward stay in both intravenous and oral may be important clinically in some settings.

Revisiting the free nipple graft: an opportunity for nipple sparing mastectomy in women with breast ptosis.

OBJECTIVE: Nipple areolar complex (NAC) sparing mastectomy improves the cosmetic outcome of patients with breast cancer. However, women with significant breast ptosis are not candidates for this technique due toexcessive skin flap length and ensuing risk of NAC ischemia.1 (-) 3 We report a novel technique using free nipple graft during skin sparing mastectomy for patients with significant ptosis while concurrently maintaining oncologic integrity. DESIGN: Case series. SETTING: Community and tertiary care hospital practices. PATIENTS: Women with breast cancer desiring NAC preservation who are otherwise candidates for nipple sparing mastectomy, but with significant breast ptosis that precludes NAC viability. All women underwent immediate, autologous breast reconstruction. INTERVENTIONS: Bilateral and unilateral free nipple grafts were harvested, placed on ice during skin sparing mastectomy and free flap reconstruction, grafted at the conclusion of the case and secured with a bolster. OUTCOME MEASURES: Full or partial NAC preservation, ischemia time, local wound complications at NAC grafting site, pathologic outcomes. RESULTS: A total of three patients underwent free nipple grafting at the time of skin sparing mastectomy and free or pedicled flap for breast cancer between March and September 2012. Of five total nipple grafts, one had partial NAC loss but did not require operative debridement. Pathologic review of areolar tissue removed during intraoperative defatting of free nipple graft demonstrated residual duct epithelium. CONCLUSIONS: Women with significant breast ptosis that would preclude them from NAC sparing mastectomy can successfully preserve their NAC using a free nipple graft. Duct epithelium present in defatted tissue during preparation of the free nipple graft suggests that oncologic integrity can also be maintained.

Reconstruction of massive localised lymphoedema of the scrotum with a novel fasciocutaneous flap: A rare case presentation and a review of the literature.

Massive localised lymphoedema (MLL) is a benign lymphoproliferative soft-tissue overgrowth in the morbidly obese patient. The diagnosis may be challenging, and is a form of secondary lymphoedema, often described as idiopathic scrotal elephantiasis. The lesion presents as a large mass in the morbidly obese, and patients seek treatment late in the disease course due to limitation of daily living or excoriation and wound breakdown. Resection, followed by reconstruction, is indicated in these cases. We present a unique case of a morbidly obese 52-year-old male with massive enlargement of the scrotum present for several years duration, despite massive weight loss (88.85 kg) from gastric bypass surgery and no other identifiable cause of lymphoedema. Scrotal lymphoedematous tissue was resected and scrotal reconstruction with a novel posterior fasciocutaneous flap from the scrotum was performed in addition to penile reconstruction with a skin graft and local fasciocutaneous flaps as well as a panniculectomy. Histologically, the tissue was characterised by marked oedema with dermal fibrosis and patchy mild perivascular chronic inflammation. Postoperative follow-up revealed wound integrity and patient satisfaction with the outcome. MLL is an important disease process with distinct clinical and histopathologic characteristics that often requires complex reconstruction. Although there are several opposing classification schema, we propose the incorporation of idiopathic scrotal elephantiasis into the diagnostic category of MLL.

The use of intra-abdominal tissue expansion for the management of giant omphaloceles: review of literature and a case report.

Giant omphaloceles present a reconstructive challenge in planning, management, and eventual closure of the abdominal wall defect. The goal of reconstruction is to recreate a functional abdominal wall domain and return the extra-anatomically placed viscera into the peritoneal cavity in a safe manner. Traditionally, placement of tissue expanders has been in the subcutaneous and intramuscular planes. Recently, however, there have been reports of intra-abdominal placement of expanders. We present a detailed review of the literature regarding the use of tissue expanders in the management of giant omphaloceles with specific emphasis on the intra-abdominal technique of placement. We also present a case report with the longest follow-up till date in which the patient underwent staged reduction using the intra-abdominal approach. Initial reports of this modality are promising both as a primary strategy and in patients in whom conventional techniques have failed. Results from our review of literature and case report suggest that this technique appears to be durable and effective with successful functional and cosmetic outcomes.

Patient with congenital optic nerve meningocele presenting with left orbital cyst.

INTRODUCTION: Meningocele of the optic nerve is a rare condition defined as dilatation of the optic nerve by spinal fluid not due to other pathology, classically presenting with headaches or progressive visual decline and usually follows a rapidly progressive course. DISCUSSION: Surgical decompression is the standard treatment with improvement or arrest of progression in most cases. We describe a case of a child with multiple congenital anomalies including a left optic nerve meningocele that progressively expanded and caused displacement of the orbit laterally resulting in severe cosmetic deformity and complete blindness in the left eye. We describe our surgical decompression as well as review the literature on optic nerve meningocele.

Effects of pregnancy on spatial cognition in female Hooded Long-Evans rats.

Studies examining the roles of estrogens and progestins on spatial cognition have been highly contradictory. To determine if the hormonal environment of pregnancy affects spatial cognition, pregnant (n = 7) and virgin (n = 7) Hooded Long-Evans rats were tested in a Morris water maze throughout the 3 weeks of pregnancy and the second week postpartum. Latency to platform, path length, swim velocity, and time in quadrant were compared over trial-days. To compare water maze performance with changes in hormone levels, serum concentrations of estradiol and progesterone were measured on the first, third, and fifth days of testing during the third week of pregnancy. Subjects learned to find the platform as indicated by decreased time and distance to platform over each trial-week and increased time spent in the quadrant where the platform had been located the previous week. However, there were no differences between treatment groups on time or distance to platform over trial-days. Swim velocity did not differ between or within groups over the 4 weeks of testing. Although primigravid and virgin females were similar in their abilities to learn the novel location of a submerged platform and return to it over time, pregnant animals demonstrated less perseveration to previously learned information and were quicker to locate the platform when it moved to a new location. Thus, reproductive status did not affect reference memory but enhanced working memory in the Morris water maze.