Autism prevalence has increased considerably, but its etiology is still poorly understood. While there have been suggestions regarding associations between air pollution exposure and neurodevelopmental disorders, several studies have looked at the effect of air pollution exposure on autism. However, the results are inconsistent. The possible role of unknown confounders is mainly blamed for this inconsistency.2), ozone (O3), sulfur dioxide (SO2), and PM10 exposure were estimated using the inverse distance weighted method.To minimize confounding effects, we evaluated the impact of air pollution exposure on autism using a family‐based case‐control study. Cases were individuals with a diagnosis of autism born between 2009 and 2012 in Isfahan city, Iran. The controls did not have a previous history of autism and were cousins of the case person. The controls were matched with the autistic cases in terms of residential location and age range. For each trimester of pregnancy, carbon monoxide (CO), nitrogen dioxide  and entire pregnancy . Likewise, exposure to NO2 during the second trimester , third trimester , and entire pregnancy  were found to be associated with increased risk of autism.The analysis indicates a significant association between CO exposure and autism in the second trimester (OR = 1.59; 2, particularly during the second and third trimesters of pregnancy, was significantly associated with a higher risk of autism.Overall, our study found higher exposure to CO and NO Recent studies provide evidence on the more critical role of environmental factors on autism.Some studies examined the association between air pollution exposure and autism; however, the results are inconsistent.The possible role of unknown confounders and differences in genetic background are mainly blamed for this inconsistency.We examined the impact of exposure to air pollution on autism in a family‐based case‐control study to minimize the role of confounders.Our results implicate a significant association between exposure to traffic related air pollution and autism, especially in pregnancy's second and third trimesters.Autism is a serious neurodevelopmental disorder characterized by varying degrees of deficit in verbal and nonverbal communication and social interaction, mostly accompanied by repetitive behavioral patterns . This census has classified children based on their functioning and severity of symptoms. The children with low functioning were selected for receiving governmental financial support and interventional services. The cases we chose come from this group of children with severe symptoms of autism. After identifying the cases, questionnaires were completed through a phone interview with mothers of children. Twenty‐three cases were excluded because (a) their residential location has changed during pregnancy (18); or (b) refused to participate in the study (5). The remaining 74 cases entered our analyses.Fundamental trouble in referral‐based studies is identifying controls from similar underlying population matched with cases. These difficulties are addressed in family‐based studies through which controls are matched genetically and demographically to cases. In this study, we have asked the mother enrolled to contact their sisters and ask if they would like to be contacted by the researchers for potential study inclusion. Those who met the required qualifications and agreed to participate were then contacted for questionnaire completion. The qualification for controls to enter the examination was that they (a) had to have no previous history of autism; (b) were cousins of the case person, (c) their mother inhabited in Isfahan during the whole pregnancy, (d) they were born between 2009 and 2012. We excluded 21 cases because their residential location had been changed or they were not residents of Isfahan during pregnancy. Overall, 54 controls were included in our analysis.The following covariates, which have been found to be associated to autism in previous studies, were collected by questionnaires: (a) Child characteristics ; (b) Parental characteristics ; (c) Family history of autism; and (d) residential location during pregnancy.2), ozone (O3), sulfur dioxide (SO2), and PM10. The monitoring data were integrated into an average of 15 days point data and inverse distance weighted interpolation method (IDW) was used for providing air pollution surfaces from these point data  .SPSS (version 23) was used for the statistical analysis. The univariate logistic regression model was used to examine the impact of variables and detect the potential confounders. The relation between air pollution exposure and autism were examined in two different logistic regression models: one crude logistic regression and one adjusted logistic regression with adjustment of effect of variables with p‐value = 0.003). Caesarean section and gestational age were comparatively lower in cases  and entire pregnancy . As well as this, autism prevalence was significantly associated with exposure to NO2 in second trimester , third trimester , and entire pregnancy   and entire pregnancy . Moreover, the association between NO2 exposure and autism in second trimester , third trimester , and entire pregnancy  remained significant (Figure To ensure that covariates did not affect our evaluation, an adjusted logistic regression model was implemented. The associations after adjusting for variables with 2 exposure during the second trimester, third trimester, and entire pregnancy would cause 9.4%–17%, 11%–16%, and 23%–17% relative increase in risk of autism respectively. Moreover, 50%–59% and 84%–102% relative increase in risk of autism for 1 ppm increase in CO exposure during the second trimester and entire pregnancy in both adjusted and unadjusted models were observed (Figure The findings of our study from both adjusted and unadjusted models estimate 10 ppb increase in NO10 and NO2 exposure to be 10 μg/m3 and 17–44 μg/m3 respectively (Burman & Norman, 3 for PM10 and 32–58 μg/m3 for NO2 (Becerra et al., The association between air pollution and autism has been observed in several studies. The study of Volk et al.  was the 2, particularly during the second and third trimesters of pregnancy, is associated with an increased risk of autism. This is in line with the findings of several other studies (Jung et al., 2 are two of the main pollutant surrogates of traffic exposure, and exposure to these pollutants can reasonably and logically be attributed to proximity to traffic (Liu et al., 2 may associate with immune dysregulation and neuroinflammation (Kalkbrenner et al., This study found exposure to CO and NOAutism is a complex neurodevelopmental disorder resulting from the contribution of gene and environmental risk factors. Even though cases and controls come from the same residential location in traditional case‐control studies, these types of studies are highly likely to be manipulated by unknown variables. An example of these unknown confounders can be seen in differences in the genetic background between cases and controls and varying sensitivities to environmental pollution between different genes. In contrast to traditional case‐control studies, family‐based case‐control studies can mitigate the impact of genetic diversity and possible unrecognized confounders. As well as these, the family‐based study would lead to less bias in selecting controls. Relative controls are routinely more interested in participating, which would lead to more accurate answers and more reliable findings and results.Despite these strengths, there are some noteworthy limitations. The most important of these limitations is the sample size restriction, which comes from the fact that there is no registration for autism in Iran. Our study included low‐functioning autistic children receiving government services and support. Another limitation that is common in many epidemiological studies with air pollution is considering outdoor air pollution estimation as the individual‐level exposure. Evidence indicates differences between indoor and outdoor air quality (Challoner & Gill, 2 associated with autism, especially during pregnancy's second and third trimesters. As exposure to these pollutants can be attributed to proximity to traffic, studies examining the association between more complex traffic‐related air pollution and autism prevalence are recommended. The findings of these studies would provide helpful information on understanding the etiology of autism and provide further prevention and remedial strategies.We evaluated the impact of prenatal exposure to air pollution on autism. A family‐based case‐control study was employed to minimize the role of unknown confounders. Overall, we found exposure to CO and NONima Ghahari and Fatemeh Yousefian conceptualized and designed the study. Nima Ghahari performed data collection. Nima Ghahari and Fatemeh Yousefian performed analysis. Nima Ghahari wrote the first draft of the manuscript. Ehsan Najafi contributed to improving the manuscript and considering the editors' suggestions. All authors read and approved the final manuscript.The authors have declared that they have no competing or potential conflicts of interests.All procedures performed in this study involving human participants were conducted in accordance with the Helsinki declaration and the institutional and national research committee's ethical standards. We contacted the cases and controls in collaboration and under the supervision of the state welfare organization of Iran. The study protocol, research plan and questionnaires were reviewed and approved by the organization's Research Ethics Committee prior to contacting the participants. All participants were informed of the study's purpose, the voluntary nature of participation, and their right to withdraw at any time.


This case report discusses the effectiveness of the Inari FlowTriever system in treating a right atrial (RA) clot in‐transit in a 55‐year‐old male patient with Becker's muscular dystrophy (BMD). BMD is an X‐linked recessive muscle disease caused by mutations in the gene that code for the protein dystrophin, which is associated with partially functional dystrophin in variable amounts. Right heart thrombi (RHT) are thrombi that can be visualized in the right atrium, right ventricle, or proximal surrounding vasculature. The Inari FlowTriever system was used to treat RA clot in‐transit and removed acute, subacute, and chronic clot in a single session without the use of thrombolytics and subsequent ICU stay. The estimated blood loss with the FlowSaver system was approximately 150 mL. This report complements the FLARE study by highlighting the effectiveness of the FlowTriever system for mechanical thrombectomy of RA clot‐in‐transit in a patient with BMD. This report discusses the use of the Inari FlowTriever system in treating a right atrial clot in‐transit in a patient with Becker's muscular dystrophy. Right heart thrombi are thrombi that can be visualized in the right atrium, right ventricle, or proximal surrounding vasculature. The Inari FlowTriever system was used to treat RA clot in‐transit and removed acute, subacute, and chronic clots in a single session without the use of thrombolytics and subsequent ICU stay. BMD is associated with partially functional dystrophin in variable amounts.Right heart thrombi (RHT) are thrombi that may be found in the right atrium (RA), right ventricle (RV), or proximal surrounding vasculature. These can feature different characteristics of being mobile or immobile.2.Inari developed the FlowTriever system and intended for the treatment of pulmonary embolism through the peripheral vasculature without thrombolytics, as well as treating clots in‐transit in the right atrium. The device consists of a large lumen catheter and large bore syringe designed to rapidly extract large volumes of clot while mitigating blood loss. The catheter features three nitinol mesh disks in varying sizes depending on the size of clot. These disks are responsible for delivering the clot to the catheter for extraction . A recent case report details the effectiveness of FlowTriever device in treating PE noted by the rapid normalization of pulmonary artery (PA) pressure and SpO22 of 85%, respiratory rate of 28 respirations per minute, blood pressure of 92/61 mm Hg, and pulmonary artery pressure of 70/24 (37) mm Hg. The patient's pulmonary embolism severity index (PESI) was 115 points and classified Class IV. This is considered high risk with a 4.0%–11.4% 30‐day mortality in this group. The FlowTriever system removed acute, subacute, and chronic clots in a single session. Figures 2 of 95%, and pulmonary artery pressure of 29/14 (17) mm Hg. The patient was not given thrombolytics and did not have any ICU stay. The estimated blood loss with the FlowSaver system was approximately 150 mL. The patient reported complete resolution of dyspnea. Long‐term anticoagulation was prescribed to the patient to minimize the chances for recurrence.A 55‐year‐old man with a history of Becker's muscular dystrophy (BMD) presented with a chief complaint of progressive dyspnea. The patient was hypotensive. The patient denied changes in mental status, loss of consciousness, and cold extremities. The patient was not taking any medications currently, for his dyspnea or BMD, and did not report any other pertinent findings during review of systems. The patient denies any history of smoking or use of corticosteroids. The patient denied taking hypotensive‐inducing medications including angiotensin‐converting enzyme inhibitors. Transthoracic echocardiogram revealed right ventricle enlargement and right atrial clot‐in‐transit extending through the tricuspid valve into the right ventricle. Computed‐tomography angiography (CTA) revealed bilateral pulmonary embolism. Figure of 70/24 7 mm Hg. 3Research regarding the cardiac involvement of BMD is limited. Although the patient did display a RV/LV ratio of 1.5, it was not possible to determine whether this is an acute process or due to the BMD. The role of the dystrophy is thus unclear in the patient's presenting symptoms. Although there are no standardized guidelines for the optimal treatment of acute PE,The FlowTriever system is unique in that it is the only FDA approved catheter device for PE. The ability to maneuver into the pulmonary segmental branches and aspirate central and more distal clotting is a major advantage of this device. Additionally, a coaxial system allows for the use of contrast injections to track the progress of the procedure. A previous study known as the FLARE study showed the safety and effectiveness of the FlowTriever system with acute intermediate‐risk PE.42 and PA pressure following mechanical thrombectomy. This case report adds valuable information regarding the use of FlowTriever MT as an effective option for removal of RA clot‐in‐transit with pulmonary embolism in a patient with BMD.The patient reported a complete resolution of their dyspnea and a notable improvement in their SpOMahfujul Z. Haque: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; supervision; validation; visualization; writing – original draft; writing – review and editing. Taha Akbar: Conceptualization; formal analysis; methodology; resources; writing – original draft. Abdulmalik Saleem: Conceptualization; data curation; writing – original draft. Mashkur Husain: Investigation; methodology; project administration; writing – original draft; writing – review and editing.None.None.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


To evaluate the role of antenatal administration of corticosteroids for fetal lung maturation on the short‐term perinatal outcome of pregnancy complicated by late fetal growth restriction (FGR).th percentile, or umbilicocerebral ratio (UCR) ≥ 95th percentile or a drop of more than 40 percentile points in abdominal circumference measurement from the 20‐week scan. For the purposes of the current study, we identified women who received a single course of steroids to improve fetal lung maturation before delivery. Each exposed pregnancy was matched with one that did not receive antenatal corticosteroids (ACS) (control), based on gestational age at delivery and birth weight. The primary adverse outcome was a composite of abnormal condition at birth, major neonatal morbidity or perinatal death.This cohort study was a secondary analysis of a multicenter prospective observational study, the TRUFFLE‐2 feasibility study, conducted between 2017 and 2018 in 33 European perinatal centers. The study included women with a singleton pregnancy from 32 + 0 to 36 + 6 weeks of gestation with a fetus considered at risk for FGR, defined as estimated fetal weight (EFW) and/or fetal abdominal circumference < 10vs 33.3 weeks), EFW (1673 vs 1634 g) and UCR (0.68 vs 0.62) at inclusion, and gestational age at delivery (35.5 vs 35.9 weeks) and birth weight (1925 vs 1948 g). No significant differences were observed between the exposed and non‐exposed groups in the incidence of composite adverse outcome  or any of its elements.A total of 86 pregnancies that received ACS were matched to 86 controls. The two groups were similar with respect to gestational age (33.1 Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.The present data do not show a beneficial effect of steroids on short‐term outcome of fetuses with late FGR. © 2023 The Authors.  What are the novel findings of this work?This study showed no benefit of antenatal corticosteroids (ACS) for fetal lung maturation on short‐term perinatal outcome in pregnancies complicated by fetal growth restriction (FGR) after 32 weeks' gestation compared with matched pregnancies that did not receive ACS.What are the clinical implications of this work?This work supports the lack of evidence that ACS should be recommended routinely for late preterm FGR. To provide the best management for these pregnancies, it may be beneficial to identify if there is a subgroup of FGR that can benefit from ACS in order to maximize the potential benefits while minimizing risks.Pregnancies affected by fetal growth restriction (FGR) are at increased risk of adverse obstetric outcome, particularly iatrogenic preterm delivery. Thus, administration of antenatal corticosteroids (ACS) to accelerate fetal lung maturation is the standard of care in order to reduce perinatal morbidity and mortality in these caseset al.Early studies demonstrated that lung growth and surfactant production are accelerated in FGR fetuses in the absence of antenatal glucocorticoid treatmentGiven these premises, we aimed to investigate the role of ACS on perinatal outcome in pregnancy complicated by late FGR.th percentile, or umbilicocerebral ratio (UCR) ≥ 95th percentile, or a drop of more than 40 percentile points in AC measurement from the 20‐week scan. The references for EFW, AC and Doppler parameters were based on local charts. In order to be eligible, the fetus had to have positive umbilical artery end‐diastolic flow and a normal computerized cardiotocogram with a short‐term variability of > 3.0 ms. Gestational age was calculated based on the last menstrual period (if certain) and/or ultrasound assessment before 22 weeks of gestation. Women were ineligible for inclusion if there was planned or impending delivery based either on maternal obstetric complications, uterine contractions or rupture of membranes, or if their fetus had known or suspected structural or chromosomal abnormality. Birth‐weight Z‐scores were calculated using the Hadlock fetal growth chartThis was a secondary analysis of the TRUFFLE‐2 feasibility study, a multicenter prospective observational cohort study conducted between 1 April 2017 and 1 July 2018 in 33 European perinatal centersFor the purposes of the current study, we identified women who received steroids to improve fetal lung maturation before delivery (exposed), according to each participating institution's local policy or clinician advice. All units considered as a single course of steroids when a total dosage of 24 mg of betamethasone or dexamethasone was administered intramuscularly or intravenously in multiple doses over a period of 48 h. Each exposed pregnancy was matched with one that did not receive ACS (non‐exposed), based on gestational age at delivery ± 10 days and birth weight ± 150 g.The primary adverse outcome was a composite of abnormal condition at birth, major neonatal morbidity or perinatal death. Abnormal condition at birth was defined as at least one of the following: 5‐min Apgar score < 7, umbilical artery pH < 7.0 or umbilical vein pH < 7.1, resuscitation with intubation, chest compressions or need for medication. Major neonatal morbidity was defined as at least one of the following: neurological abnormality ; cardiovascular abnormality ; respiratory morbidity ; or sepsis  or meningitis).n (%) and continuous data as median (interquartile range). Background data and perinatal outcome were compared between the exposed and non‐exposed groups using Kruskal–Wallis test or Fisher's exact test, as appropriate. Statistical analysis was performed using SPSS software .Categorical data are presented as Complete delivery and outcome data were available for 856 newborns without major congenital abnormalities. Of these, 97 pregnancies received a single course of steroids, comprising 83 (86%) that received betamethasone and 14 (14%) that received dexamethasone, which was given within 2 weeks before delivery in 57 (59%). Repeat courses were not administered. A total of 86 (exposed) pregnancies were matched to 86 non‐exposed controls . Women who received ACS within 14 days before delivery, compared to those with an interval ≥ 14 days, had significantly higher gestational age at steroid administration , lower gestational age at delivery  and higher rate of composite adverse outcome  , were included at an earlier gestational age, had lower EFW and higher UCR, and delivered at an earlier gestational age a neonate with lower birth weight, associated with a higher rate of composite adverse outcome Table .vs 16%; P = 0.04) and respiratory morbidity  in the ACS group, whereas all other parameters were similar between the two groups , according to the interval between corticosteroid administration and delivery.Delivery details and perinatal outcome of the exposed and non‐exposed groups are further specified in Table ps Table . A similrs Table . Figure This study showed no benefit of administration of ACS for fetal lung maturation or other neonatal morbidity in pregnancies complicated by FGR after 32 weeks of gestation. Composite adverse outcome and other delivery and neonatal outcomes were similar between exposed and non‐exposed pregnancies. Only 11% of the study population received corticosteroids. The decision to administer corticosteroids was left to the individual clinician and was apparently guided by the perception of increased perinatal risk. Women who received corticosteroids had a lower gestational age at inclusion, lower EFW and higher UCR compared to those who did not.vs 20%) and ≥ 14 days (14% vs 30%). However, as shown in Figure The present data do not show a beneficial effect of ACS on short‐term outcome in a prospectively selected and appropriately FGR phenotyped cohort. The small sample size and the fact that no matched control could be found for the 11 women with the highest risk represent limitations of the study given the possibility that a type‐II error may still be present, and do not allow definitive conclusions to be drawn regarding the benefit or disadvantages of steroids in FGRThe main strength of this study is that the effects of steroids on perinatal outcome of late FGR were evaluated in a selected population of late FGR fetuses followed up prospectively until delivery. By matching on birth weight and gestational age at delivery, exposed and non‐exposed pregnancies were similar concerning the two most relevant predictors of adverse perinatal outcome.In the first trial on the effects of steroids in cases of preterm birth, a non‐significantly higher fetal mortality was reported in cases of severe maternal hypertension and FGRThe role of steroids in appropriately grown late preterm infants has been studied extensively and benefits have been demonstratedRecent evidence suggests that the use of glucocorticoids in the perinatal period could be associated with adverse effect on neurodevelopmental outcomesIn conclusion, our findings highlight the need for studies focusing on the effect of ACS in late preterm FGR. In order to provide the best prenatal management for these pregnancies, it may be necessary to identify whether there is a subgroup of FGR that can benefit from ACS, and if so, to evaluate the best timing of this intervention in order to maximize the potential benefits while minimizing risks. At present, we believe that there is insufficient evidence to recommend ACS to be given routinely in the context of late preterm FGR.Table S1 Delivery characteristics and perinatal outcome of 49 pregnancies that received antenatal corticosteroids (ACS) < 14 days before delivery and 49 matched pregnancies that did notClick here for additional data file.Table S2 Delivery characteristics and perinatal outcome of 37 pregnancies that received antenatal corticosteroids (ACS) ≥ 14 days before delivery and 37 matched pregnancies that did notClick here for additional data file.


Right heart cement embolization is a rare but potentially life‐threatening complication of vertebroplasty surgeries. Transthoracic echocardiography is the first‐line imaging modality for detecting cement particles in cardiac chambers. Anticoagulation treatments or surgical interventions are necessary, depending on the patient's condition. Right heart cement embolization is a rare but potentially life‐threatening complication of vertebroplasty surgeries. Transthoracic echocardiography is the first‐line imaging modality for detecting cement particles in cardiac chambers. Anticoagulation treatments or surgical interventions are necessary, depending on the patient's condition. It can cause life‐threatening conditions such as ventricular rupture if left undetected. In this case report, we present a 57‐year‐old woman with a history of laminectomy diagnosed with right atrial cement embolization during echocardiography as an incidental finding.Cement embolization is the main complication of vertebroplasty due to the embolization of poly methyl methacrylate (PMMA) in the paravertebral venous circulation, followed by the pulmonary vasculature or the right heart.The reported frequency rate of pulmonary cement embolization following vertebroplasty ranges between 4.6% and 26.9%,To prevent thrombotic events, oral anticoagulation therapy is usually recommended in asymptomatic patients with small fragments of cement (pulmonary or right heart) embolization.Cardiac perforation and tamponade are catastrophic manifestations of this complication, necessitating urgent surgery.This case report presents a patient with right atrial cement embolization originating from a recent laminectomy surgery. The embolization was diagnosed as an incidental finding during angiography and the subsequent echocardiography.2A 57‐year‐old woman with a history of typical chest pain associated with elevated cardiac troponin was referred to our tertiary cardiac center with a diagnosis of non‐ST‐elevation myocardial infarction (NSTEMI) for further evaluation and coronary angiography.In her past medical history, the patient had a history of breast cancer, treated completely many years earlier, and a history of vertebral column laminectomy (lumbar) 2 weeks before her new cardiac symptoms and hospital admission.Limited bedside transthoracic echocardiography was performed with a focus on the left and right ventricular systolic functions and regional wall motion abnormalities.Coronary angiography, performed as an early invasive approach, showed triple‐vessel coronary artery disease. During the angiography and fluoroscopy, two large mobile spiral calcified masses were noticed in the right heart and a smaller one in the right lung moving with cardiac and respiratory motions Figure .Further evaluation by spiral chest computed tomography (CT) scan and pulmonary CT angiography revealed large foreign bodies in the lung and the heart Figures  and 3.We performed transthoracic and 3D transesophageal echocardiography Figures , 6, 7, 8Given the patient's history of chemotherapy, we considered the probability of the presence of the remnant of a chemotherapy superior vena cava port with organized thrombus formation around it. Nevertheless, her family ruled out this likelihood stating that the patient had never undergone portal implantation. Subsequently, on account of her recent laminectomy, we considered the less likely diagnosis of probable cement embolization in the right atrium and the pulmonary vasculature .We scheduled the patient for open‐heart surgery to remove the foreign body (cement) from the right atrium. However, the patient and her family refused consent for open‐heart surgery. Thus, the patient was discharged with anticoagulation therapy and was advised to return for 1‐month follow‐up echocardiography to evaluate the emboli development.The patient failed to return for follow‐up visits. Further follow‐up contacts indicated that the patient was hospitalized for septicemia originating from a surgical site infection and expired due to organ failure caused by the septicemia 3 months after the visit to our center.3Cement embolization with PMMA via the paravertebral venous system following vertebroplasty is the most significant complication of this noncardiac surgery.The literature features a few case reports of cement embolization.Imaging modalities such as chest X‐rays and CT scans are the first steps toward an accurate diagnosis.The contrast agents used in CT angiography might hide cement particles in the pulmonary vascular bed. Thus, simple chest X‐rays and spiral chest CT scans (without contrast injection) are essential in patients with a history of vertebroplasty to investigate possible cement embolization. Transthoracic echocardiography constitutes the first‐line imaging study for detecting cement particles in cardiac chambers and complications.Most hitherto‐reported cases are asymptomatic or mildly atypically symptomatic cases in which mass detection was incidental. This group of patients could receive conservative treatment with oral anticoagulation drugs; nevertheless, in other symptomatic cases with such life‐threatening signs as ventricular perforation and tamponade, invasive surgical approaches, and cement extraction are deemed the gold‐standard treatment.Our cement embolization case was diagnosed incidentally, as well, because the patient was referred for coronary evaluation in an NSTEMI setting. Given her triple‐vessel disease, we recommended open‐heart surgery; otherwise, we could have chosen conservative oral anticoagulation therapy alone.4If left untreated, right heart cement embolization is a rare but potentially life‐threatening complication of vertebroplasty surgeries. This condition remains asymptomatic and can be detected as an incidental finding. Transthoracic echocardiography constitutes the first‐line imaging modality for detecting cement particles in cardiac chambers and their complications. Anticoagulation treatments or surgical interventions are necessary, depending on the patient's condition.Solmaz Borjian: Conceptualization; writing – original draft. Mohammad Amin Borjian: Data curation; visualization. Aryan Ayati: Writing – review and editing. Arezou Zoroufian: Conceptualization; supervision; writing – review and editing.None.All authors declare that there were no competing interests.All authors have consented for publication of the article.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.Video S1.Click here for additional data file.


Advances. In the awarded paper, we examine published evidence on non‐shared environment effects in individuals diagnosed with autism spectrum disorder (ASD) . Regardless of zygosity, twins are also the same age and generally have the same parents . In contrast, sibling studies include offspring of different ages who subsequently may have different prenatal and postnatal environments. Siblings are also more likely than twins to have different fathers. Although twin studies can save time and costs compared with traditional case‐control studies where researchers need to find matched controls, there are some limitations. If one twin in the pair provides incomplete or unusable data for some reason, this may affect the researcher's ability to include the twin pair in statistical analyses. Another limitation to twin studies include the rarity of twins, especially those discordant for traits. There are also concerns whether or not being a twin places an individual at an increased risk for certain outcome and if results from twin studies can be generalized to non‐twin populations   or discordance . Using qualitative discordance, we have found 25 MZ pairs (and 37 DZ pairs) discordant for ASD, 16 MZ (and 39 DZ) pairs discordant for ADHD, and 34 MZ pairs (and 44 DZ pairs) discordant for neurodevelopmental conditions . There are no clear standards on what defines quantitative discordance for neurodevelopmental conditions; however, some recent studies by our research group have used the cut‐off of the standard measurement of error on a validated tool for ASD traits  as the criterion for quantitative discordance , the need to report special study characteristics related to the use of twins is critical.In our systematic review, a major challenge for our team when reviewing the available studies for inclusion was the lack of consistent and comprehensive reporting related to the design and analysis of twin studies. We were surprised to learn that—to the best of our knowledge—no known standards have ever been established for reporting the results of twin studies. While authors may use various reporting guidelines based on the type of study they perform  or adoption studies (either studies of twins adopted by different parents or an adopted sibling into a family) that allow researchers to further explore the effects of genetics and/or environment on outcomes of interest (Carlsson et al., Lynnea Myers: Conceptualization; Writing – original draft. Sven Bölte: Conceptualization; Supervision; Writing – review & editing.All authors declare no direct conflict of interest related to this editorial. S.B. discloses that he has in the last 3 years acted as an author, consultant, or lecturer for Medice and Roche. He receives royalties for textbooks and diagnostic tools from Hogrefe, Kohlhammer, and UTB.


Calocitta formosa) and black‐throated magpie‐jay  occur along the western coast of Mexico and Central America. The two species differ markedly in throat color and tail length, and prior observation suggests a narrow hybrid zone in southern Jalisco where individuals have mixed throat color. This study aims to assess the existence and temporal stability of this putative hybrid zone by comparing throat color between georeferenced historical museum specimens and modern photos from iNaturalist with precise locality information. Our results confirm the existence of a narrow hybrid zone in Jalisco, with modern throat scores gradually increasing from the parental ends of the cline toward the cline center in a sigmoidal curve characteristic of hybrid zones. Our temporal comparison suggests that the hybrid zone has not shifted its position between historical (pre‐1973) and modern (post‐2005) time periods—a surprising result given the grand scale of habitat change to the western Mexican lowlands during this time. An anomalous pocket of white‐throated individuals in the northern range of the black‐throated magpie‐jay hints at the possibility of prehistorical long‐distance introduction. Future genomic data will help disentangle the evolutionary history of these lineages and better characterize how secondary contact is affecting both the DNA and the phenotype of these species.Hybrid zones are natural experiments for the study of avian evolution. Hybrid zones can be dynamic, moving as species adjust to new climates and habitats, with unknown implications for species and speciation. There are relatively few studies that have comparable modern and historic sampling to assess change in hybrid zone location and width over time, and those studies have generally found mixed results, with many hybrid zones showing change over time, but others showing stability. The white‐throated magpie‐jay ( We compare historical museum specimens to modern citizen science photos to test whether the hybrid zone between two species of magpie‐jays has changed over time. By scoring throat coloration across a geographic transect, we find that a narrow hybrid zone exists between the two species and that it has not changed substantially over time. Hybrid zone stability is notable in this system because of the dramatic habitat changes across the landscape of these two species in the lowlands of Western Mexico. Many hyStudying temporal changes in hybrid zones can be challenging. Time‐series data are needed at multiple sites along a transect, but the combination of adequate sampling over space and time is rare  and white‐throated magpie‐jay  offer an ideal test case for using museum specimens and citizen science photos to assess temporal change in a hybrid zone. The two species are easily distinguishable in photos . The western lowlands of Mexico have experienced significant habitat alteration, especially after the 1970s when expansion of year‐round irrigation directly led to a shift in the proportion of mesic habitat from 5% to over 60%  to 5 (white), with scores of 2–4 given to birds with a mix of black and white feathers Figure . BecauseOur historical data were taken from 280 georeferenced museum specimens from western Mexico collected from 1902 to 1973. We used a wide range of historical dates to increase sample size because the most intense human habitat alterations along Mexico's Pacific Coast occurred after 1975  and modern  transects. In the historical transect, analyzing across five geographical zones revealed a single significant difference in throat scores between zones C and D, i.e., at the species transition zone , but there were also significant differences within species: a marginally significant difference between zones A and B (p = .054) in C. colliei and a highly significant difference between zones D and E .The overall percentage of individuals with mixed phenotypes  was similar between the historical , with the population closer to the area of contact having a more intermediate phenotype. Similarly, in the range of C. formosa, population 7 had a significantly more intermediate phenotype than population 8 (Table p = .023). The comparison of cline centers between modern and historical data suggests geographic stability of the hybrid zone between time periods  haplotypes across the same transition area and monophyly of the two species in the mtDNA phylogeny . Here, the proportion of white throats increased from 28% to 33% from the historical to the modern time period. As mentioned above, it is possible that we were not able to entirely remove juvenile birds from our sampling, but this would not explain why there is a consistent geographic bias to this pattern unless the proportion of juvenile birds or developmental processes is somehow different at this site. One hypothesis that could explain this pattern is a human introduction of white‐throated magpie‐jays that pre‐dates the museum specimens we studied from the early 1900s. Magpie‐jays are often kept as pets, and introduced populations have popped up regularly across Mexico ; funding acquisition (lead); formal analysis (supporting); writing – original draft (lead); writing – review and editing . Devon A. DeRaad: Formal analysis (supporting); writing – review and editing . Alana K. Pizarro: Conceptualization ; formal analysis (lead); writing – original draft (supporting); writing – review and editing .The authors declare no competing interests.Appendix S1Click here for additional data file.


Recent structural and functional studies have provided some answers to the question of whether the supercomplex organization confers an advantage for cellular energy conversion. However, the jury is still out, regarding the universality of these claims. In this review, we discuss the current knowledge on the functional significance of MRC supercomplexes, highlight experimental limitations, and suggest potential new strategies to overcome these obstacles.The mitochondrial respiratory chain (MRC) is a key energy transducer in eukaryotic cells. Four respiratory chain complexes cooperate in the transfer of electrons derived from various metabolic pathways to molecular oxygen, thereby establishing an electrochemical gradient over the inner mitochondrial membrane that powers ATP synthesis. This electron transport relies on mobile electron carries that functionally connect the complexes. While the individual complexes can operate independently, they are  Mitochondrial respiratory chain complexes can associate into supramolecular structures termed respiratory supercomplexes. This review discusses their structure, assembly and potential physiological functions. As the most versatile form of chemical energy in cells, ATP is synthesized in large quantities by mitochondrial activity. Biochemical reactions, many occurring in the cytoplasm, convert carbohydrates and lipids to mitochondrial acetyl‐CoA. This central metabolite is processed in the mitochondrial matrix by the tricarboxylic acid cycle TCA; Fig . Electroet al, Saccharomyces cerevisiae, do not contain a conventional CI, but rather possess non‐proton‐translocating peripheral membrane NADH dehydrogenases . The reduced quinone (QH2) subsequently transfers two electrons to cytochrome bc1 reductase (CIII), which exists as an obligate homodimer  with the shuttling of H+ into the IMS via a mechanism called Q‐cycle , where molecular oxygen is reduced to water , the first and largest of the MRC multiprotein complexes in mammals, consisting of 45 subunits and comprising a mass of approx. 1 MDa  form a single unit, which can catalyze the entire process of mitochondrial respiration. Thereby, Q and Cytc mediate electron transfer via enclosed pathways, never exchanging with the exterior of the unit , present only minor amounts of CI‐containing SCs. The second most prevalent assembly of CI is the CI + CIII2 configuration , CIV can occur in its monomeric, as well as in its dimeric (CIV2) form.Supercomplexes are also formed between CIII and CIV without CI, with the stoichiometries CIIIvely Fig . Whereas2 complex  are sample preparation artifacts , it does not contribute to the assembly of the respirasome, as the formation of the CIII2 + CIV SC is not necessary for respirasome formation  , as well as Rcf2 (yeast‐specific), were previously suggested to mediate assembly and stability of CIIIThe physiological functions of SCs remain controversial, despite more than two decades of research  to the Q headgroup, and thereby helps to connect electron flow in the MRC Fig . Becausec molecules and catalyzing the transfer of electrons from NADH to O2  between the respective Cytc binding sites  and CIV . The exclusive presence of one configuration or the other in knock‐out cells of the corresponding isoform led to some changes in mitochondrial bioenergetics. However, no differences in respiratory parameters were observed between SCAF1 or COX7A2 knock‐out and wild‐type cells, where the two MRC organizations co‐exist. The increment in respiratory rate supported by the addition of succinate (a CII substrate) to permeabilized cells already respiring CI substrates was shown to be lower in cells expressing the S‐MRC compared to C‐MRC, suggesting that the electrons from CI saturate the downstream MRC segment (Q to CIV) at a greater extent in the S configuration. Preferential utilization of the NADH versus FADH2 route parallels with the fraction of total CIII and CIV distributed in respirasomes. This suggests the existence of a kinetic advantage for electron transfer within SCs possibly linked to the proximity of electron carrier binding sites. However, NADH‐ and FADH2‐linked respiration are not fully additive in either configuration, arguing against Q pool partitioning. Moreover, the lack of COX7A2 causes a decrease in total CIV amount and enzymatic activity by 50%, which, although it does not affect endogenous and coupled respiration, reduces spare respiratory capacity. This relevant confounding variable can contribute to the observed decrease in CII minus CI‐ and ATP‐driven respiration in S‐MRC cells. Lastly, the authors showed that stimulation of pyruvate dehydrogenase (PDH) activity to promote a switch toward oxidative metabolism in human fibroblasts reduces SCAF1 steady‐state levels and favors the C‐MRC configuration. This observation establishes a direct link between the MRC organization and cellular metabolism, controlled by PDH activity. Intriguingly, while the study proposes that a metabolic shift toward oxidative metabolism destabilizes SCAF1, data from human and mouse tissues indicate that SCAF1 expression is induced by PGC1α and enhances respiratory capacity , these subtle bioenergetic advantages of SC formation can be the basis for selection. Employing the recent structural insights into respiratory SCs should allow engineering of further sets of genetic mutants to fully unravel the intricacies and physiological impact of SC formation.Supercomplex formation constitutes another example for a growing theme of gathering functionally related activities in common complexes or into proximal localization. This strategy, which is widely employed in life, is used extensively in mitochondria (Linden To fully unravel the functional interplay of respiratory chain complexes in SCs and its mechanistic benefit, it might be necessary to reconstitute purified SCs into proteoliposomes to study their performance in a minimal system, free from confounding secondary variables.c or Q, and RCs in order to test how they might determine the dependency on SC/respirasome formation to achieve optimal electron transport rates.The functional connectivity of the respiratory chain by mobile electron carriers is likely a key aspect of SC/respirasome formation. It would be important to determine the absolute and relative concentrations of Cytet al, While this manuscript was under editorial proof, an article was published where a more than 50% reduction in SC and respirasome formation was achieved in a mouse model, without overly perturbing respiration or physiology (Milenkovic Once these mutants are available, it would be very interesting to score how they impact stress tolerance and competitive fitness.The interdependency of assembly of the different respiratory chain complexes has suggested that mature complexes might facilitate assembly of the partner complex through direct contacts. However, assembly also occurs in the absence of the partner complex. To unravel the contribution for the co‐assembly pathways for overall assembly, efficiency will be an important aspect of future research.Andreas Kohler: Conceptualization; writing – original draft; writing – review and editing. Antoni Barrientos: Conceptualization; writing – original draft; writing – review and editing. Flavia Fontanesi: Conceptualization; writing – original draft; writing – review and editing. Martin Ott: Conceptualization; writing – original draft; writing – review and editing.The authors declare that they have no conflict of interest.


Providing higher‐intensity unpaid care (higher care hours or care within the household) is associated with negative impacts on people's paid employment, mental health and well‐being. The evidence of effects on physical health is mixed and carer's social and financial outcomes have been under‐researched. The biggest evidence gap, however, is on how outcomes vary by factors other than type or level of care provision, in particular socio‐demographic factors. Our study used two waves of data (2017/19 and 2018/2020) from the United Kingdom Household Longitudinal Study for people aged 16 and older. We investigated the effects of providing care for 10 or more hours a week or within the household in interaction with people's socio‐demographic characteristics. Outcomes included mental and physical health, social isolation, employment status and earnings. We found that caring responsibilities interacted with gender, ethnicity, socio‐economic status , or age to affect carers differentially in a number of areas of their lives leading to, and exacerbating, key disadvantages and inequalities. Providing unpaid care at higher hours or within the household impacts negatively on paid employment, mental health and well‐beingFindings on association with physical health are mixedThere is evidence of gender differences for some outcomes but not much is known about inequalities in carer's experiencesSocial determinants ‐ identifying as female, ethnic minority or lower socio‐economic group ‐ interacts with care provision to result in greater negative effects on key life domainsYounger age in conjunction with care responsibilities is associated with poorer mental health and greater social isolation; older age with worse physical healthHigher‐intensity caring is also associated with higher odds of social isolation or loneliness1How care needs are met, and disabled and older people enabled to live independent lives, is an important societal and social justice issue. It has had varied traction in the political and policy sphere, although has been higher on the agenda and public consciousness in recent years in many countries, the UK included , we identified people aged 16 and older providing unpaid care at time 1  of (a) ten or more hours a week; (b) within the household. We then looked at how interaction of care provision and socio‐demographic at time 1 was associated with a number of outcomes at time 2   and 10 2018/20) of the UKHLS ?’‘Do you provide some regular service or help for any sick, disabled or elderly person not living with you?’The variables for caring responsibilities were derived from three questions asked of respondents at time 1:iii‘Thinking about everyone who you look after or provide help for, both those living with you and not living with you ‐ in total, how many hours do you spend each week looking after or helping them?’And the follow‐up question:Non‐carers were defined as people who answered no to both the first two questions. Higher care hour carers were defined as people who answered yes to either or both questions (i) and (ii) and indicated that they were providing care for 10 or more hours a week in question. Co‐resident carers were defined as people who answered yes question (i) (either on its own or together with question (ii)).Caring for ten or more hours a week was selected because previous research shows that this is the threshold at which impacts on carers are greatest; few or no impacts are observed at lower hours ; ethnicity ; highest educational qualification  as a measure of socio‐economic status; and age group . Highest educational qualification is a well‐used measure of socio‐economic status and was used in our study because it has a good response rate, is easy to measure and includes people who are unemployed. The social class variables available in UKHLS use information from current job. As a result, over 40% of responses are ‘inapplicable’.2.4We considered five outcomes separately at time 2: employment status; annual earnings from paid employment; physical health; mental health; and social participation (loneliness or isolation). Employment status was recoded into two categories: 0 = in paid‐ or self‐employment; 1 = not in paid employment. The continuous variable for earnings was based on a question about monthly earnings from paid employment and thus excluded earnings from self‐employment. We multiplied the monthly figure by 12 to give annual earnings. For employment and earnings, we excluded sample members who were in full‐ or part‐time education or training at the same time as paid employment and sample members who were over the UK state pension age at the time (66 and older). For health outcomes, the variables used were the Physical and Mental Components of the Short‐Form 12 Health Survey  which measure physical and mental health, respectively; they have been validated for use in the general population  the effect of care provision; (b) the effect of people's socio‐demographic characteristics; and (c) the combined, interactive, effect. We used two‐step multivariate regression models which used the factors on their own and with interaction terms. We looked at care provision and carer characteristics at time 1 (Wave 9) and outcomes at time 2 (Wave 10). Multivariate logistic regression was used for categorical outcome variables: employment status and social participation. Multivariate linear regression was used for continuous outcome variables: physical health score (PCS) and mental health score (MCS). For analysis of earnings, as this variable has a skewed distribution with a substantial number of zeros, we used two‐part Generalised Linear Models Mullahy, . We usedModels controlled for covariates potentially associated with each outcome, based on previous research where available  and in domains where there has been a research gap . However, some carers were doubly disadvantaged. Structural disadvantage, role captivity, choice, alternatives and opportunities and financial and other resources may help to explain why. The SDH framework shows how social determinants contribute to health outcomes in several key ways. Some authors have argued that because of the extensive effects of care provision on health and well‐being, unpaid caring should also be considered a social determinant, as part of living and working conditions (Spiers et al., Our study has some limitations. Whilst a strength is that we look at the interaction between care responsibilities and individual social determinants of health, because of sample sizes and the difficulties of interpretation we were unable to look at further interaction between, for example caring, gender and ethnicity. Clearly, there will be variation within these broad sub‐groups and further research would benefit from exploring some of these intersections, as also pointed out by Hengelaar et al in their 5In conclusion, we found that caring responsibilities interact with socio‐demographic factors to affect carers differentially in a number of life domains leading to, and exacerbating, key disadvantages and inequalities. Our findings reinforce the need for differentiation of carer support. One clear example is the need for mental health support and prevention for younger carers and physical health support and prevention for older carers. One of the pathways by which social factors determine health and other outcomes is by the ability to access health, long‐term care and other services (Solar & Irwin, The authors declare no conflicts of interest.Ethical approval for the UKHLS data used in this study was obtained by the University of Essex Ethics Committee which has approved all data collection on the UKHLS main study and innovation panel waves.


Recurrent respiratory papillomatosis (RRP) is a rare disease characterized by recurrent papilloma along the aerodigestive tract. In this case, we describe a 16‐year‐old with longstanding laryngeal RRP secondary to vertical transmission of human papillomavirus (HPV) who presented with symptomatic pulmonary involvement and was successfully treated with systemic bevacizumab. The case describes the clinical and radiological improvement with therapy as well as the adverse effects that occurred and resolved with dose adjustments. Recurrent respiratory papillomatosis with is a rare disease caused by HPV 6 and 11. This article describes successful treatment of recurrent respiratory papillomatosis with pulmonary involvement with systemic bevacizumab. Recurrent respiratory papillomatosis (RRP) is a rare disease commonly caused by human papillomavirus (HPV) 6 and 11. It is characterized by recurrent exophytic papilloma primarily in the larynx, and occasionally in other parts of the aerodigestive tract. It has an estimated incidence of 1.8 per 100,000 adults and 4.3 per 100,000 children.A 16‐year‐old Māori female with known RRP since infancy, was referred to the respiratory clinic after a chest x‐ray was performed in the emergency department (ED) revealing an increasing right mid‐zone lesion.The patient was diagnosed with RRP at 11 months old after presenting with a hoarse voice. A laryngoscopy at the time showed laryngeal papilloma. The histopathology of this showed benign squamous cell tissue which was positive for human papilloma virus 11. The patient's mother had a history of genital warts, including cervical warts, at the time of the patient's birth.Over the next 16 years, 115 laryngoscopies were performed for micro‐debridement with laser debulking of recurrent papillomas. Her main symptoms included dysphonia and cough. When the patient was 8 years old, a computed tomography (CT) scan of the chest revealed two thin‐walled cysts in the right upper and lower lobes. No respiratory symptoms were reported at this time and baseline spirometry was normal.The patient did not have any other medical history. Her regular medications at the time of review included combined oral contraceptives and melatonin. She had trialled intra‐lesional Cidofovir and intra‐lesional Bevacizumab in the past without success.At age 16 the patient presented to our ED with cough and haemoptysis. A chest x‐ray showed an enlarging right mid‐zone nodule., The patient did not have any infective symptoms and her examination and blood workup were unremarkable. This was her fourth presentation in 12 months to ED with a cough and sore throat. She was referred to the adult respiratory service for further workup. In the 2 years prior to the first adult respiratory review, the patient underwent nine laryngoscopies for micro‐debridement.A CT chest showed a new 14 mm lobulated pulmonary nodule abutting the known right lower lobe cyst, a new multi‐cystic lesion in the right lower lobe and a stable thin‐walled cyst in the right upper lobe  to reduce the side effect profile. It was noted at this time the patient's cough had resolved. The patient then completed three further doses of 5 mg/kg bevacizumab at six weekly intervals with complete resolution of RRP‐related symptoms. After the sixth infusion, the infusion was extended to 9 weeks for three doses. Following the ninth infusion, IV Bevacizumab will be given 12‐weekly for three doses with the aim of maintaining the patient on infusions 16‐weekly.The patient was reviewed 7 months into bevacizumab treatment in the respiratory clinic and reported the cough and haemoptysis had resolved. During the first 6 months of treatment, the patient had a mild influenza A infection which was not related to Bevacizumab treatment and she did not require oxygen or anti‐viral therapy. The patient did not have any further ED presentations with cough or require further antibiotics for respiratory tract infections. A CT Chest had been performed 9 weeks after initiating treatment which showed a reduction in the size of the two cystic lesions and complete resolution of the 14 mm lobulated lesion in the right lower lobe Figure .The patient has had symptomatic improvement from a laryngeal perspective and a direct laryngoscopy performed by the otolaryngologist 7 months into treatment showed complete remission of disease without any remaining papilloma. The patient has not required micro‐debridement or laser debulking of papillomas since starting bevacizumab treatment. The patient is being monitored six‐monthly by the respiratory and otaralyngology clinics.RRP is a challenging disease that is associated with significant morbidity such as voice disturbance and airway obstruction. The current mainstay of treatment is surgery with cold instruments, laser, or micro‐debridement to remove papillomas and to prevent disease spread. On average, patients with RRP will require four surgeries per year to achieve control. Up to 20% of patients require adjuvant systemic treatment due to inadequate disease control by surgery alone.Bevacizumab is a humanized monoclonal antibody against vascular endothelial growth factor A (VEGF‐A). Systemic bevacizumab has been shown to reduce surgical frequency by indirectly inhibiting papilloma growth. The papilloma epithelium and underlying vascular epithelium show strong expression of VEGF, Vascular endothelial growth factor receptor‐1 (VEGFR‐1) and VEGFR‐2.A systematic review by Pogoda et al of all case series to date of systemic bevacizumab in the treatment of RRP found that 95% of the 43 patients treated with systemic bevacizumab responded to treatment with a reduction in surgery, 56% of all patients in this series no longer required surgery.This case adds to the growing literature on the use of systemic treatments for RRP. To our knowledge, this is the first reported case of bevacizumab treatment for lung involvement of RRP in New Zealand or Australia.Dr Amy O'Brien, Respiratory Registrar, Te Whatu Ora Waikato Hospital, New Zealand. First author. Dr Eskandarain Shafuddin, Consultant Respiratory Physician, Te Whatu Ora Waikato Hospital, New Zealand. Supervisor.None declared.The authors declare that appropriate written informed consent was obtained for the publication of this manuscript and accompanying images.


Penile self‐mutilation may result from a suicidal attempt during a major depression crisis. The management of this urological emergency should be multidisciplinary. A macroscopic penile reimplantation performed meticulously by a urological surgeon may yield an excellent cosmetic and functional outcome.Penile self‐mutilation is an infrequent form of self‐harming behavior seen primarily in patients with schizophrenia spectrum disorders and rarely reported in those with major depressive disorders.We herewith present a major depression related case of penile self‐mutilation successfully managed by macroscopic penile reimplantation performed 8 h after the incident. Penile mutilation in general may result in life‐threatening hemorrhage therefore it requires immediate surgical intervention.The first PSM mentioned in the English literature was by Strock in 1901.The gold standard treatment for penile amputation is early reimplantation which if successful should yield satisfactory functional and cosmetic results.2A 33‐year‐old South African man and prison inmate was rushed to the accident and emergency unit of Klerksdorp/Tshepong hospital complex following a self‐inflicted penile amputation and neck laceration due to depression using a sharp knife. He was referred from a correctional service center in Northwest province to the Tshepong facility that deals with trauma emergency cases and presented about 2 h following injury. Further interrogation revealed that he is known to have a depressive illness. There was no history of drug or alcohol abuse.On examination, he was hemodynamically stable, fully conscious, alert but in pain, depressed, anxious, and had a wound on his left side in the middle zone of the neck and an almost completely severed actively bleeding penis Figure . BleedinThe urethra was refreshened, spatulated, and reanastomosed over a 16 French catheter in a tension free fashion using continuous 4/0 vicryl sutures. Both cavernosal bodies were sutured using interrupted 2/0 vicryl sutures, the neurovascular bundles approximated with interrupted 4/0 vicryl sutures and the skin closed with chromic 3/0 (Figure On day 1 postoperative, the patient was seen by the psychiatrist who concluded that he had major depression. The patient was kept in the ward for a week then discharged on antibiotics, analgesia, and a transurethral catheter.Postoperative course was grossly uneventful, a very small area of skin necrosis was noted on the distal part of the glans in the first week which was almost completely healed altogether with the wound by 4 weeks when reviewed as an outpatient and the transurethral catheter was removed.At 8 weeks postoperative, he reported good and rigid erection with normal ejaculation but no sensation on the glans and up to 3 cm proximally. The wound showed good cicatrization in progress (Figure At 4 months follow‐up visit, he reconfirmed having good erections during masturbations and reported in addition, a full recovery of sensation on the penile skin. However, the glans was still numb. The phallus looked cosmetically satisfactory (Figure 3PSM may be a rare phenomenon often associated with psychiatric disorders such as schizophrenia spectrum; substance abuse; personality and gender dysmorphic disorders. Bipolar and depression disorders are very uncommon associated condition with very few cases reported.There appears to be an increasing incidence but whether this is due to an increased level of reporting in recent years remains unclear.The primary major literature review on PSM was published in 1979 with few cases of genital self‐mutilation reported thereafter involving both genders.The motivational factor liable for PSM varies. About one‐tenth of self‐mutilators intended suicide secondary to depression and anxiety.There is a need for close follow‐up of depressed patients to detect any overt psychotic tendency in the future. It is suggested that in the presence of overt psychotic symptoms, PSM should be considered related to psychotic depression.The amputated phallus should be wrapped in saline‐soaked gauzes and placed in a sealed plastic bag which is stored in ice slush “bag in bag”.Early replantation of the amputated penis is the gold standard. There have been reports of successful microscopic and macroscopic reimplantation. Distal penile amputation is technically difficult to repair, particularly vascular anastomosis due to small vessels.The amputation in this case was at mid penile shaft and no microvascular technique was used.Ischemic time is paramount for a successful reimplantation. Tissues with less muscles such as penis can survive 24 h of ischemia. Successful reimplantations have been carried out with a cold ischemic time of fewer than 16 h.Complications resulting from PSM varied consistently with the severity of the injury inflicted and the extent of surgical repair undertaken.Our patient was followed several weeks after discharge by the multidisciplinary team and besides the meatal stenosis for which he is currently of self‐intermittent dilatation, none other of the above complications were observed.4Successful management of penile self‐mutilation should include a multidisciplinary team in pre‐ and post‐operative period. It should be treated as an emergency without delays. A multidisciplinary postoperative follow ups are crucial part of care and should reassess holistically the patient to prevent repetition of the self‐harm and completion of the suicidal act.Despite the severity of the trauma involving the penis and taking into account the ischemic time, replantation should be considered as part of therapeutic options guided by pre and intraoperative re‐evaluation. A final and definitive intraoperative decision as in our case led to a successful reimplantation with satisfactory cosmetic and functional results.Mohammed Saleh E.Khalifa Salem: Writing – original draft. Abdul Alherek: Writing – original draft. Francis Muangalayi: Writing – original draft. Alain Kabongo Tshiala: Writing – original draft. Alain Mwamba Mukendi: Methodology; writing – original draft; writing – review and editing.None.The authors declare no conflicts of interest.Written informed consent was obtained from the patient for publication of this manuscript and accompanying pictures. A copy of the written consent is available for review by the Editor in Chief of this journal.