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Since its first introduction by Martin and colleagues (1993) and with further revisions by Sterne et al (1996), the submental artery flap (SMAF) has proven to be an effective, reliable, safe, and valuable option in head, neck, and facial reconstructive surgeries. The SMAF utilizes a long pedicle based on the submental artery, a branch of the facial artery, which provides good reach to the lower two-thirds of the face with excellent cosmetic outcomes. It also maintains a good skin color match for facial and cervical defects with a mostly hidden donor site scar (in the majority of cases the donor site can be primarily closed after raising the flap). Although the use of the SMAF is associated with high patient and surgeon satisfaction along with low rates of complications, disadvantages including flap thickness and the hair-bearing nature of the submental skin, which may be problematic for coverage of orofacial defects, especially in male patients. Although it has been almost 30 years since its introduction, and the SMAF has been successfully used in over 500 reported cases of pediatric and adult patients, a comprehensive review of the different aspects of the SMAF is lacking in the medical literature.

The temporoparietal fascial flap (TPFF) is a versatile tool that can be used in the reconstruction of head and neck and distal upper and lower extremity defects. The TPFF may be harvested as a pedicle or free flap as well as with the temporalis muscle and/or adjacent calvarial bone as a composite flap. As a free flap, the TPFF has been used as a joint gliding surface with coverage of nerves and tendons, for extremity soft tissue repair, for tracheal and pharyngeal coverage and for defects of the nose, scalp, and auricle. This article focuses on the use of the free TPFF in the pediatric population through systemic review of the medical literature. Current perspectives on the use of this flap and microsurgery in general in pediatric patients are addressed.

Mesenchymal stromal cells (MSCs) have demonstrated extensive capacity to modulate a catabolic microenvironment toward tissue repair. The fate, biodistribution, and dwell time of the in vivo delivered MSCs largely depend on the choice of the cell delivery route. Intramuscular (IM) delivery of MSCs is clinically safe and has been used for the effective treatment of local pathologies. Recent findings have shown that the secretome of the IM-delivered MSCs enters the circulation and provides systemic effects on distant organs. In addition, muscle tissue provides a safe residence for the delivered MSCs and an extended secretorily active dwell time compared with other delivery routes. There are, however, controversies concerning the fate of MSCs post IM-delivery and, specifically, into an injured site with proinflammatory cues. This review seeks to provide a brief overview of the fate and efficacy of IM-delivered MSCs and to identify the gaps that require further assessment for adoption of this promising route in the treatment of systemic disease. Stem Cells Translational Medicine 2019;8:456–465

With multiple COVID-19 vaccine candidates in development and the United States Food and Drug Administration (FDA) approval of three vaccines, widespread availability may only be months away. As vac...

Tweetable abstract As vaginoplasties become increasingly prevalent, it is imperative to develop efficient techniques to achieve adequate postoperative pain control. Currently available pain management methods following vaginoplasties are briefly discussed.

“Drastic times call for drastic measures”—Hippocrates. The COVID-19 pandemic has had vast and lasting impacts on virtually every aspect of life. Without question, the sports world today looks very different than it looked a year ago. Professional sports leagues adapted to the pandemic by implementing bubbles and strict testing protocols (Dove et al., 2020), but college sports have been slower to adapt. All spring college athletes lost a full season of competition when National Collegiate Athletic Association (NCAA) leagues canceled sporting events in March 2020 and the same thing happened for some fall and winter athletes. With many gyms and other training facilities closed due to the regional lockdown regulations due to the pandemic around the country, it is difficult for college athletes to train on their own and be physically prepared for a collegiate season. More importantly, being separated from teammates has long term impacts on team culture and both mental and physical health. The question remains: how do college athletes stay connected with teammates and prepare for competitions despite being spread out across the country or even the world?

BACKGROUND: The lymph node ratio (LNR) is an additional informative factor complementing anatomic TNM staging in breast cancer patients. The aim of this study was to evaluate the role of LNR in the cancer-specific and overall survival (OS) in a cohort of pT1/2 breast cancer patients and examine its correlation with circulating sex hormone concentrations in postmenopausal cases of the cohort from eastern China islands. METHODS: Clinical and pathological characteristics, preoperational sex hormone and tumor markers concentrations, and breast cancer-specific survival (BCSS) and OS were analyzed retrospectively in 732 pathological T1/2 breast cancer patients. RESULTS: The LNR was calculated, and the cut-off value was defined as 0.042 by receiver operative characteristic (ROC) curve according to the patient’s mortalities. Patients with LNR ≥0.042 exhibited worse BCSS and OS than others (P

Metoidioplasty consists of lengthening and straightening the hormonally hypertrophied clitoris. The goals of the procedure include masculinizing the external genitalia and enabling standing micturition. Metoidioplasty may be performed as a stand-alone procedure or an interval procedure prior to phalloplasty. While most often performed with urethral lengthening, metoidioplasty may also be performed as a “simple release” (i.e., without urethral lengthening). Secondary procedures typically include scrotoplasty and placement of testicular implants. While satisfaction with this procedure is high, complications can occur. Complications are commonly categorized as either urologic (i.e., strictures and fistula) or wound healing (i.e., wound disruption, infection, bleeding, etc.). This narrative review discusses postoperative outcomes, including both satisfaction and complications. Published data on complications include fistula and stricture rates from 0%-50% and 0%-63%, respectively. Overall satisfaction with appearance ranges from 48%-100%, and patient ability to void while standing ranges from 67%-100%. Metoidioplasty is a safe and effective procedure for transgender men. Further research regarding surgical techniques and outcomes will help reduce complications and improve overall patient satisfaction.

Background: Arterial cannulation and intra-arterial (IA) fluid and blood resuscitation in the patients with severe shock is an easier approach compared with the intravenous (IV) access if concerns regarding the efficiency and safety of this approach are addressed. Objectives: We hypothesized that IA fluid resuscitation is more effective than IV resuscitation in restoring cardiac contractions (CC) of cardiac-arrested mice following severe hemorrhagic shock. Methods: Mice (N = 22) were anesthetized using ketamine/xylazine. Arterial and venous systems accessed through cannulation of the carotid artery and the Jugular vein, respectively. As much blood as possible was aspirated from the carotid artery access. Mice were observed until the complete cessation of chest wall motions. Following 30 seconds delay, IV (N = 5) and IA access (N = 6) were used for fluid resuscitation using Ringer Lactate (RL) in a similar volume to the aspirated blood. Mice were observed for restoration of chest wall motions. In phase-IIof the study, after cessation of chest motions, mice (N = 11) underwent a thoracotomy and CCs were observed. In three mice, IV RL Infusion after cardiac arrest failed to restore CCs and was followed by IA RL infusion. In eight mice, following cardiac arrest intermittent IA RL infusion was performed. Results: While IV RL Infusion failed to restore chestmotion inmice (N = 5), IA RL infusion restored chestmotion in allmice examined (N = 6) (P = 0.0067). In three mice, IV RL infusion after cardiac arrest showed no effect on CC. After failure of venous infusion, IA RL infusion was performed which resulted in restoration of CC for 13.33 ± 1.76 minutes. In eight mice, intermittent IA infusion of RL after cardiac arrest, sustained CC for 31.43 ± 10.9 minutes (P = 0.017). Conclusions: IA fluid resuscitation is superior to IV resuscitation in hemorrhagic shock induced cardiac arrest.

Introduction: Diaphragmatic rupture (DR) is an uncommon, potentially serious complication following blunt or penetrating ab- dominal trauma. Even with a high index of suspicion, the diagnosis of DR can easily be missed for a long period post injury. Delayed or missed diagnosis (delayed diagnosis of diaphragmatic rupture (DDDR)) and delayed diaphragmatic rupture (DDR) are possible explanations in cases where the initial operative exploration fails to show the diaphragmatic damage. Case Presentation: Here we present a patient with suspected DR that was not seen on initial open abdominal exploration, but was suggested by subsequent serial imaging. This injury was ultimately identified on laparoscopic exploration. The procedure was converted to open (celiotomy) due to poor tolerance of the pneumoperitoneum required for laparoscopy, and the laceration was primarily repaired. We propose that DDR and DDDR be considered as a dierential diagnosis in patients with a previous thoraco- abdominal trauma when presenting with radiologic/clinical signs suspicious for DR, even when the immediate post traumatic ex- ploration failed to demonstrate a DR. Conclusions: A high index of suspicion is essential for early detection of DDR and DDDR. Patients with high impact injuries or surrounding organ damage should be followed with serial clinical examinations, follow-up radiologic assessments, and even re- exploration in situations highly suspicious for diaphragmatic injuries.

Introduction: Delayed splenic rupture (DSR) is an unusual outcome following blunt abdominal trauma. Although DSR is defined as bleeding more than 48 hours after blunt trauma in a previously hemodynamically stable patient, a review of the reported cases in the literature shows that in almost all of the cases the initial CT imaging revealed some form of damage to the spleen. Case Presentation: Here we describe an extremely rare condition in a case that presented with a DSR following blunt trauma and had a normal appearing spleen in the initial post trauma MDCT scan. Conclusions: DSR is a serious consequence of trauma and is associated with a significantly higher mortality rate compared with the overall mortality for acute splenic injuries. A High index of suspicion along with the liberal serial utilization of the imaging studies are the essential elements for early detection of DSR.We propose that DSR be considered as a differential diagnosis in patients presenting with hemodynamic instability late post trauma, even when the immediate post trauma MDCT scan has shown a normal appearing spleen. We suggest that every patient with a high impact injury or injuries to peri-splenic organs should have a repeat MDCT scan 2 - 3 days post trauma or before the patients is discharged from hospital.

Introduction: Lung herniation following blunt chest trauma is extremely rare and only a few hundred cases of this pathology have been reported in the English language medical literature. This type of lung hernia is divided into intercostal, parasternal, or supraclavicular subtypes based on the exact location of the chest wall defect. Traumatic intercostal lung hernia is even more uncommon. Delayed presentation of a traumatic lung hernia has been reported in two cases in the medical literature where cases had a delayed presentation of 2-29 days. Case Presentation: We present a case of 72-year-old white male who had a delayed presentation of an intercostal post traumatic lung hernia (PTLH) 50 years after severe blunt chest trauma. Conclusions: This is a rare case of a delayed presentation of a traumatic intercostal lung hernia. Based on our literature search, this case seems to be the first reported case with such a long delay prior to presentation. We suggest that in patients with even a remote history of blunt chest trauma, a physical examination and preoperative evaluation including assessment for possible PTLH be considered before patients undergo positive pressure ventilation. We also suggest that PTLD be considered in the differential diagnosis for patients with blunt traumatic chest injuries and rib fractures.

Objective The mechanisms of contrast-induced nephropathy are not fully understood and sensitive biomarkers of contrast-induced nephropathy are yet to be found. We investigated whether urinary fibrinogen could be a potential biomarker for contrast-induced nephropathy. Methods To create a contrast-induced nephropathy model, mice received a prostaglandin synthesis inhibitor (indomethacin) and a nitric oxide synthase inhibitor (Nω-Nitro-L-arginine methyl ester) intraperitoneally followed by a different dose of iodixanol. In the control group, normal saline was administered. Urinary fibrinogen and serum creatinine were analyzed using enzyme-linked immunosorbent assay. Kidneys were used to quantify fibrinogen using qRT-PCR and Western blot and for histopathological examination. Results Histopathological examination demonstrated mild renal injury in the low-dose group, and moderate renal injury in the high-dose group. Urinary fibrinogen levels were significantly increased in an iodixanol dose-dependent manner (control vs. low-dose group, P Conclusions We propose that urinary fibrinogen could be used as a potential biomarker for early contrast-induced nephropathy diagnosis.

Objectives: Extracranial carotid artery true aneurysm is extremely uncommon, and definite treatment has traditionally involved open surgical repair. Although successful management of the internal carotid artery aneurysms using endovascular stenting and embolization has recently been reported, only a limited number of cases have been reported. Methods: We present a case of symptomatic carotid true aneurysm repaired with covered stent and coil embolization of the external carotid artery. We also review the English literature and discuss the epidemiology, causes, diagnosis, and management options of internal carotid artery aneurysms. Results: The patient did not have any complications, and was discharged home on the postoperative day 1 in stable condition. Conclusion: Our report suggests that endovascular procedure is feasible in the treatment of extracranial carotid artery aneurysms.

Sexual dysfunction in chronic renal failure patients undergoing hemodialysis is common. It is demonstrated that the zinc level is significantly lower in the hemodialysis patients.In this clinical trial, we investigate the effect of zinc supplement therapy on the serum levels of sexual hormones in hemodialysis male patients.We carried out a clinical trial study including 100 of our male patients with end-stage renal disease on hemodialysis. Testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and zinc plasma level were measured in all of the patients. The patients received zinc supplement (zinc sulfate, 250 mg/day) for 6 weeks, and sex hormones and zinc plasma level were checked again.Serum level of FSH and prolactin did not have any significant changes before and after intervention, but serum level of testosterone, LH, and zinc increased significantly.These results suggest that although zinc administration did not have a definite effect on hemodialysis patients with sexual dysfunction, it can cause increase in the serum level of sex hormones which may improve the sexual function of the patients in some aspects.

The decision to stop or continue resuscitation in a patient with blunt trauma and cardiac arrest arriving pulseless to the hospital has always been controversial. While many authors still believe that it is a futile effort, with no chance of success for complete neurological recovery, some recent reports have challenged the idea. Here we report complete recovery of a severely injured patient following a motor vehicle accident who lost vital signs completely before arrival at our trauma center. No cardiac motion was detected on ultrasound examination on arrival. Emergency department thoracotomy, open cardiac massage, massive blood transfusion, damage control laparotomy with abdominal and pelvic packing, followed by angio-embolization of pelvic bleeding, and staged abdominal exploration were performed. This case is an example showing that resuscitation of patients with blunt trauma and cardiac arrest arriving pulseless to the hospital is not always futile.

Turner's syndrome (TS) has been documented as the most common cause of aortic dissection in young women. However, little attention from vascular surgery has been paid to these patients. We report the first case of ruptured type B aortic dissection with aberrant right subclavian artery treated successfully with hybrid endovascular and open procedures in a patient with TS. Left carotid to subclavian artery bypass, thoracic endovascular aortic repair, and coil embolization of the aberrant right subclavian and left subclavian arteries were performed in an emergency setting. Literature on epidemiology, causes, and management options of acute aortic dissection in TS patients are reviewed and discussed.

Introduction Multiple sclerosis (MS) is the most common chronic autoimmune demyelinating disease of the central nervous system. The purpose of this study is to determine the relationship between the site of the cervical discopathy and cervical spinal cord plaque in MS patients. Methods This retrospective study included all patients with a definite diagnosis of MS who were treated at an outpatient clinic between September 2004 and September 2011. All patients underwent cervical magnetic resonance imaging (MRI) for primary investigation of the disease. Cervical MRI scans were evaluated for detection of any evidence of cervical discopathy and cervical MS plaques. Any correlation between the site of the MS lesions and discopathy was recorded. Results From 536 patients who were involved in the study, 214 patients had both cervical discopathy and cervical cord plaques. In this group 148 (69.1% of patients) had cervical plaque at the same site of cervical discopathy. The number of patients with cervical cord plaque and discopathy at same site was significantly higher than those with plaque and discopathy at different sites (P Conclusion The study data suggests a possible correlation between cervical discopathy and cervical MS plaque.

Zinc deficiency is known to occur in widely diverse areas of world. It has now been recognized in many disease states, such as ESRD patients on maintenance hemodialysis (HD). The purpose of this research was to study the effects of zinc supplementation on the concentration of serum zinc, total cholesterol, triglyceride, and cholesterol fractions (HDL, LDL) in HD patients.In a double blind trial, the effects of oral zinc supplementation on the serum concentration of zinc, total cholesterol, HDL and LDL cholesterol, and triglyceride in HD patients were evaluated.After 42 days, the mean serum zinc concentration among participants in the zinc-supplemented group increased. There was a significant elevation in the serum total cholesterol and also in mean the serum LDL and HDL cholesterol and serum triglyceride for the subjects in the zinc-supplemented group.A suboptimal level of the serum total cholesterol concentration is a factor associated with malnutrition and morbidity in the HD patients. Maintenance HD patients with both low serum zinc and low serum total cholesterol concentrations may benefit from zinc supplementation. Therefore, it is advisable to obtain baseline measurement of the serum zinc and total cholesterol concentrations in maintenance HD patients.

INTRODUCTION Sentinel lymph node biopsy is emerging as the new standard for axillary staging in breast cancer. Intra-operative assessment of the sentinel lymph nodes allows immediate completion of axillary dissection during the same anaesthetic. This project was a quality assurance practice to establish feasibility, time-to-report, as well as accuracy of performing intra-operative assessment of sentinel lymph nodes using touch imprint cytology in our centre. PATIENTS AND METHODS This prospective audit included 146 sentinel lymph nodes from 74 consecutive patients with invasive breast cancer. All patients underwent axillary sentinel lymph node biopsy using combined blue dye and radiocolloid technique. Results of intra-operative touch imprint cytology using haematoxylin and eosin staining were compared with the definitive histopathology results. RESULTS Mean time to report touch imprint cytology was 25.7 ± 6.4 min (range, 15–40 min). Histopathology demonstrated metastasis in 25 sentinel nodes from 17 (23%) patients. Intra-operative touch imprint cytology detected 15 nodes in 11 patients, giving a sensitivity of 60% (nodes) and 66.7% (patients) and specificity of 99.2% (nodes) and 98.2% (patients) based on the number of nodes and patients involved, respectively. Touch imprint cytology failed to show metastatic involvement in 10 nodes from 6 patients; of these, five nodes had micrometastasis (< 2 mm) and the other five had macrometastasis. One touch imprint cytology positive node contained isolated tumour cells only. Using intra-operative touch imprint cytology made a change in treatment of 11(14.9%) patients, and spared second axillary procedure in 7 (9.4%) patients. CONCLUSIONS Intra-operative sentinel lymph node assessment using touch imprint cytology is feasible within a busy NHS practice. We now offer touch imprint cytology to patients following appropriate counselling.

Perimesencephalic nonaneurysmal haemorrhage (PMNH), a term first coined in 1985, is a diagnosis of exclusion. It is considered a benign form of subarachnoid haemorrhage with a good prognosis and a low risk of rebleeding. Its precise aetiology has not yet been determined. Haemorrhage of venous origin has been proposed as a cause, and has been demonstrated to be associated with venous abnormalities of the basal vein of Rosenthal. We present a patient with PMNH in whom an 80% stenosis at the union of the vein of Galen with the straight sinus is demonstrated. We thus propose hypertensive venous rupture secondary to venous sinus stenosis as an alternative cause for PMNH.

Acquired coarctation of the thoracic aorta is a rare phenomenon in adults. The etiology is often idiopathic, but severe stenosis can develop from prior surgery, blunt thoracic aortic injuries, or severe atherosclerotic/atheroembolic disease. Common symptomatic presentations include refractory upper extremity hypertension and new-onset congestive heart failure. We present the case of a 52-year-old man who developed acquired thoracic aortic coarctation 30 years after a blunt trauma and deceleration injuries to the aorta requiring open surgical aortic repair. He presented with poorly controlled hypertension and new-onset heart failure and was treated surgically with endovascular repair.

We read with interest the report by Lalwani et al. from New Delhi, India reporting 8 cases of delayed/late presentation of small bowel (SB) stricture following blunt abdominal trauma (BAT). Eight cases being reported from a single centre is an indication that this pathological phenomenon is more common than it has previously been described. Lalwani et al. have not mentioned the exact number of cases of BAT that were reviewed between 1996 and 2008 at their centre, which if known would help in estimating the incidence of delayed mesenteric stricture following BAT. We report here a case of a young man who had a delayed presentation of SB obstruction secondary to a stricture 16 days following a motorcycle crash. In our case, the initial computed tomography (CT) scan showed that the patient had a mesenteric haematoma, which was managed conservatively. The repeat enhanced-CT scan 16 days posttrauma—when the patient presented with vomiting and increased abdominal pain—showed a stenotic loop of distal ileum adjacent to an expanded mesenteric mass. Pathological evaluation following exploratory laparotomy and resection of the loop revealed a loop of stenotic SB with oedematous mesentery, mucosal atrophy, ulcerations and serosal fibrous adhesions which indicate ischaemic changes. We have found and referenced 12 other reports (mainly case reports) of delayed SB obstruction after BAT from the medical literature. Since then we have also reported a different case of a young man who had a delayed presentation (5 weeks) of SB perforation following a BAT (motorcycle accident). It is of note to mention that this patient was also found to have a mesenteric haematoma on initial abdominal CT scan which was managed conservatively. An exploratory laparotomy at the time of delayed presentation (peritonitis) 5 weeks after the initial trauma showed a perforated thickened loop of the ileum forming a phlegmon in the lower abdomen. In the English medical literature, we found only 8 other reports of delayed post-traumatic presentation of ileal/jejunal perforation following BAT. The fact that there are very few reported cases in the literature for both the complications (SB stricture and/or perforation following BAT), is an evidence that these pathologies are not well represented and reported in the literature. A shared feature in the majority of the reported cases in the literature is the presence of minor tears and contusions of the mesentery, and/or mesenteric haematoma. Direct mechanical intestinal injury is unlikely to be the cause in situations where delayed presentation of SB stricture or perforation lags a few weeks or even months post-trauma. It is also unrealistic that an initial post-traumatic SB perforation goes undiagnosed for such a long period of time. In the above-mentioned case series of 8 patients with delayed post-traumatic SB stricture reported by Lalwani et al., the authors have reported a history of mesenteric tear repair in one of the patients, diagnostic laparoscopy in the second patient, and laparotomy with lysis of adhesion in the third patient (highly likely to cause mesenteric tears). There was also a reported case (fourth patient) with a thrombus involving the portal vein, extending into the superior mesenteric vein which could affect the blood circulation in the SB mesentery. Although the immediate post-traumatic abdominal CT scans of the patients have not been reported by the authors, it would be interesting to know whether there has been any evidence to suggest the presence of mesenteric injuries or SB wall haematoma both of which could affect the blood circulation of a part of the bowel in the other four cases.

Thyroid hormones are totally involved in the regulation of body weight, lipid metabolism, and insulin resistance. Therefore it is anticipated that thyroid hormones may have a role in the pathogenesis of non alcoholic fatty liver disease (NAFLD) and non alcoholic steatohepatitis (NASH). In this study, we reviewed the current literature on the association between thyroid dysfunction and NAFLD/NASH. A search for English language medical literature reporting an association between thyroid dysfunction and NAFLD/NASH in humans was conducted across PubMed, ISI Web of Science, and Scopus in August, 2013. Out of 140 studies initially identified through the search, 11 relevant articles were included in the final review. Thyroid dysfunctions in the form of overt or subclinical hypothyroidism are prevalent among patients with NAFLD/NASH. Hypothyroidism appears to be an independent risk factor for NAFLD/NASH in some studies; however, other newly published studies failed to find such an association. The results of the studies on the role of thyroid abnormalities in NAFLD/NASH are inconsistent, and further research is recommended to determine the relationship between hypothyroidism and NAFLD/NASH and the underlying mechanisms.

In donors known to have medical conditions associated with kidney damage, caution is exercised when accepting donor kidneys. Myelofibrosis can affect kidney function in a variety of ways, but is not generally considered a contraindication to donation. We present the case of a 27-year-old woman with known myelofibrosis who died from an upper gastrointestinal bleed. After cardiac death, both the kidneys were donated. The first recipient was a 34-year-old lady with focal segmental glomerular sclerosis in her single pelvic kidney. There was delayed graft function and the kidney continued to function poorly due to a significant donor vascular disease. The second recipient was a 27-year-old man with posterior urethral valves. Similar donor vascular disease caused this transplant to fail. The kidney damage did not fit any pattern reported in myelofibrosis, but may represent part of a spectrum of damage seen with this disease. This case highlights the need for caution when accepting kidneys from donors with chronic medical conditions even when young, and may be of use to transplant teams when considering accepting future donations from patients with myelofibrosis.

Traumatic inferior vena cava (IVC) injuries are associated with high mortality rates, despite all improvements in the technical skills and prehospital and hospital care. Selective conservative management of the penetrating abdominal injuries involving IVC has not been widely discussed before. Here, we report a case of a young female with a single gunshot wound to her abdomen, who presented to our level 1 trauma center 10 minutes after injury and was hemodynamically stable. A computed tomographic scan revealed a large liver laceration with a trajectory through the liver and the IVC. The IVC was surrounded by a moderate amount of fluid, consistent with a contained retroperitoneal hematoma. We discuss the outcome of nonoperative management of this patient along with a review of the literature.

Patients who undergo breast reduction surgery have a low risk of being found to have breast cancer, but they need to be made aware of it—and doctors need to debate whether routine histological examination of tissue specimens is a good idea. We sought the views of Tom Treasure, a surgeon (doi:10.1136/bmj.b759), Jeremy Sugarman, an ethicist (doi:10.1136/bmj.b753), and Tessa Boase, a lay person (10.1136/bmj.b776)