pSPObooster: A Plasmid System to Improve Sporulation Efficiency of Saccharomyces cerevisiae Lab Strains.

Common Saccharomyces cerevisiae lab yeast strains derived from S288C have meiotic defects and therefore are poor sporulators. Here, we developed a plasmid system containing corrected alleles of the MKT1 and RME1 genes to rescue the meiotic defects and show that standard BY4741 and BY4742 strains containing the plasmid display faster and more efficient sporulation. The plasmid, pSPObooster, can be maintained as an episome and easily cured or stably integrated into the genome at a single locus. We demonstrate the use of pSPObooster in low- and high-throughput yeast genetic manipulations and show that it can expedite both procedures without impacting strain behavior.

Real-world experience with biosimilar infliximab-adba and infliximab-dyyb among infliximab-naïve patients with inflammatory bowel disease in the Veterans Health Administration.

The Veterans Health Administration (VHA) listed the infliximab (IFX) biosimilar, IFX-dyyb (Inflectra), on the Veterans Affairs National Formulary (VANF) in May 2017. In September 2018, biosimilar IFX-abda (Renflexis) became the VANF IFX product. The recommended formulary changes from one IFX biosimilar to another provided a unique opportunity to study IFX utilization patterns in IFX-naïve Veterans with Inflammatory Bowel Disease (IBD). This study aimed to describe IFX and healthcare utilization during the 365 days after initiation with IFX reference product (RP) or biosimilars IFX-dyyb and IFX-adba. This descriptive study was performed using the VHA Corporate Data Warehouse. All Veterans initiated on IFX-RP (Remicade) or biosimilars IFX-dyyb and IFX-adba between September 1, 2016 and December 30, 2019 were included and followed for 365 days. Veterans enrolled in the VHA for at least 365 days with no evidence of IFX before their index date were considered IFX-naïve. Continuous data on IFX use, laboratory measurements, and healthcare utilization were reported with means, 95% confidence interval (CI), medians, and interquartile ranges. Frequency, proportions, and 95% CIs were presented for categorical variables. Statistical tests included ANOVA and Kruskal-Wallis for continuous outcomes, Poisson regression for count-based outcomes (i.e., healthcare utilization visits), and Chi-square for dichotomous outcomes. The study identified 1763 IFX-naïve patients with IBD, and 785, 441, and 537 was indexed to RP, IFX-dyyb, and IFX-adba, respectively. Statistical differences were observed in IFX utilization measures related to dosing, adherence, and persistence. The proportion of days covered (PDC) during the 365-day follow-up period varied among the IFX groups: IFX-RP at 66%, IFX-dyyb at 60%, and IFX-abda at 69% (P value < .001). Persistence with the index IFX product during the 365-day follow-up period also varied: IFX-RP at 43%, IFX-dyyb at 32%, and IFX-abda at 51% (P value < .001). Healthcare utilization and laboratory findings were similar among the IFX groups. IFX utilization and laboratory patterns were clinically similar among the IFX biosimilars and RP groups, suggesting that providers did not modify their practice with biosimilars. Statistically significant differences in IFX utilization patterns are explained by formulary dynamics when the VANF product switched from IFX-dyyb to IFX-abda.

Endometrial Cell-Type Specific Regulation of the Endocannabinoids System and the Impact of Menstrual Cycle and Endometriosis.

Introduction: Anandamide (AEA) and 2-arachidonoylglycerol are endogenous agonists of the cannabinoid receptors and regulate and control many cellular functions. Their activities are governed by enzymes and proteins that regulate their synthesis, receptor binding, transport, and degradation, which are known as the endocannabinoid system (ECS). The aim of this study was to investigate the regulation of endocannabinoid activity in the endometrium by studying the RNA and protein expression of the ECS within endometrial cell types and during different menstrual cycle stages and the impact of endometriosis. Materials and Methods: The RNA expression of 70 ECS genes was assessed using RNA sequencing of isolated endometrial epithelial and stromal cells. Subsequent immunofluorescence-stained endometrial samples on ECS components of interest were objectively analyzed via an agnostic and automated image analysis pipeline to extract quantitative information. Differential gene and protein expression was investigated between the two cell types, menstrual cycle phases, and endometriosis cases and controls. Results: Sufficient RNA expression was detected for 45 genes, and 17 (38%) genes were significantly different between epithelial and stromal cells. FAAH RNA was significantly higher in epithelial cells compared with stromal cells. Protein expression analysis of the main synthesizing (NAPE-PLD) and catabolizing (FAAH and NAAA) enzymes of AEA revealed a significantly stronger epithelial expression compared to stromal cells. The RNA and protein expression of CB1 receptors was very low with no significant difference between epithelial and stromal cells. Eleven ECS genes were regulated across the menstrual cycle, and there was no gene with significant difference between endometriosis cases and controls in epithelial cells. Discussion: Differential expression of ECS genes supports a cell type-specific endocannabinoid activity in the endometrium. As endocannabinoids are short-lived signaling molecules, higher RNA and protein expression of FAAH in the epithelial cells suggests an active regulation of endocannabinoid activity in epithelial cells within the endometrium.

Formation of Nanodiamonds during Pyrolysis of Butanosolv Lignin.

The preparation of artificial diamonds has a long history driven by decreased costs compared to naturally occurring diamonds and ethical issues. However, fabrication of diamonds in the laboratory from readily available biomass has not been extensively investigated. This work demonstrates a convenient method for producing nanodiamonds from biopolymer lignin at ambient pressure. Lignin was extracted from Douglas Fir sawdust using a butanosolv pretreatment and was pyrolyzed in N2 at 1000 °C, followed by a second thermal treatment in 5% H2/Ar at 1050 °C, both at ambient pressure. This led to the formation of nanodiamonds embedded in an amorphous carbon substrate. The changes occurring at various stages of the pyrolysis process were monitored by scanning electron microscopy, Fourier transform infrared spectroscopy, and nuclear magnetic resonance spectroscopy. High resolution transmission electron microscopy revealed that nanodiamond crystallites, 4 nm in diameter on average, formed via multiple nucleation events in some carbon-containing high density spheres. It is proposed that highly defected graphene-like flakes form during the pyrolysis of lignin as an intermediate phase. These flakes are more deformable with more localized π electrons in comparison with graphene and join together face-to-face in different manners to form cubic or hexagonal nanodiamonds. This proposed mechanism for the formation of nanodiamonds is relevant to the future fabrication of diamonds from biomass under relatively mild conditions.

Exploring the Germline Genetics of In Situ and Invasive Cutaneous Melanoma: A Genome-Wide Association Study Meta-Analysis.

Importance: It is unknown whether germline genetic factors influence in situ melanoma risk differently than invasive melanoma risk. Objective: To determine whether differences in risk of in situ melanoma and invasive melanoma are heritable. Design, Setting, and Participants: Three genome-wide association study meta-analyses were conducted of in situ melanoma vs controls, invasive melanoma vs controls, and in situ vs invasive melanoma (case-case) using 4 population-based genetic cohorts: the UK Biobank, the FinnGen cohort, the QSkin Sun and Health Study, and the Queensland Study of Melanoma: Environmental and Genetic Associations (Q-MEGA). Melanoma status was determined using International Statistical Classification of Diseases and Related Health Problems codes from cancer registry data. Data were collected from 1987 to 2022, and data were analyzed from September 2022 to June 2023. Exposure: In situ and invasive cutaneous melanoma. Main Outcomes and Measures: To test whether in situ and invasive melanoma have independent heritable components, genetic effect estimates were calculated for single-nucleotide variants (SNV; formerly single-nucleotide polymorphisms) throughout the genome for each melanoma. Then, SNV-based heritability was estimated, the genetic correlation between melanoma subtypes was assessed, and polygenic risk scores (PRS) were generated for in situ vs invasive status in Q-MEGA participants. Results: A total of 6 genome-wide significant loci associated with in situ melanoma and 18 loci with invasive melanoma were identified. A strong genetic correlation (genetic r = 0.96; 95% CI, 0.76-1.15) was observed between the 2 classifications. Notably, loci near IRF4, KLF4, and HULC had significantly larger effects for in situ melanoma compared with invasive melanoma, while MC1R had a significantly larger effect on invasive melanoma compared with in situ melanoma. Heritability estimates were consistent for both, with in situ melanoma heritability of 6.7% (95% CI, 4.1-9.3) and invasive melanoma heritability of 4.9% (95% CI, 2.8-7.2). Finally, a PRS, derived from comparing invasive melanoma with in situ melanoma genetic risk, was on average significantly higher in participants with invasive melanoma (odds ratio per 1-SD increase in PRS, 1.43; 95% CI, 1.16-1.77). Conclusions and Relevance: There is much shared genetic architecture between in situ melanoma and invasive melanoma. Despite indistinguishable heritability estimates between the melanoma classifications, PRS suggest germline genetics may influence whether a person gets in situ melanoma or invasive melanoma. PRS could potentially help stratify populations based on invasive melanoma risk, informing future screening programs without exacerbating the current burden of melanoma overdiagnosis.

Exploring Sense of Purpose and Conscientiousness as Correlates to Health and Well-Being With Indigenous and Low Socioeconomic Communities on Coast Salish Territories, Vancouver, Canada.

Research is needed to better understand factors promoting health and well-being with Indigenous Peoples and people with socioeconomic barriers in Canada, given they face multiple social determinants that are barriers to health. Individual dispositions, sense of purpose and conscientiousness, are known to predict health and well-being in broader samples. In a community-based approach, guided by Indigenous Elders with traditional ways of knowing, we aimed to determine whether these measures correlate with self-rated health and well-being among Indigenous (n = 149) and non-Indigenous (n = 151) Peoples in Vancouver, Canada. The majority of participants (mean age 49 years, and 58% male) had relatively low income (≤$15,000/year) and educational attainment (

Il faudrait davantage de recherches pour mieux comprendre les facteurs qui favorisent la santé et le bien-être des populations autochtones et des personnes confrontées à des obstacles socio-économiques au Canada. En effet, ces dernières sont confrontées à de multiples déterminants sociaux qui constituent des obstacles à la santé. Les dispositions individuelles, le sens du devoir et la prise de conscience sont connus pour prédire la santé et le bien-être dans des échantillons plus larges. Dans le cadre d'une approche communautaire, guidée par des aînés autochtones ayant des connaissances traditionnelles, nous avons cherché à déterminer si ces mesures sont en corrélation avec l'auto-évaluation de la santé et du bien-être chez les autochtones (n = 149) et les non-autochtones (n = 151) de Vancouver, au Canada. La majorité des participants (âge moyen de 49 ans et 58 % d'hommes) avaient des revenus (≤ 15 000 $/an) et un niveau d'éducation (études secondaires non terminées) relativement faibles. Les facteurs étaient valides et fiables dans tous les groupes. Les scores moyens étaient similaires entre les groupes autochtones et non autochtones, et plus faibles chez les participants ayant un revenu inférieur que chez ceux ayant un revenu supérieur. Les corrélations étaient similaires entre les groupes autochtones et non autochtones : le sens du devoir est significativement corrélé avec la santé (SF-6; 0,34 et 0,28, p < 0,001) et la satisfaction à l' égard de la vie (0,55 et 0,58, p < 0,001), et la prise de conscience est corrélée avec la santé (0,19 et 0,18, p < 0,05). Les corrélations étaient similaires entre les groupes de revenus. Lors de l'étude et de la promotion de la santé, de l'équité et du bien-être des communautés autochtones et à faible statut socio-économique, le sens du devoir et les dispositions individuelles sont des facteurs à prendre en compte au même titre que les déterminants sociaux de la santé.

Suppressive Effect of Black Soldier Fly Larvae Frass on Fusarium Wilt Disease in Tomato Plants.

This study investigated the effect of black soldier fly larvae (BSFL) frass derived from BSFL reared on a diet composed of fruit/vegetable/bakery/brewery residues (FVBB diet) and on the Gainesville diet (GV diet) on the development of tomato (Solanum lycopersicum) Fusarium wilt caused by Fusarium oxysporum f. sp. lycopersici (FOL). Tomato plants were grown in a substrate inoculated with FOL that was amended (10%, v:v) or not (control) with either a commercial compost, pasteurized (70 °C for 1 h) frass from BSFL reared on a FVBB diet, non-pasteurized frass from BSFL reared on a FVBB diet, pasteurized frass from BSFL reared on the GV diet, or non-pasteurized frass from BSFL reared on the GV diet. The results show that frass from BSFL reared on the GV diet, irrespective of pasteurization, inhibited FOL root colonization and reduced the severity of tomato Fusarium wilt to a far greater extent than frass from BSFL reared on a FVBB diet and commercial compost made of peat, seaweed, and shrimps. This study suggests that BSFL frass, depending on the larval rearing diet, has the potential to serve as a pasteurized or non-pasteurized soil amendment with prophylactic properties against FOL in tomato plants, opening new avenues of research for the valorization of BSFL frass.

Predicting disease recurrence in patients with endometriosis: an observational study.

BACKGROUND: Despite surgical and pharmacological interventions, endometriosis can recur. Reliable information regarding risk of recurrence following a first diagnosis is scant. The aim of this study was to examine clinical and survey data in the setting of disease recurrence to identify predictors of risk of endometriosis recurrence. METHODS: This observational study reviewed data from 794 patients having surgery for pelvic pain or endometriosis. Patients were stratified into two analytic groups based on self-reported or surgically confirmed recurrent endometriosis. Statistical analyses included univariate, followed by multivariate logistic regression to identify risk factors of recurrence, with least absolute shrinkage and selection operator (Lasso) regularisation. Risk-calibrated Supersparse Linear Integer Models (RiskSLIM) and survival analyses (with Lasso) were undertaken to identify predictive features of recurrence. RESULTS: Several significant features were repeatedly identified in association with recurrence, including adhesions, high rASRM score, deep disease, bowel lesions, adenomyosis, emergency room attendance for pelvic pain, younger age at menarche, higher gravidity, high blood pressure and older age. In the surgically confirmed group, with a score of 5, the RiskSLIM method was able to predict the risk of recurrence (compared to a single diagnosis) at 95.3% and included adenomyosis and adhesions in the model. Survival analysis further highlighted bowel lesions, adhesions and adenomyosis. CONCLUSIONS: Following an initial diagnosis of endometriosis, clinical decision-making regarding disease management should take into consideration the presence of bowel lesions, adhesions and adenomyosis, which increase the risk of endometriosis recurrence.

Distinct Patterns of Endothelial Cell Activation Produced by Extracellular Histones and Bacterial Lipopolysaccharide.

OBJECTIVE: Vascular endothelial cells (ECs) sense and respond to both trauma factors (histone proteins) and sepsis signals (bacterial lipopolysaccharide, LPS) with elevations in calcium (Ca2+), but it is not clear if the patterns of activation are similar or different. We hypothesized that within seconds of exposure, histones but not LPS would produce a large EC Ca2+ response. We also hypothesized that histones would produce different spatio-temporal patterns of Ca2+ events in veins than in arteries. METHODS: We studied cultured ECs (Ea.Hy926) and native endothelial cells from surgically-opened murine blood vessels. High-speed live cell imaging of Ca2+ events were acquired for 5 minutes before and after stimulation of cultured ECs with histones or LPS alone or in combination. Histone-induced EC Ca2+ events were also compared in native endothelial cells from resistance-sized arteries and veins. Ca2+ activity was quantified as "Ca2+ prevalence" using custom spatiotemporal analysis. Additionally, cultured ECs were collected after 6 hours of exposure to histones or LPS for RNA sequencing. RESULTS: ECs - both in culture and in blood vessels - rapidly increased Ca2+ activity within seconds of histone exposure. In contrast, LPS exposure produced only a slight increase in Ca2+ activity in cultured ECs and no effect on blood vessels over 5-minute recording periods. Histones evoked large aberrant Ca2+ events (>30 seconds in duration) in both veins and arteries, but with different spatio-temporal patterns. Ca2+ activity in arterial ECs appeared as "rosettes", with Ca2+ events that propagated from one cell to all adjacent surrounding cells. In veins, ECs responsed individually without spreading. Suprisingly, exposure of cultured ECs to LPS for 5-minutes before histones potentiated EC Ca2+ activity by an order of magnitude. Exposure of ECs to histones or LPS both increased gene expression, but different mRNAs were induced. CONCLUSIONS: LPS and histones activate ECs through mechanisms that are distinct and additive; only histones produce large aberrant Ca2+ events. ECs in arteries and veins display different patterns of Ca2+ responses to histones.

The cytidine deaminase APOBEC3C has unique sequence and genome feature preferences.

APOBEC proteins are cytidine deaminases that restrict the replication of viruses and transposable elements. Several members of the APOBEC3 family, APOBEC3A, APOBEC3B, and APOBEC3H-I, can access the nucleus and cause what is thought to be indiscriminate deamination of the genome, resulting in mutagenesis and genome instability. Although APOBEC3C is also present in the nucleus, the full scope of its deamination target preferences is unknown. By expressing human APOBEC3C in a yeast model system, I have defined the APOBEC3C mutation signature, as well as the preferred genome features of APOBEC3C targets. The APOBEC3C mutation signature is distinct from those of the known cancer genome mutators APOBEC3A and APOBEC3B. APOBEC3C produces DNA strand-coordinated mutation clusters, and APOBEC3C mutations are enriched near the transcription start sites of active genes. Surprisingly, APOBEC3C lacks the bias for the lagging strand of DNA replication that is seen for APOBEC3A and APOBEC3B. The unique preferences of APOBEC3C constitute a mutation profile that will be useful in defining sites of APOBEC3C mutagenesis in human genomes.

Design and Rationale of the V-Wave Shunt MitraClip Study.

Heart failure (HF) and moderate-to-severe mitral regurgitation (MR) with residual elevations in left atrial pressure (LAP) after MitraClip may remain symptomatic and experience subsequent HF readmissions. The V-Wave interatrial shunt system is a permanent interatrial septal implant that shunts blood from the left-to-right atrium and serves to continuously unload the left atrium. Although the V-Wave shunt has previously been studied in patients with HF, the safety and feasibility of its deployment at the time of the MitraClip procedure is unknown. The V-Wave Shunt MitraClip Study (NCT04729933) is an early feasibility study that aims to demonstrate the safety and efficacy of implantation of the V-Wave shunt device at the time of MitraClip procedure. Patients with moderate-to-severe secondary MR with left ventricular ejection fraction 20% to 50% and New York Heart Association functional class III/IV symptoms despite optimal medical therapy, residual mean LAP ≥20 mm Hg after MitraClip, and mean LAP-right atrial pressure difference ≥5 mm Hg are included. The primary safety end point is a composite outcome of all-cause death, stroke, myocardial infarction device embolization, cardiac tamponade, or device-related re-intervention or surgery at 30 days. Patients will be followed up to 5 years. Enrollment is ongoing, with 30-day results expected by the end of 2024. The V-Wave Shunt Mitraclip Study aims to demonstrate the safety and efficacy of the implantation of the V-Wave interatrial shunt device at the time of index MitraClip placement which may serve as an adjunctive method by which continuous left atrial unloading may be achieved.

The Risk of Lung Cancer in Rheumatoid Arthritis and Rheumatoid Arthritis-Associated Interstitial Lung Disease.

OBJECTIVE: We aimed to evaluate lung cancer risk in patients with rheumatoid arthritis (RA) and RA-interstitial lung disease (ILD). METHODS: We performed a retrospective, matched cohort study of RA and RA-ILD within the Veterans Health Administration (VA) between 2000 and 2019. Patients with RA and RA-ILD were identified with validated administrative-based algorithms, then matched (up to 1:10) on age, gender, and VA enrollment year to individuals without RA. Lung cancers were identified from a VA oncology database and the National Death Index. Conditional Cox regression models assessed lung cancer risk adjusting for race, ethnicity, smoking status, Agent Orange exposure, and comorbidity burden among matched individuals. Several sensitivity analyses were performed. RESULTS: We matched 72,795 patients with RA with 633,937 patients without RA (mean age 63 years; 88% male). Over 4,481,323 patient-years, 17,099 incident lung cancers occurred. RA was independently associated with an increased lung cancer risk (adjusted hazard ratio [aHR] 1.58 [95% confidence interval (CI) 1.52-1.64]), which persisted in never smokers (aHR 1.65 [95% CI 1.22-2.24]) and in those with incident RA (aHR 1.54 [95% CI 1.44-1.65]). Compared to non-RA controls, prevalent RA-ILD (n = 757) was more strongly associated with lung cancer risk (aHR 3.25 [95% CI 2.13-4.95]) than RA without ILD (aHR 1.57 [95% CI 1.51-1.64]). Analyses of both prevalent and incident RA-ILD produced similar results (RA-ILD vs non-RA aHR 2.88 [95% CI 2.45-3.40]). CONCLUSION: RA was associated with a >50% increased risk of lung cancer, and those with RA-ILD represented a particularly high-risk group with an approximate three-fold increased risk. Increased lung cancer surveillance in RA, and especially RA-ILD, may be a useful strategy for reducing the burden posed by the leading cause of cancer death.

American Academy of Pediatrics Recommended Cardiac Screening Questions in Preparticipation Physical Evaluation Forms.

To evaluate the utilization of the American Academy of Pediatrics' (AAP) cardiovascular screening questions within preparticipation physical evaluation forms from the 50 state high school athletic associations. We found that fewer than one-half of state forms incorporated all 10 AAP questions; moreover, a subset failed to adhere to criteria recommended by either the AAP or American Heart Association.

The Modified Frailty Index Predicts Major Complications in Oncoplastic Reduction Mammoplasty.

BACKGROUND: An important component of preoperative counseling and patient selection involves surgical risk stratification. There are many tools developed to predict surgical complications. The Modified Frailty Index (mFI) calculates risk based on the following five elements: hypertension, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and functional status. Recent literature demonstrates the efficacy of the mFI across multiple surgical disciplines. We elected to investigate its utility in oncoplastic reductions (OCR). METHODS: A retrospective review of all patients with breast cancer who underwent OCR from 1998 to 2020 was queried from a prospectively maintained database. Patient demographics, comorbidities, and surgical details were reviewed. The mFI was computed for each patient. The primary clinical outcome was the development of complications. RESULTS: 547 patients were included in the study cohort. The average age was 55 and the average body mass index was 33.5. The overall complication rate was 19% (n = 105) and the major complication rate was 9% (n = 49). Higher frailty scores were significantly associated with the development of major complications (P < 0.05). mFI scores of 0 had a major complication rate of 5.7%; scores of 1, 13%; and scores of 2, 15.1%. The relative risk of a major complication in patients with elevated mFI (>0) was 2.2. Age, body mass index, and resection weights were not associated with complications (P = 0.15, P = 0.87, and P = 0.30 respectively) on continuous analysis. CONCLUSIONS: Elevated mFI scores are associated with an increased major complication profile in patients who are undergoing OCR. Hypertension and diabetes are the most common comorbidities in our population, and this tool may assist with preoperative counseling and risk stratification. Benefits of this risk assessment tool include its ease of calculation and brevity. Our study is the first to demonstrate its utility in OCR; however, further study in high-risk patients would strengthen the applicability of this frailty index.

Periareolar Skin-Sparing Mastectomy and Immediate Implant-Based Reconstruction: A Reappraisal.

INTRODUCTION: Skin-sparing mastectomy (SSM) is often used when tumor location prohibits performing a nipple-sparing mastectomy (NSM). We examined a square excision of the nipple-areolar complex (NAC) and an X-shaped purse string closure after implant-based reconstruction. METHODS: A retrospective review was performed on patients undergoing periareolar SSM and immediate implant-based reconstruction from January 2015 through December 2022, specifically identifying those patients who had square NAC excision and skin closure. RESULTS: Twenty-nine patients met the inclusion criteria. They underwent 54 periareolar SSM and immediate implant-based reconstruction (bilateral 25, unilateral 4). Indications for surgery were cancer (30) and prophylactic (24; 2 patients had bilateral cancer). Reconstructive methods included tissue expander (TE) (36 [66.7%]) and direct-to-implant (DTI) (18 [33.3%]). The mean mastectomy weights and final implant sizes were similar between the 2 groups. Overall wound complications occurred in 13 (24.1%) of the breasts: mastectomy skin flap necrosis (MSFN; 10 [18.5%]) and infection (3 [5.6%]). Reconstructive failure occurred in 3 cases: TE, 1 (infection); DTI, 2 (MSFN/exposure). MSFN by reconstructive method: TE, 4 (11.1%); DTI, 6 (33.3%) (P = 0.05, comparing MSFN rates between TE and DTI methods). The mean initial TE fill volume was 247.1 cc; mean implant size in the DTI group was 417.8 cc (P < 0.0001). CONCLUSIONS: The square NAC excision and closure can minimize the surgical incision in implant reconstruction. Two-stage TE reconstruction permits lower initial fill volumes, which reduces the risk of MSFN after box to X closure of SSM and implant-based reconstruction. It is useful in small- to moderate-sized breasts with mild ptosis in patients who are not candidates for NSM.