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Competing Interests: M.Y.N. has received funding from Circle CVI, Arterys, TeraRecon, Lode, GE, and Bayer. The remaining authors declare no conflict of interest.

Septal extension graft (SEG) is an adaptable tool that controls, supports, and stabilizes the nasal tip projection, rotation, length, and shape. Recent studies comparing SEGs to more conventional columellar strut grafts found that SEGs provided improved results. This prospective cohort study included 66 patients divided into 2 groups based on their indications. Group 1 was patients who underwent septorhinoplasty using osteochondral septal extension graft (OSEG), and group 2 underwent septorhinoplasty using cartilaginous SEG. The main reason for undergoing OSEG was insufficient septal cartilage (P<0.001). The outcomes were not significantly different between both groups, with the % of patients who experienced positive outcomes ranging from 78.8% to 97%. The OSEG is a safe, valid, and effective option in septorhinoplasty that can be used in patients with insufficient cartilaginous septum., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Associated with high-risk human papillomavirus infection, invasive stratified mucin-producing carcinoma is a recently characterized adenocarcinoma of the cervix. It often occurs in association with adjacent stratified mucin-producing intraepithelial lesion. Differentiated vulvar intraepithelial neoplasia and related invasive squamous cell carcinoma often arise in background vulvar lichen sclerosus with TP53 mutation as the underlying molecular signature. We present a unique case of vulvar invasive stratified mucin-producing carcinoma-like component coexisting with invasive squamous cell carcinoma in a 64-year-old woman. Both neoplastic components were proven TP53 -driven processes arising in the background of differentiated vulvar intraepithelial neoplasia and lichen sclerosus. The invasive stratified mucin-producing carcinoma-like component behaved aggressively in this case, evidenced by the presence of lymphovascular invasion and inguinal lymph node metastasis., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 by the International Society of Gynecological Pathologists.)

Objectives: We describe our novel modified spreader flap, which involves keeping the large cartilaginous septal T hump attached to the upper lateral cartilages to increase the thickness and length of the flap. Our objectives were to assess hump reduction and recurrence, nasal axis deviation, dorsal width, internal nasal valve grade, and Rhinoplasty Outcome Evaluation (ROE) score preoperatively and one year postoperatively., Materials and Methods: In a prospective study that included 21 patients who met the criteria, patients were followed up for 1 year after surgery, with an assessment of the dorsal projection, tip projection, axis deviation, dorsal width, and internal nasal valve grade. In addition, the modified Cottle maneuver and Rhinoplasty Outcome Evaluation score were also performed and obtained, respectively., Results: Our novel technique was performed in 20 patients (95.2%). In 1 additional patient, we added a regular auto-spreader flap on the contralateral side. One year postoperatively, the axis was found in the midline in all patients (100%). Assessment of internal valve collapse showed that collapse was reduced to grade 0 in 13 patients (61.9%) and grade 1 in 8 patients (38.1%). There were no hump recurrences or visible irregularities. The results showed a statistically significant difference between the pre- and postoperative values in dorsal projection, dorsal width, and rhinoplasty outcome evaluation score., Conclusions: This novel technique shows promising statistically significant results in reducing dorsal hump projection and width, correcting axis deviation, and improving internal nasal valve and rhinoplasty outcome evaluation score, while being less cartilage and time-consuming., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Objectives: To investigate the indication, site, techniques, and complications at the donor and recipient sites of temporalis fascia grafting in rhinoplasty, and patients' satisfaction with the surgical outcomes., Methods: This retrospective cohort study was performed at King Abdulaziz University Hospital, Saudi Arabia, between January 2015 and January 2020. The predictor variable was the temporalis fascia in different forms. Reported variables comprised individuals' satisfaction, dorsal nasal irregularities, and contour definitions. Moreover, further variables were considered, including age, gender, the reason behind surgery, surgical type, and graft size and site. A rhinoplasty doctor, other than a surgeon, has assessed the dorsal augmentation findings by inspecting and palpating the dorsum. Data analyses were achieved through SPSS., Results: A total of 69 patients were enrolled in this study; 44.9% of them underwent rhinoplasty with the temporalis fascia in cartilage wrapped by the temporalis fascia form, 43.5% in a blanket form, and 11.6% in a ball form. The average subject satisfaction outcome score was 10.44 preoperatively and 19.72 postoperatively ( P = 0.001).No dorsal irregularities were detected by inspection in all forms of the temporalis fascia, whereas 3 patients with the blanket and 2 patients with the cartilage wrapped by the temporalis fascia had irregularities, which were detected on palpation., Conclusions: In rhinoplasty, the temporalis fascia is a favorable choice for nasal reconstruction since it is simple in harvesting and can be made in different forms and shapes for many purposes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Objective: We sought to perform a systematic, comprehensive, and nationwide cross-sectional analysis of surgical capacity in Lebanon., Background: Providing surgical care in refugee areas is increasingly recognized as a global health priority. The surgical capacity of Lebanon where at least 1 in 6 inhabitants is currently a refugee remains unknown., Methods: The Surgical Capacity in Areas with Refugees cross-sectional study included 3 steps: (1) geographically mapping all hospitals providing surgical care in Lebanon, (2) systematically assessing each hospital's surgical capacity, and (3) identifying surgical care gaps/disparities. First, a list of hospitals in Lebanon and their locations was generated combining data from the Lebanese Ministry of Health and Syndicate of Hospitals. Specialty, rehabilitation, and maternity facilities were excluded. Second, the validated 5 domain Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) tool was administered in each hospital through a face-to-face or phone interview. Hospitals' PIPES indices were computed; data were aggregated and analyzed for geographic and private/public disparities., Results: A total of 129 hospitals were geographically mapped; 20% were public. The PIPES tool was administered in all hospitals (100%). The mean PIPES index was 10.98 (Personnel = 14.91, Infrastructure = 15.36, Procedures = 37.47, Equipment = 21.63, Supplies = 24.78). The number of hospital beds, operating rooms, surgeons, and anesthesiologists per 100,000 people were 217, 8, 16, and 9, respectively. Deficiencies in infrastructure were significant, whereby 62%, 36%, 16%, and 5% of hospitals lack incinerators, pretested blood, intensive care units, and computed tomography, respectively. Continuous external electricity was lacking in 16 hospitals (12%). Compared to private hospitals, public hospitals had a lower PIPES index (10.48 vs 11.1, P = 0.022), including lower Personnel and Infrastructure scores (12.31 vs 15.57, P = 0.03; 14.04 vs 15.7, P = 0.003, respectively). Geographically, the administrative governorates with highest refugee concentrations had the lowest PIPES indices., Conclusions: Evaluating surgical capacity in Lebanon reveals significant deficiencies, most pronounced in public hospitals in which refugee care is provided and in areas with the highest refugee concentration.

Background: Surgery for severe mitral regurgitation is indicated if symptoms or left ventricular dilation or dysfunction occur. However, prognosis is already reduced by this stage, and earlier surgery on asymptomatic patients has been advocated if valve repair is likely, but identifying suitable patients for early surgery is difficult. Quantifying the regurgitation may help, but evidence for its link with outcome is limited. Cardiovascular magnetic resonance (CMR) can accurately quantify mitral regurgitation, and we examined whether this was associated with the future need for surgery., Methods and Results: One hundred nine asymptomatic patients with echocardiographic moderate or severe mitral regurgitation had baseline CMR scans and were followed up for up to 8 years (mean, 2.5±1.9 years). CMR quantification accurately identified patients who progressed to symptoms or other indications for surgery: 91% of subjects with regurgitant volume ≤55 mL survived to 5 years without surgery compared with only 21% with regurgitant volume >55 mL (P<0.0001). A similar separation was observed for regurgitant fraction ≤40% and >40%. CMR-derived end-diastolic volume index showed a weaker association with outcome (proportions surviving without surgery at 5 years, 90% for left ventricular end-diastolic volume index <100 mL/m(2) versus 48% for ≥100 mL/m(2)) and added little to the discriminatory power of regurgitant fraction/volume alone., Conclusions: CMR quantification of mitral regurgitation was associated with the development of symptoms or other indications for surgery and showed better discriminatory ability than the reference-standard CMR-derived ventricular volumes. CMR may be able to identify appropriate patients for early surgery, with the potential to change clinical practice, although the clinical benefits of early surgery require confirmation in a clinical trial., (© 2016 American Heart Association, Inc.)

Objective: We aimed to compare blood pressure (BP) levels recorded using the semiautomatic oscillometric Omron i-C10 BP device in patients with or without hypertension in three different settings: (a) when used by a doctor or a nurse at the office (OBP); (b) when used for self-measurement by the patient at the office (SMOBP); and (c) when used for 7 consecutive days at home (HBP)., Materials and Methods: A total of 247 individuals were invited to participate, but 78 of these individuals declined and a further seven were excluded, leaving a final cohort of 162 participants., Results: The mean OBP was higher than HBP (difference 8.1±14/3.1±8.8 mmHg, P<0.0001) and so was SMOBP compared with HBP (difference 7.0±13/4.2±7.3 mmHg, P<0.0001). Sixteen participants (9.9%) had at least 10 mmHg higher systolic SMOBP than OBP and 28 (17%) participants had at least 10 mmHg lower systolic SMOBP than OBP. Participants who were current smokers had a larger mean difference between systolic OBP and SMOBP than nonsmokers (OBP-SMOBP in smokers: 6.6±9.4 mmHg, OBP-SMOBP in nonsmokers: 0.5±9.2 mmHg, P=0.011 between groups)., Conclusion: Self-measurement of BP in the office does not preclude an increase in BP when levels in the individual patients are compared with HBP using the same equipment. Thus, SMOBP with a semiautomatic device does not lead to a reduction in the white-coat effect in the same manner as fully automatic devices.

Functional disorders are one of the most common diagnoses in neurologic practice, but this is not reflected in current classification systems. The 11th revision of the World Health Organization's International Classification of Diseases (ICD-11) in 2017 offers an opportunity for these disorders to appear within both neurologic and psychiatric categories for the first time. We discuss the rationale for this proposal and highlight the potential benefits for health professionals and patients., (© 2014 American Academy of Neurology.)

Microglandular hyperplasia (MGH) is a benign proliferation of endocervical glands with relatively uniform columnar or cuboidal nuclei, and rare to absent mitoses. Endometrial adenocarcinomas with mucinous differentiation or a microglandular pattern can closely mimic MGH, often resulting in a diagnostic dilemma in small biopsy specimens. Rare unusual morphologic features-mild to moderate nuclear atypia, solid or reticular growth pattern, hobnail and signet ring cells-have been previously reported in MGH. We present 9 cases of unusual, mitotically active-between 5 and 11 mitotic figures per 10 HPF-MGH, all of which presented as endocervical polyps and had morphologic features otherwise typical of MGH. The patients' age ranged between 35 and 56 yr, 2 patients were postmenopausal. High-risk human papillomavirus status was available in 7 patients, all of which were negative. The Ki-67 proliferation index ranged between 1% and 15%, and all cases were negative for p16, carcinoembryonic antigen, and vimentin immunostains. The clinical follow-up ranged from 3 to 76.2 mo, with a median of 40.7 mo, all patients were doing well without evidence of endocervical or endometrial malignancy. In summary, this case series documents the presence of rare cases of MGH demonstrating significant mitotic activity (up to 11/10 HPF) without a negative impact on the clinical prognosis. Mitotic activity alone should be interpreted with caution in small biopsy specimens with microglandular growth pattern. Immunohistochemical stains, especially p16, carcinoembryonic antigen, and vimentin, may be helpful-in addition to the patient's clinical history and human papillomavirus status to rule out endocervical or endometrial malignancy.

When the WHO's Topic Advisory Group for Neurology (TAG) started work on revision of the ICD-10 diagnostic codes in June 2009, the issues were daunting. The existing classification was produced a generation ago and the need to move to the digital age was becoming imperative. Appreciating modern advances in genetics and immunology, and the consequent changes in understanding of the pathophysiology of disorders of the nervous system, WHO's charge to the TAG was to produce a comprehensive, up-to-date disease classification, while providing published or consensus evidence for each coding change. In addition, the task would be to focus on ways to reduce the treatment gap while considering the utility of ICD-11 when used in primary care and nonspecialist settings. The project mushroomed over the 3 years since our first meeting and continues to do so. The work was made even more difficult as the group needed to add "content models" for the major codes for the first time (i.e., providing a definition for each disorder, along with appropriate diagnostic tests and outcome). The ICD-11 is meant to be updated as new knowledge develops, rather than waiting some years for another whole-scale revision, but this process has yet to be defined.

The combination of cyclophosphamide and topotecan (cyclo/topo) has shown objective responses in relapsed Ewing sarcoma, but the response duration is not well documented. We reviewed characteristics and outcome of 14 patients with Ewing sarcoma, treated uniformly at a single institution and offered cyclo/topo at first relapse. Six patients (43%) had relapse at distant sites. All patients received first-line salvage therapy with cyclophosphamide 250 mg/m and topotecan 0.75 mg/m, daily for 5 days repeated every 21 days. The median number of cycles was 4 (range 1 to 10). All toxicities were manageable, the most common being transient cytopenias. There were also 4 episodes of febrile neutropenia, and 3 episodes of gross hematuria. Response was assessable in 13 patients and showed progressive disease in 6 (46%), stable disease in 4 (31%), and partial response in 3 (23%). Nine patients had local control, consisting of radical surgery in 2, radiation in 3, and a combination in 4 patients. Response, when it occurred, was maintained for a median of 8 months (range, 4 to 28 mo). Four patients (29%) are alive at 3, 7, 9, and 110 months after relapse; 1 is receiving cyclo/topo, 1 is on third-line therapy, and 2 are in second and fourth remission. The low toxicity of this combination, and the lack of sustained responses, warrant its investigation in combination with targeted or novel therapeutic agents in relapsed disease.

Background: Current indications for surgery in patients with significant aortic regurgitation (AR) focus on symptoms and left ventricular dilation/dysfunction. However, prognosis is already reduced by this stage, and earlier identification of patients for surgery could be beneficial. Quantifying the regurgitation may help, but there are limited data on its link with outcome. Cardiovascular magnetic resonance (CMR) can accurately quantify AR, and we examined whether this was associated with the future need for surgery., Methods and Results: One hundred thirteen patients with echocardiographic moderate or severe AR were monitored for up to 9 years (mean 2.6 ± 2.1 years) following a CMR scan, and the progression to symptoms or other indications for surgery was monitored. AR quantification identified outcome with high accuracy: 85% of the 39 subjects with regurgitant fraction >33% progressed to surgery (mostly within 3 years) in comparison with 8% of 74 subjects with regurgitant fraction ≤ 33% (P<0.0001); the area under the curve on receiver operating characteristic analysis was 0.93 (P<0.0001). This ability remained strong on time-dependent Kaplan-Meier survival curves. CMR-derived left ventricular end-diastolic volume >246 mL had good, although lower, discriminatory ability (area under the curve 0.88), but the combination of this measure with regurgitant fraction provided the best discriminatory power., Conclusions: High degrees of CMR-quantified AR were associated with the development of symptoms or other indications for surgery. Quantifying AR showed slightly better discriminatory ability than "gold standard" CMR ventricular volume assessment. This could provide a new paradigm for the timing of surgical intervention but requires confirmation in a clinical trial.