Objective: Antibiotics (ABX) are widely used for life-threatening infections and also for routine surgical operations. Compelling evidence suggests that ABX-induced alterations of gut microbiota composition, termed dysbiosis, are linked with diverse disease states including neurological and neurodegenerative conditions. To combat the consequences of dysbiosis, probiotics (PBX) are widely used. ABX-induced dysbiosis is reported to impair neurological function after spinal cord injury. Traumatic peripheral nerve injury (TPNI) results in profound neurologic impairment and permanent disability. It is unknown whether ABX treatment-induced dysbiosis has any impact on TPNI-induced functional recovery, and if so, what role medical-grade PBX could have on TPNI recovery.

Results: In this study, ABX-induced dysbiosis and PBX-induced microbiota enrichment models were used to explore the potential role of gut microbiome in TPNI. Stool analysis with 16S ribosomal RNA (rRNA) gene sequencing confirmed ABX-induced dysbiosis and revealed that ABX-induced changes could be partially restored by PBX administration with an abundance of butyrate producing bacteria. Pre-injury ABX significantly impaired, but pre-injury PBX significantly improved post-TPNI functional recovery. Importantly, post-injury PBX protected against pre-injury ABX-induced functional impairment. These findings demonstrate that reestablishment of gut microbiota composition with butyrate producing PBX during ABX-induced dysbiosis could be a useful adjuvant therapy for TPNI.

Keywords: 16S rRNA analysis; Antibiotics; Functional recovery; Gut microbiota; Peripheral nerve injury; Probiotics.

Background: The rapid evolution of seminal fluid proteins (SFPs) has been suggested to be driven by adaptations to postcopulatory sexual selection (e.g. sperm competition). However, we have recently shown that most SFPs evolve rapidly under relaxed selective pressures. Given the role of SFPs in competition for fertilization phenotypes, like the ability to transfer and store sperm and the modulation of female receptivity and ovulation, the prevalence of selectively relaxed SFPs appears as a conundrum. One possible explanation is that selection on SFPs might be relaxed in terms of protein amino acid content, but adjustments of expression are essential for post-mating function. Interestingly, there is a general lack of systematic implementation of gene expression perturbation assays to monitor their effect on phenotypes related to sperm competition.

Results: We successfully manipulated the expression of 16 SFP encoding genes using tissue-specific knockdowns (KDs) and determined the effect of these genes' perturbation on three important post-mating phenotypes: female refractoriness to remating, defensive (P1), and offensive (P2) sperm competitive abilities in Drosophila melanogaster. Our analyses show that KDs of tested SFP genes do not affect female refractoriness to remating and P2, however, most gene KDs significantly decreased P1. Moreover, KDs of SFP genes that are selectively constrained in terms of protein-coding sequence evolution have lower P1 than KDs of genes evolving under relaxed selection.

Conclusions: Our results suggest a more predominant role, than previously acknowledged, of variation in gene expression than coding sequence changes on sperm competitive ability in D. melanogaster.

Keywords: Gene expression; Post-mating phenotypes; RNAi knockdowns; Seminal fluid proteins; Sperm competition.

Background: Latina adolescents in the USA report some of the lowest rates of physical activity of any demographic subgroup; this is paralleled by a markedly higher lifetime risk of obesity, type 2 diabetes, and other conditions related to inactivity. Despite this, to date, no fully powered clinical trials have tested physical activity interventions specifically for this population. High use of mobile technologies (including text messages, smartphone apps, and social media) suggests this could be an appropriate intervention channel, while also having potential for broad reach. This paper describes the protocol for Chicas Fuertes, a fully powered randomized trial of a mobile technology-based physical activity intervention for Latina adolescents.

Methods: We plan to recruit 200 Latina teens (age 13-18) in San Diego, CA, currently engaging in ≤ 150 min/week of moderate-to-vigorous physical activity (MVPA) to be assigned 1:1 to the intervention or control groups. Those randomly assigned to the intervention group receive a one-on-one goal setting session followed by 6 months of mobile technology-based intervention, including a personalized website, Fitbit activity tracker and app, individually tailored text messages based on Fitbit data, and daily intervention content on Instagram. Those randomized to the control group receive only a Fitbit activity tracker. The main outcome is change in weekly minutes of MVPA from baseline to 6 months, measured both objectively (ActiGraph accelerometers and Fitbit Inspire HR) and subjectively (7-Day Physical Activity Recall Interview). Additional outcomes are maintenance of activity change at 12 months and changes in psychosocial constructs, including social support and self-efficacy, engagement with mobile technology channels, and costs of intervention delivery. We are also examining the potential mediators and moderators of the intervention. The efficacy of the intervention is analyzed using a mixed effects regression model, adjusting for any potential confounders not balanced by randomization. All analyses of accelerometer measured MVPA are also adjusted for wear time.

Discussion: The Chicas Fuertes trial uses widely available mobile technologies to target critical health behavior, physical activity, in Latina teens, a population with a high lifetime risk of lifestyle-related diseases. The results will speak to the efficacy and acceptability of the intervention, which has the potential for broad dissemination.

Trial registration: ClinicalTrials.gov NCT04190225 . Registered on November 20, 2019.

Keywords: Exercise; Fitbit; Health disparities; Latinas; Randomized controlled trials; Social media; Teens; Text messaging; mHealth.

Background: Prolidase deficiency (PD) is an autosomal recessive inborn multisystemic disease caused by mutations in the PEPD gene encoding the enzyme prolidase D, leading to defects in turnover of proline-containing proteins, such as collagen. PD is categorized as a metabolic disease, but also as an inborn error of immunity. PD presents with a range of findings including dysmorphic features, intellectual disabilities, recurrent infections, intractable skin ulceration, autoimmunity, and splenomegaly. Despite symptoms of immune dysregulation, only very limited immunologic assessments have been reported and standard therapies for PD have not been described. We report twin females with PD, including comprehensive immunologic profiles and treatment modalities used.

Case presentation: Patient 1 had recurrent infections in childhood. At age 13, she presented with telangiectasia, followed by painful, refractory skin ulcerations on her lower limbs, where skin biopsy excluded vasculitis. She had typical dysmorphic features of PD. Next-generation sequencing revealed pathogenic compound heterozygous mutations (premature stop codons) in the PEPD gene. Patient 2 had the same mutations, typical PD facial features, atopy, and telangiectasias, but no skin ulceration. Both patients had imidodipeptiduria. Lymphocyte subset analysis revealed low-normal frequency of T_reg cells and decreased frequency of expression of the checkpoint molecule CTLA-4 in CD4⁺ T_EM cells. Analysis of Th1, Th2, and Th17 profiles revealed increased inflammatory IL-17⁺ CD8⁺ T_EM cells in both patients and overexpression of the activation marker HLA-DR on CD4⁺ T_EM cells, reflecting a highly activated proinflammatory state. Neither PD patient had specific antibody deficiencies despite low CD4⁺CXCR5⁺ T_fh cells and low class-switched memory B cells. Plasma IL-18 levels were exceptionally high.

Conclusions: Immunologic abnormalities including skewed frequencies of activated inflammatory CD4⁺ and CD8⁺ T_EM cells, decreased CTLA-4 expression, and defects in memory B cells may be a feature of immune dysregulation associated with PD; however, a larger sample size is required to validate these findings. The high IL-18 plasma levels suggest underlying autoinflammatory processes.

Keywords: Autoimmunity; Inborn error of immunity; Leg ulcers; Prolidase deficiency; T cells.

Background: Medical students demonstrate higher levels of psychological distress compared with the general population and other student groups, especially at exam times. Mindfulness interventions show promise in stress reduction for this group, and in the reduction of cortisol, an established clinical marker of the body's stress response. This study investigated the relationship of mindfulness to exam-induced stress, salivary cortisol and exam performance in undergraduate medical students.

Methods: A controlled pre-post analysis design with within-groups comparisons. 67 medical students completed the five facet mindfulness questionnaire (FFMQ) and provided saliva samples, from which cortisol was extracted, during group work (control/baseline) and immediately prior to end of year 2 examinations (experimental). Academic performance data was extracted for comparison with measures.

Results: Exam-induced salivary cortisol concentration showed a significant negative relation with exam performance. Total FFMQ score showed a significant positive relation with exam performance and a significant negative relation with exam-induced salivary cortisol. The specific mindfulness facets of acting with awareness, non-judging and non-reacting also showed a positive correlation with exam performance.

Conclusions: This study suggests that there exists an important relationship between mindfulness and the physiological biomarker of stress, cortisol, and this manifests into improved assessment outcomes potentially through healthier, more adaptive coping and stress management strategies. In particular, this study identifies the acting with awareness, non-judging and non-reacting facets of mindfulness to be significantly associated with exam performance suggesting that these may be important facets for clinical educators to target when helping students with mindfulness practice.

Keywords: Medical school; Medicine; Meditation.

Aim: The aim of this scoping review is to explore the evidence by which community service providers have integrated reablement models of staff training and client assessment into practice.

Background: The concept of reablement, which has emerged during the last two decades globally, has recently been defined by health experts from 11 countries through a Delphi study. Reablement is seen as a way to support integrated frameworks that achieve person-centred, long-term care and assistance across community settings. International research indicates there is some evidence of developing models of reablement that include staff training and individual components of client assessment. However, evidence of integrating reablement into interdisciplinary practice continues to be sparse.

Methods: The review adopted the preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) approach. Inclusion criteria for the review related to community care, primary care, long-term care, and residential care. Populations of interest included service providers, interdisciplinary staff, trainers, and assessors.

Results: A total of 11 papers were reviewed. The studies varied in their approach to reablement training and client assessment frameworks. Three studies included assessment of staff well-being. All included evidence-based, person-centred components that can be integrated across health care settings. Single disciplinary approaches were used in all studies and some included training evaluation.

Conclusion: This review has identified that currently reablement models are not yet embedded as frameworks for practice by community service providers in primary health care settings. Different programmes of training and assessment are being designed based on single disciplinary approaches and the context in which they are delivered. Further developmental work is required to integrate the components of discipline-specific training programmes within interdisciplinary frameworks. This will achieve not only an integrated framework for delivery across settings but also further the success of 'ageing in place' policy.

Keywords: assessment; community; frameworks; interdisciplinary; reablement; training.

Hepatocellular carcinoma is a malignancy associated with high mortality and increasing incidence. Early detection of this disease could help increase survival and overall patient benefit. Non-invasive strategies for the diagnosis of this medical condition are of utmost importance. In this scope, the detection of hepatocellular carcinoma biomarkers could provide a useful diagnostic tool. Aptamers represent as short, single-stranded DNAs or RNAs that can specifically bind selected analytes, and also as pseudo-biorecognition elements that can be employed for electrode functionalization. Also, other types of DNA sequences can be used for the construction of DNA-based biosensors applied for the quantification of hepatocellular carcinoma biomarkers. Herein, we will be analyzing recent examples of aptasensors and DNA biosensors for the detection of hepatocellular carcinoma biomarkers like micro-RNAs, long non-coding RNAs, exosomes, circulating tumor cells and proteins. The literature data is discussed comparatively in a critical manner highlighting the advantages of using electrochemical biosensors in diagnosis, as well as the use of nanomaterials and biocomponents in the functionalization of electrodes for improved sensitivity and selectivity.

Keywords: DNA sequences; Hepatocellular carcinoma (HCC); aptamers; biomarkers; electrochemical biosensors; miRNAs..

The comparison of chloroplast genome (cpDNA) sequences among different plant species is an important source of plant molecular phylogenetic data. In this paper, the cpDNA sequences of 13 different oil-tea camellia samples were compared to identify an undetermined oil-tea camellia species from Hainan Province. The cpDNA of the samples was sequenced and resequenced, and divergence hotspots and simple sequence repeat (SSR) variations were analyzed. Bayesian inference (BI) and maximum-likelihood (ML) phylogenetic trees were constructed based on the full cpDNA sequences. The cpDNA sequences were 156512∼157089 bp in length and had the circular tetrad structure typical of angiosperms. The inverted repeats (IRs) of different species included varying contractions and expansions. The cpDNA sequences of the samples of the undetermined species of oil-tea camellia from Hainan Province and Camellia gauchowensis from Xuwen County were identical. In total, 136 genes were annotated, including 91 protein-coding genes (PCGs), 37 tRNA genes and 8 rRNA genes. The GC content of the cpDNA was 37.3%. The small single-copy (SSC)/IR boundary was rich in variation. Divergence hotspots were mainly located in the intergenic space (IGS) and coding sequences (CDSs), and there were obvious differences in divergence hotspots among species. The same divergence hotspots were found in Camellia vietnamensis, Camellia gauchowensis and the undetermined species of oil-tea camellia from Hainan Province. A total of 191∼198 SSR loci were detected. Most of the SSRs included A or T, and the distribution of SSRs in the cpDNA was uneven. Different species shared common SSRs and exhibited unique SSRs. Based on the full cpDNA sequences, the evolutionary relationships of different species of Camellia were well identified. The thirteen samples were classified into 2 clades and 6 subclades, and the different sections of Camellia clustered on the same branch in 2 clades and 2 subclades. Camellia vietnamensis was more closely related to the undetermined species of oil-tea camellia from Hainan Province and the sample of Camellia gauchowensis from Xuwen County than to the sample of Camellia gauchowensis from Luchuan County. Camellia osmantha was closely related to Camellia gauchowensis and Camellia vietnamensis. In conclusion, the cpDNA of different oil-tea camellia species has a conserved tetrad structure with certain length polymorphisms. SSRs are expected to be developed as "barcodes" or "identity cards" for species identification. SSR variations and other factors result in abundant divergence hotspots in the CDSs and IGS (one non-CDS region), indicating that full cpDNA sequences can be used for the species identification and phylogenetic analysis of Camellia. Accordingly, the undetermined species of oil-tea camellia from Hainan Province is likely Camellia vietnamensis, Camellia vietnamensis and Camellia gauchowensis may be the same species, and additional genetic evidence is needed to determine whether Camellia osmantha is a new independent species. The previous division of related sections of Camellia may need readjustment based on full cpDNA sequences.

Keywords: SSRs; cpDNA; divergence hotspots; oil-tea camellia; phylogenetic tree.

The treatment for middle cerebral artery subocclusive thrombi is not standardized. Here, we report a case of M1 subocclusive thrombus with lateral lenticulostriate artery occlusion that was successfully treated with mechanical thrombectomy. This article describes a treatment strategy for M1 subocclusive thrombus, focusing on the indications for mechanical thrombectomy. A 58-year-old male on admission for pneumonia had a sudden onset of dysarthria and motor deficits. He has a history of dilated cardiomyopathy and underwent left ventricular assist device implantation 3 years ago. At onset, his National Institutes of Health Stroke Scale (NIHSS) score was nine. Computed tomography angiography demonstrated a filling defect in the distal right M1 segment of the middle cerebral artery. Angiography confirmed the presence of a subocclusive thrombus within the distal right M1 segment, although peripheral blood flow was maintained. Mechanical thrombectomy was performed for the M1 subocclusive thrombus using a direct aspiration first-pass technique, resulting in successful aspiration of the thrombus on the first pass. After the procedure, recanalization of the lateral lenticulostriate artery was detected, and the patient demonstrated full recovery (NIHSS score 0). Mechanical thrombectomy can be considered as a treatment option in cases of acute ischemic stroke caused by M1 subocclusive thrombus with lateral lenticulostriate artery occlusion, which presents with a high NIHSS score or neurological deterioration.

Keywords: ischemic stroke; lenticulostriate artery; mechanical thrombectomy; middle cerebral artery; subocclusion.

Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome was one of the first mitochondrial disorders to be identified and characterized, being described as early as 1984. The clinical manifestations of MELAS vary but stroke-like episodes are a defining feature. Mutations in at least 17 mitochondrial DNA (mtDNA) located genes have been shown to be associated with this disorder. Mary Ann, the youngest child of Josiah and Sarah Wedgwood, was born in August 1778 when Sarah was aged 44 years. Mary Ann was of short stature and was physically and mentally retarded. She suffered from partial and generalized seizures and episodes of cortical blindness. She died at the age of eight years. Descriptions of her illness remain and she is depicted with disabilities as can be seen in a family portrait. Her illness is consistent with MELAS. The illnesses of her elder siblings and of their mother are in keeping with a maternally inherited pathological mtDNA mutation, supporting this diagnosis. Her illness is the key to the remarkable illnesses that affected the Wedgwood family. Through her eldest sibling, Susannah, married to Robert Darwin, the disorder was passed to the next generation, a generation that included Charles Darwin and his elder brother, Erasmus.

Keywords: brachydactyly; charles darwin’s illness; cortical blindness; melas; mitochondrial; mtdna; ocular hypertelorism; seizures; stroke-like episode; wedgwood illness.

We report on a 79-year-old man diagnosed with localized Merkel cell carcinoma (MCC) who also had acetylcholine receptor antibody (Ach-R-Ab)-positive myasthenia gravis (MG) controlled on prednisolone, mycophenolate and intravenous immunoglobulin (IVIG). His MCC was initially treated with radiation, followed by chemotherapy on metastatic recurrence. Chemotherapy initially stabilized the disease, but he experienced significant fatigue and his disease progressed within 3 months. After careful consideration of the risk of a myasthenic crisis, he was commenced on avelumab. He had initial partial response, though he ultimately developed progressive disease which led to a decision for best supportive care at 10 months post starting immunotherapy. Importantly, as per spirometry, his MG remained stable throughout immunotherapy. We present the current case to demonstrate that MG should not be viewed as an absolute contraindication to immunotherapy in scenarios where there are limited alternate therapeutic options.

Keywords: neurology; oncology.

The presence of vertebral tuberculosis (TB) in developing countries and Southeast Asia is well known, but developed nations such as the USA and UK also claim a good share because of immigrants and the HIV population. We present a unique case series of two patients with chronic abdominal pain where various differentials and arduous investigation were employed. Finally, after a few months, we could locate the lower thoracic Pott's spine and commenced the treatment with successful resolution of symptoms. Surgeons and gastroenterologists should rule out the spinal cause of abdominal pain and also be aware of other atypical presentations before labeling it functional or irritable bowel syndrome (IBS) or somatoform disorders. Extensive investigation, cost, delay in diagnosis, and emotional disturbances could be the end product commonly encountered in a neuropathic abdominal pain patient if a high level of suspicion is not kept at the initial presentation. Above all, potential bony deformity, neurological deficits, and their irreversible sequelae such as paraparesis can also be thwarted.

Keywords: abdominal pain; compressive fracture; pott’s spine; skeletal tuberculosis; tuberculosis.

Documented re-infection of COVID-19 is uncommon and doing a major spinal surgery in an elderly patient right after the recovery from the first event is itself a major undertaking. Re-infection after successful surgery points to the possibility of COVID-19 infection being a post-surgical complication. Here, we report a case of a 72-years-old elderly female who had presented to us with features of COVID-19 infection confirmed by reverse transcription polymerase chain reaction assay and unstable spinal fracture who underwent a pedicle screw fixation for the fracture of the third and fourth thoracic vertebrae after two consecutive negative serology assays. A month after discharge from the hospital, she presented with severe symptoms of COVID-19 again confirmed by two consecutive polymerase chain reaction assays. She was managed conservatively and was discharged without significant respiratory and neurological complications. We described this case in detail in addition to reviewing the pertinent literature.

Keywords: COVID-19; re-infection; spinal fracture..

Introduction: Smoked and smokeless forms of tobacco is a preventable cause of morbidity and mortality with inevitable effects on the oral cavity as well. The aim of the study was to find out the prevalence of tobacco users among the patients who visited dental outpatient departments of a tertiary care hospital. Methods: A descriptive cross-sectional study was carried out among 255 patients visiting the dental outpatient department of a tertiary care hospital over the duration of six months. Data collection was done through personal interviews and clinical examinations. History of tobacco use was taken and patients were divided into current users, never users and ever users. Clinical examination was done using Decayed Missing Filled Teeth index, community periodontal index modified and loss of attachment. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. Results: Among 255 patients, 91 (35.69%) (95% Confidence Interval = 29.81-41.57) patients used tobacco. Among them, 72 (28.2%) were current users, who had taken tobacco at least once during the past 30 days and 19 (7.5%) were ever users who had taken tobacco but not during the past 30 days. Conclusions: The prevalence of tobacco use among our study participants is similar in comparison to that of the general population. Our study shows greater prevalence of the use of a smokeless form of tobacco than the smoked form of tobacco.

Keywords: dental caries; periodontal disease; tobacco..

[This corrects the article DOI: 10.3389/fnagi.2021.735524.].

Keywords: ApoE4; MODEL-AD; TREM2; late-onset AD; mouse model.

Introduction: Hyponatremia is a frequent problem in chronic liver disease. To the best of our knowledge, no study of hyponatremia in chronic liver disease has been conducted in our setting. The aim of this study is to study the prevalence of hyponatremia in patients with chronic liver disease attending the outpatient department of a tertiary care hospital.

Methods: This descriptive cross-sectional study was conducted in 114 patients with chronic liver disease attending the out-patient department of a tertiary care hospital in Kathmandu, Nepal between November 2020 and July 2021. Ethical approval was taken from the Institutional Review Committee of Nepal Medical College and Teaching Hospital (Reference number: 028-077/078). Convenience sampling was done. The collected data was entered and analyzed in Microsoft Excel. Calculation of point estimate at 95% confidence interval was done along with frequency and proportion for binary data.

Results: Among 114 patients with chronic liver disease studied, 47 (41.22%) (32.18-50.25 at 95% Confidence Interval) patients had hyponatremia (≤130mmol/L) with mean age of 53.44±7.57 years. Thirty (63.8%) patients out of these were males and 17 (36.2%) patients were females.

Conclusions: The prevalence of hyponatremia among patients with chronic liver disease was found to be higher when compared to other similar studies.

Keywords: hyponatremia; liver diseases; Nepal; sodium..

Acute kidney injury (AKI) is a common critical clinical disease characterized by a sharp decline of renal function. Ischemia-reperfusion (IR) is one of the main causes of AKI. The mortality of AKI remains high due to the lack of early diagnosis and cause specific treatment. IR rapidly initiates innate immune responses, activates complement and innate immune cells, releasing a large number of injury-related molecules such as high mobility group box-1 (HMGB1), inflammatory mediators such as caspase-3, and then recruits immune inflammatory cells including M1 macrophages (Mϕ) to the microenvironment of injury, causing apoptosis and necrosis of renal tubular epithelial cells (TECs). Dead cells and associated inflammation further activate the adaptive immune system, which not only aggravates tissue damage, but also initiates M2 Mϕ participated inflammatory clearance, tissue repair and regeneration. Mϕ, professional phagocytes, and TECs, semi-professional phagocytes, can phagocytose around damaged cells including apoptotic Mϕ and TECs, which are key innate immune cells to regulate the outcome of injury, repair or fibrosis. In recent years, it has been found that erythropoietin (EPO) not only binds to the homodimeric receptor (EPOR)₂ to induce erythropoiesis, but also binds to the heterodimeric receptor EPOR/βcR, also known as innate repair receptor, which plays renoprotective roles. Properdin is the only positive regulator in the complement activation of alternative pathway. It also can effectively identify and bind to early apoptotic T cells and facilitate phagocytic clearing by Mϕ through a non-complement activation-dependent mechanism. Our previous studies have shown that Mϕ and TECs associated with EPO and its receptors and properdin are involved in IR injury and repair, but the underlying mechanism needs to be further explored. As an important carrier of cell-to-cell signal transmission, exosomes participate in the occurrence and development of a variety of renal diseases. The role of exosomes involved in the interaction between Mϕ and TECs in IR-induced AKI is not fully defined. Based on the available results in the role of Mϕ and TECs in renal IR-induced AKI, this review discussed the role of Mϕ polarization and interaction with TECs in renal IR injury, as well as the participation of EPO and its receptors, properdin and exosomes.

Background: A recently indicated immunotherapy strategy, combined with mechanical circulatory support (MCS), seems to improve outcomes in patients with fulminant giant cell myocarditis (GCM). However, characterizing a definitive clinical outcome of this strategy remains challenging, and the autoimmunity associated with the onset of GCM remains controversial.

Case summary: A 26-year-old man with poor control of atopic dermatitis and ulcerative colitis presented with cardiogenic shock requiring MCS. He was diagnosed with fulminant GCM; hence, immunotherapy (including steroids and intravenous immunoglobulin) was administered and an extracorporeal left ventricular assist device (LVAD) was needed. As the patient complained of prominent fatigue and double vision before myocarditis onset, and acetylcholine receptor-binding antibody titres were elevated, he was diagnosed with myasthenia gravis (MG). No anti-striational antibodies known to be associated with GCM in patients with MG were found in the patient's serum. Cyclosporin-based immunosuppression under LVAD therapy led to an almost complete resolution of his muscle weakness, intermittent ptosis, and cardiac dysfunction along with the histopathological remission of GCM resulting in LVAD removal. He remained at home without recurrence of GCM and worsening symptoms of MG over the 6-month period following discharge.

Discussion: We describe a case of GCM with multiple autoimmune disorders, which recovered by treatment with early cyclosporin-based immunosuppressive therapy under LVAD therapy. The present case suggests the involvement of unknown anti-striational antibodies in the development of GCM in patients with MG and may provide information to guide a novel therapeutic regimen for patients with fulminant GCM requiring mechanical circulatory support.

Keywords: Autoimmune disorder; Bridge to recovery; Case report; Giant cell myocarditis; Myasthenia gravis; Ventricular assist device.

Introduction: Ureteric calculi are lying at any point of ureter from the pelvic ureteric junction to the vesicoureteral junction. If left untreated, ureteropelvic junction obstruction can lead to hydronephrosis. With the improved availability of computed tomography and ultrasound scanning, hydronephrosis is being diagnosed more frequently. The main aim of this study is to find out the prevalence of moderate Hydronephrosis among ureteral calculus on ultrasonography imaging in a tertiary care center of Nepal.

Methods: A descriptive cross-sectional study was conducted among 110 acute ureteral calculus cases at Radiodiagnosis and Imaging Department of Chitwan Medical College and Teaching Hospital, Bharatpur from 15th August 2020 to 15th May 2021. The ethical approval was taken from the Institutional Review Committee of same institution. Convenient sampling technique was used to select the participant. The collected data was entered in excel 16 and analysed in Statistical Package for Social Sciences. Point estimate at 95% Confidence Interval was done and frequency and percentage were calculated.

Results: Out of the 110 cases of acute ureteral calculus, 31 (28.2%) (19.79-36.60 at 95% Confidence Interval) has moderate hydronephrosis in the ultrasonographic imaging. The mean age of participants was 31.61±8.51 years and male to female ratio was 1.97:1. Vesicoureteric junction was the most common site for ureteric calculus 39 (35.5%).

Conclusions: The ultrasound is an easy method to be applied, and a fast one to help and diagnose obstructive hydronephrosis. The main causes of hydronephrosis are kidney stones, followed by ureteral stones, with a moderate degree of hydronephrosis.

Keywords: hydronephrosis; ultrasonography; ureteral calculus..

For large lower lip defects, a thin flap combined with a tendon is the standard reconstructive option. However, this method can result in flap ptosis, which occurred in two of our patients. To correct the ptosis, we transplanted costal cartilage into the reconstructed lower lips, which produced good or moderate results. We report our experience based on long-term follow-up. In case 1, reconstruction was performed with a latissimus dorsi myocutaneous flap. Within 10 years of the first cartilage transplant, two additional surgeries were required due to cartilage/screw breakage. These problems may have been triggered by the bulkiness of the flap and/or the angle at which the cartilage was anchored in place. There have not been any further problems for 3 years. In case 2, reconstruction was performed with a free anterolateral thigh flap. The skin around the flap had poor extensibility, and the patient had marked Class II occlusion. We grafted cartilage without fixing it to the mandible. However, temporary interference with the maxillary dentition was observed. In conclusion, costal cartilage grafts are effective against flap ptosis after free flap reconstruction of the lower lip in patients without Class II occlusion. To achieve long-term stability, the optimal angle and positioning of the cartilage and the extensibility of the skin must be thoroughly investigated before surgery, and a thick piece of cartilage must be firmly fixed in place.