Endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative drainage technique for patients with malignant biliary obstruction. However, few reports have discussed the occurrence of late-onset rupture of hepatic artery pseudoaneurysms following EUS-HGS. A recently available drill dilator equipped with a long screw segment was used in the dilation step of EUS-HGS. We highlight the potential concern that this long screw segment may increase the risk of damage to the hepatic artery, leading to late-onset life-threatening rupture of a pseudoaneurysm.

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BACKGROUND: The male genital structures of arthropods are key features in the taxonomic and phylogenetic study of these organisms. The male genitalia of the head louse Pediculus humanus capitis are complex organs which are partly composed of structures that dynamically extrude during copulation.
METHODS: Here, we describe the morphology of the genitalia of P. humanus capitis at the copulation stage, and at rest, by using stereoscopic microscopy, confocal laser scanning microscopy (CLSM), and scanning electron microscopy (SEM).
RESULTS: CLSM and SEM images revealed that the vesica is composed of two distinct anatomical parts, the proximal lobe and the distal lobe. Both lobes have short and narrow spines, as well as long and wide scales with either sharp or rounded tips. The rounded scales vary in size and have a wavy base and rounded tips, and thus resemble a tongue in appearance. We identified a gland-like area on the penis with 11 shallow circular depressions, and a flat area with 14-16 exit orifices. The apical end of the penis has a foliaceous trifurcation and serves to expel the contents of the ejaculatory duct. These characteristics were recorded for all the specimens analyzed, indicating that these structures are highly conserved; to our knowledge, they have not been previously reported for any suborder of lice.
CONCLUSIONS: To the best of our knowledge, our results reveal for the first time the morphological details, and complexity, of the male genitalia of the head louse P. humanus capitis at different stages of copulation. The new approach described here provided information that should be taken into consideration in future research on the genitalia of lice. Application of this approach will also impact the taxonomic and phylogenetic study of other insect taxa.

Tracheostomy remains a topical surgical procedure. The history of tracheostomy is marked by the development of various instruments, including the three-bladed tracheostomy dilator from the middle of the 19th century. The purpose of this historical note is to recall the use of this unusual instrument.

OBJECTIVE: For the past four decades, routine daily postoperative anal dilation by parents has been the standard treatment following a primary posterior sagittal anorectoplasty (PSARP). However, the clinical benefit of this practice has never been formally investigated. It is known that dilations can have a significant negative psychological impact on patients and families, and therefore, we aimed to study if routine dilations after a PSARP are necessary.
METHODS: A prospective, single institution randomized controlled clinical trial was conducted on patients with anorectal malformations (ARM) at our institution between 2017 and 2019. Patients were randomized to either a dilation or non-dilation group following their PSARP. Inclusion criteria included age less than 24 months and all patients undergoing primary repair of their ARM (except for cloaca). Patient characteristics, type of ARM, presence of colostomy, postoperative stricture, need for a skin level revision (Heineke-Mikulicz anoplasty (HMA)), and need for redo PSARP were recorded. The primary outcome of the trial was stricture formation. The secondary outcome included strictures requiring interventions. A p-value of less than 0.05 was considered statistically significant. Institutional approval was obtained for this study and informed consents were obtained from all the patients.
RESULTS: 49 patients were included in our study. 5 (21%) in the dilation group and 8 (32%) in the non-dilation group developed strictures (p=0.21). Of these, 3 (13%) patients in the dilation group required HMA, and 4 (16%) patients in the non-dilation group required HMA (p=0.72). 4 patients required a redo operation for strictures: 2 in the dilation arm (these patients despite the plan to do dilations, chose not to do them consistently) and 2 in the non-dilation arm (p=0.59).
CONCLUSIONS: Routine dilations after PSARP do not significantly reduce stricture formation. Based on these results, non-dilation is a viable alternative, and HM anoplasty remains a good back-up plan if a stricture develops.
METHODS: Level I.

BACKGROUND: While two-thirds of women will experience dyspareunia and vaginal dilators are often used to treat dyspareunia, outside of a single case report, no study has investigated the potential of low-dose, high frequency movement-based dilator therapy for dyspareunia in premenopausal female patients.
OBJECTIVE: To determine the utility of low-dose, high frequency movement-based dilator use for dyspareunia in premenopausal female patients.
METHODS: Retrospective study of women presenting to outpatient hospital-based pelvic floor physical therapy office in a tertiary care center. All adult premenopausal female patients who were referred to pelvic floor physical therapy for dyspareunia and completed movement-based dilator therapy (MBDT) and met study criteria (n = 26) were included for analysis.
METHODS: Patient change in pain level status using Numeric Pain Rating Scale with intercourse was compared between initial evaluation and time of discharge from pelvic floor physical therapy.
RESULTS: Among the 26 women who met criteria for this study, the average pain score decreased from 8.3 (SD 2.2) before treatment to 1.3 (SD 2.0) after treatment and was statistically significant (P< .001). Complete resolution of dyspareunia was reported in 58% of patients. Patients completed between 2 and 6 total pelvic floor physical therapy visits (average 3.7, SD1.5), over 0-44 weeks (mean 9.6 weeks, SD 8.3).
CONCLUSIONS: Low-dose, high frequency, movement-based dilator therapy significantly reduced or resolved the experience of pain with penetrative vaginal intercourse with dyspareunia. Future prospective studies with larger samples and the inclusion of sexual functional status should be considered to explore the full potential of this modality in treatment of premenopausal patients with dyspareunia. Miles K, Miles S. Low Dose, High Frequency Movement Based Dilator Treatment for Dyspareunia: Retrospective Analysis of 26 Cases. Sex Med 2021;9:100344.

Nuclear shape alteration in ocular tissues, which can be used as a metric for overall cell deformation, may also lead to changes in gene expression and protein synthesis that could affect the biomechanics of the tissue extracellular matrix. The biomechanics of iris tissue is of particular interest in the study of primary angle-closure glaucoma. As the first step towards understanding the mutual role of the biomechanics and deformation of the iris on the activity of its constituent stromal cells, we conducted an ex-vivo study in freshly excised porcine eyes. Iris deformation was achieved by activating the constituent smooth muscles of the iris. Pupillary responses were initiated by inducing miosis and mydriasis, and the irides were placed in a fixative, bisected, and sliced into thin sections in a nasal and temporal horizontal orientation. The tissue sections were stained with DAPI for nucleus, and z-stacks were acquired using confocal microscopy. Images were analyzed to determine the nuclear aspect ratio (NAR) using both three-dimensional (3D) reconstructions of the nuclear surfaces as well as projections of the same 3D reconstruction into flat two-dimensional (2D) shapes. We observed that regardless of the calculation method (i.e., one that employed 3D surface reconstructions versus one that employed 2D projected images) the NAR increased in both the miosis group and the mydriasis group. Three-dimensional quantifications showed that NAR increased from 2.52 ± 0.96 in control group to 2.80 ± 0.81 and 2.74 ± 0.94 in the mydriasis and miosis groups, respectively. Notwithstanding the relative convenience in calculating the NAR using the 2D projected images, the 3D reconstructions were found to generate more physiologically realistic values and, thus, can be used in the development of future computational models to study primary angle-closure glaucoma. Since the iris undergoes large deformations in response to ambient light, this study suggests that the iris stromal cells are subjected to a biomechanically active micro-environment during their in-vivo physiological function.

There are many predisposing factors associated with vaginismus, but there is lack of data in the literature regarding which and how of these factors influence the success rate of treatment. Our aim is to investigate the effects of factors that are considered as predisposing factors for vaginismus on treatment prognosis and success rate, with cognitive-behavioral therapy and desensitization exercises after sexual therapy.
Patients with vaginismus were divided into three groups. Group 1: patients who successfully completed vaginal penetration exercises after sexual therapy and experienced vaginal sexual intercourse; Group 2: patients who started penetration exercises but could not reach success; Group 3: patients who discontinued treatment before starting exercises. Demographic and sexual parameters were compared between the groups.
There were statistically significant differences between the groups in terms of history of vaginismus in relatives (4.3%, 23% and 35.7%, p=0.047, respectively), the unsuccessful therapy history (69%, 61% and 21.4%, p=0.014, respectively), and anal and/or oral sex ratios (47.8%, 7.7% and 57.1%, p=0.019, respectively). Mean number of sessions were significantly higher in patients saying, \"It is my fault\" than among those perceiving it as a common problem (10.6±2.9 ve 7.5±5.7, p=0.042, respectively), and in patients with sexual disorder in their male partners than those not having any problem (13.3±3.7 ve 8.2±3.7, p=0.013, respectively).
Patients are more resistant to treatment if they have a history of vaginismus among relatives or when one of the couple say, it is his or her fault.

OBJECTIVE: There are many predisposing factors associated with vaginismus, but there is lack of data in the literature regarding which and how of these factors influence the success rate of treatment. Our aim is to investigate the effects of factors that are considered as predisposing factors for vaginismus on treatment prognosis and success rate, with cognitive-behavioral therapy and desensitization exercises after sexual therapy.
METHODS: Patients with vaginismus were divided into three groups. Group 1: patients who successfully completed vaginal penetration exercises after sexual therapy and experienced vaginal sexual intercourse; Group 2: patients who started penetration exercises but could not reach success; Group 3: patients who discontinued treatment before starting exercises. Demographic and sexual parameters were compared between the groups.
RESULTS: There were statistically significant differences between the groups in terms of history of vaginismus in relatives (4.3%, 23% and 35.7%, p=0.047, respectively), the unsuccessful therapy history (69%, 61% and 21.4%, p=0.014, respectively), and anal and/or oral sex ratios (47.8%, 7.7% and 57.1%, p=0.019, respectively). Mean number of sessions were significantly higher in patients saying, \"It is my fault\" than among those perceiving it as a common problem (10.6±2.9 ve 7.5±5.7, p=0.042, respectively), and in patients with sexual disorder in their male partners than those not having any problem (13.3±3.7 ve 8.2±3.7, p=0.013, respectively).
CONCLUSIONS: Patients are more resistant to treatment if they have a history of vaginismus among relatives or when one of the couple say, it is his or her fault.

This study investigated whether a change in posture affected the activity of the upper-airway dilator muscle genioglossus in participants with and without obstructive sleep apnea (OSA). During wakefulness, a monopolar needle electrode was used to record single motor unit activity in genioglossus in supine and upright positions to alter the gravitational load that causes narrowing of the upper airway. Activity from 472 motor units was recorded during quiet breathing in 17 males, nine of whom had OSA. The mean number of motor units for each participant was 11.8 (SD 3.4) in the upright and 16.0 (SD 4.2) in the supine posture. For respiratory-modulated motor units, there were no significant differences in discharge frequencies between healthy controls and participants with OSA. Within each breath, genioglossus activity increased through the recruitment of phasic motor units and an increase in firing rate, with an overall increase of ~6 Hz (50%) across both postures and participant groups. However, the supine posture did not lead to compensatory increases in the peak discharge frequencies of inspiratory and expiratory motor units, despite the increase in gravitational load on the upper airway. Posture also had no significant effect on the discharge frequency of motor units that showed no respiratory modulation during quiet breathing. We postulate that, in wakefulness, any increase in genioglossus activity to compensate for the gravitational effects on the upper airway is achieved primarily through the recruitment of additional motor units in both healthy controls and participants with OSA.