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The present study aimed to investigate the pharyngeal and nasal microbiota composition in children with adenotonsillar hypertrophy (AH) and assess longitudinal alterations in both microbiota after a probiotic oral spray treatment. A cohort of 57 AH patients were enrolled and randomly assigned to the probiotic and placebo groups for a 5-month treatment course. Pharyngeal and nasal swabs were collected before and after treatment and analyzed by 16S rRNA-based metataxonomics and axenic cultures for pathobiont identification. 16S rRNA sequences from pharyngeal and nasal swabs of 65 healthy children (HC) were used as microbiota reference profiles. We found that the pharyngeal and nasal microbiota of AH children were similar. When compared to HC, we observed an increase of the genera Rothia , Granulicatella , Streptococcus , Neisseria , and Haemophilus , as well as a reduction of Corynebacterium , Pseudomonas, Acinetobacter, and Moraxella in both microbiota of AH patients. After probiotic treatment, we confirmed the absence of adverse effects and a reduction of upper respiratory tract infections (URTI). Moreover, the composition of pharyngeal microbiota was positively influenced by the reduction of potential pathobionts, like Haemophilus spp., with an increase of beneficial microbial metabolic pathways. Finally, the probiotic reduced the abundance of the pathobionts Streptococcus mitis and Gemella haemolysans in relation to AH severity. In conclusion, our results highlight the alterations of the pharyngeal and nasal microbiota associated with AH. Moreover, probiotic administration conferred protection against URTI and reduced the presence of potential pathobionts in patients with AH., Importance: Adenotonsillar hypertrophy (AH) is considered the main cause of breathing disorders during sleep in children. AH patients, after significant morbidity and often multiple courses of antibiotics, often proceed to tonsillectomy and/or adenoidectomy. Given the potential risks associated with these procedures, there is a growing interest in the use of nonsurgical adjuvant therapies, such as probiotics, that could potentially reduce their need for surgical intervention. In this study, we investigated the pharyngeal and nasal microbiota in patients with AH compared with healthy children. Furthermore, we tested the effects of probiotic spray administration on both disease symptoms and microbiota profiles, to evaluate the possible use of this microbial therapy as an adjuvant for AH patients.

The urgency to find complementary therapies to current SARS-CoV-2 vaccines, whose effectiveness is preserved over time and not compromised by the emergence of new and emerging variants, has become a critical health challenge. We investigate the possibility of jamming the opening of the Receptor Binding Domain (RBD) of the spike protein of SARS-CoV-2 with small compounds. Through in silico screening, we identified two potential candidates that would lock the Receptor Binding Domain (RBD) in a closed configuration, preventing the virus from infecting the host cells. We show that two drugs already approved by the FDA, mithramycin and dihydroergotamine, can block infection using concentrations in the μM range in cell-based assays. Further STD-NMR experiments support dihydroergotamine's direct interaction with the spike protein. Overall, our results indicate that repurposing of these compounds might lead to potential clinical drug candidates for the treatment of SARS-CoV-2 infection., Competing Interests: The authors declare no competing financial interest., (© 2023 The Authors. Published by American Chemical Society.)

Gut microbiota (GM) modulation can be investigated as possible solution to enhance recovery after COVID-19. An open-label, single-center, single-arm, pilot, interventional study was performed by enrolling twenty patients recently recovered from COVID-19 to investigate the role of a mixed probiotic, containing Lactobacilli, Bifidobacteria and Streptococcus thermophilus , on gastrointestinal symptoms, local and systemic inflammation, intestinal barrier integrity and GM profile. Gastrointestinal Symptom Rating Scale, cytokines, inflammatory, gut permeability, and integrity markers were evaluated before (T 0 ) and after 8 weeks (T 1 ) of probiotic supplementation. GM profiling was based on 16S-rRNA targeted-metagenomics and QIIME 2.0, LEfSe and PICRUSt computational algorithms. Multiple machine learning (ML) models were trained to classify GM at T 0 and T 1 . A statistically significant reduction of IL-6 ( p < 0.001), TNF-α ( p < 0.001) and IL-12RA ( p < 0.02), citrulline ( p value < 0.001) was reported at T 1 . GM global distribution and microbial biomarkers strictly reflected probiotic composition, with a general increase in Bifidobacteria at T 1 . Twelve unique KEGG orthologs were associated only to T 0 , including tetracycline resistance cassettes. ML classified the GM at T 1 with 100% score at phylum level. Bifidobacteriaceae and Bifidobacterium spp. inversely correlated to reduction of citrulline and inflammatory cytokines. Probiotic supplementation during post-COVID-19 may trigger anti-inflammatory effects though Bifidobacteria and related-metabolism enhancement.

Goat cheese is an important element of the Mediterranean diet, appreciated for its health-promoting features and unique taste. A pivotal role in the development of these characteristics is attributed to the microbiota and its continuous remodeling over space and time. Nevertheless, no thorough study of the cheese-associated microbiota using two metaomics approaches has previously been conducted. Here, we employed 16S rRNA gene sequencing and metaproteomics to explore the microbiota of a typical raw goat milk cheese at various ripening timepoints and depths of the cheese wheel. The 16S rRNA gene-sequencing and metaproteomics results described a stable microbiota ecology across the selected ripening timepoints, providing evidence for the microbiologically driven fermentation of goat milk products. The important features of the microbiota harbored on the surface and in the core of the cheese mass were highlighted in both compositional and functional terms. We observed the rind microbiota struggling to maintain the biosafety of the cheese through competition mechanisms and/or by preventing the colonization of the cheese by pathobionts of animal or environmental origin. The core microbiota was focused on other biochemical processes, supporting its role in the development of both the health benefits and the pleasant gustatory nuances of goat cheese.

Alterations of gut microbiota have been identified before clinical manifestation of type 1 diabetes (T1D). To identify the associations amongst gut microbiome profile, metabolism and disease markers, the 16S rRNA-based microbiota profiling and 1 H-NMR metabolomic analysis were performed on stool samples of 52 T1D patients at onset, 17 T1D siblings and 57 healthy subjects (CTRL). Univariate, multivariate analyses and classification models were applied to clinical and -omic integrated datasets. In T1D patients and their siblings, Clostridiales and Dorea were increased and Dialister and Akkermansia were decreased compared to CTRL, while in T1D, Lachnospiraceae were higher and Collinsella was lower, compared to siblings and CTRL. Higher levels of isobutyrate, malonate, Clostridium , Enterobacteriaceae, Clostridiales, Bacteroidales, were associated to T1D compared to CTRL. Patients with higher anti-GAD levels showed low abundances of Roseburia , Faecalibacterium and Alistipes and those with normal blood pH and low serum HbA 1c levels showed high levels of purine and pyrimidine intermediates. We detected specific gut microbiota profiles linked to both T1D at the onset and to diabetes familiarity. The presence of specific microbial and metabolic profiles in gut linked to anti-GAD levels and to blood acidosis can be considered as predictive biomarker associated progression and severity of T1D.

Astroblastomas are neuroepithelial tumours defined by the presence of MN1 rearrangement and are typically located in the cerebral hemispheres. Rare cases of astroblastoma-like tumours carrying an EWSR1-BEND2 fusion have been recently described in the brain stem and spinal cord. We report a paediatric case of neuroepithelial astroblastoma-like tumour occurring in the spine and carrying a novel MAMLD1-BEND2 fusion. We believe that our case aligns with the rare astroblastoma-like tumours with EWSR1-BEND2 fusion, in terms of non-hemispheric location, pathology, methylation profile and activation of BEND2 transcription. Whether they may represent a distinct entity or a variant of MN1-altered astroblastoma is not clear., (© 2022 British Neuropathological Society.)

This is the first study on gut microbiota (GM) in children affected by coronavirus disease 2019 (COVID-19). Stool samples from 88 patients with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and 95 healthy subjects were collected (admission: 3-7 days, discharge) to study GM profile by 16S rRNA gene sequencing and relationship to disease severity. The study group was divided in COVID-19 (68), Non-COVID-19 (16), and MIS-C (multisystem inflammatory syndrome in children) (4). Correlations among GM ecology, predicted functions, multiple machine learning (ML) models, and inflammatory response were provided for COVID-19 and Non-COVID-19 cohorts. The GM of COVID-19 cohort resulted as dysbiotic, with the lowest α-diversity compared with Non-COVID-19 and CTRLs and by a specific β-diversity. Its profile appeared enriched in Faecalibacterium , Fusobacterium , and Neisseria and reduced in Bifidobacterium , Blautia , Ruminococcus , Collinsella , Coprococcus , Eggerthella , and Akkermansia , compared with CTRLs ( p < 0.05). All GM paired-comparisons disclosed comparable results through all time points. The comparison between COVID-19 and Non-COVID-19 cohorts highlighted a reduction of Abiotrophia in the COVID-19 cohort ( p < 0.05). The GM of MIS-C cohort was characterized by an increase of Veillonella , Clostridium , Dialister , Ruminococcus , and Streptococcus and a decrease of Bifidobacterium , Blautia , Granulicatella , and Prevotella , compared with CTRLs. Stratifying for disease severity, the GM associated to "moderate" COVID-19 was characterized by lower α-diversity compared with "mild" and "asymptomatic" and by a GM profile deprived in Neisseria , Lachnospira , Streptococcus , and Prevotella and enriched in Dialister , Acidaminococcus , Oscillospora , Ruminococcus , Clostridium , Alistipes , and Bacteroides. The ML models identified Staphylococcus , Anaerostipes , Faecalibacterium , Dorea , Dialister , Streptococcus , Roseburia , Haemophilus , Granulicatella , Gemmiger , Lachnospira , Corynebacterium , Prevotella , Bilophila , Phascolarctobacterium , Oscillospira , and Veillonella as microbial markers of COVID-19. The KEGG ortholog (KO)-based prediction of GM functional profile highlighted 28 and 39 KO-associated pathways to COVID-19 and CTRLs, respectively. Finally, Bacteroides and Sutterella correlated with proinflammatory cytokines regardless disease severity. Unlike adult GM profiles, Faecalibacterium was a specific marker of pediatric COVID-19 GM. The durable modification of patients' GM profile suggested a prompt GM quenching response to SARS-CoV-2 infection since the first symptoms. Faecalibacterium and reduced fatty acid and amino acid degradation were proposed as specific COVID-19 disease traits, possibly associated to restrained severity of SARS-CoV-2-infected children. Altogether, this evidence provides a characterization of the pediatric COVID-19-related GM., Competing Interests: Author GM, VG, and SG are employed by GenomeUp SRL, Viale Pasteur, 6, 00144, Rome, Italy. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Romani, Del Chierico, Macari, Pane, Ristori, Guarrasi, Gardini, Pascucci, Cotugno, Perno, Rossi, Villani, Bernardi, Campana, Palma, Putignani and the CACTUS Study Team.)

This work presents Fragment Graph DataBase (FGDB), a graph database of ligand fragments extracted and generated from the protein entries available in the Protein Data Bank (PDB). FGDB is meant to support and elicit campaigns of fragment-based drug design, by enabling users to query it in order to construct ad hoc, target-specific libraries. In this regard, the database features more than 17 000 fragments, typically small, highly soluble and chemically stable molecules expressed via their canonical Simplified Molecular Input Line Entry System (SMILES) representation. For these fragments, the database provides information related to their contact frequencies with the amino acids, the ligands they are contained in and the proteins the latter bind to. The graph database can be queried via standard web forms and textual searches by a number of identifiers (SMILES, ligand and protein PDB ids) as well as via graphical queries that can be performed against the graph itself, providing users with an intuitive and effective view upon the underlying biological entities. Further search mechanisms via advanced conjunctive/disjunctive/negated textual queries are also possible, in order to allow scientists to look for specific relationships and export their results for further studies. This work also presents two sample use cases where maternal embryonic leucine zipper kinase and mesotrypsin are used as a target, being proteins of high biomedical relevance for the development of cancer therapies. Database URL: http://biochimica3.bio.uniroma3.it/fragments-web/., (© The Author(s) 2022. Published by Oxford University Press.)

Carfilzomib is a last generation proteasome inhibitor (PI) with proven clinical efficacy in the treatment of relapsed/refractory multiple myeloma. This drug is considered to be extremely specific in inhibiting the chymotrypsin-like activity of the 20S proteasome, encoded by the β5 subunit, overcoming some bortezomib limitations, the first PI approved for multiple myeloma therapy which is however burdened by a significant toxicity profile, due also to its off-target effects. Here, molecular approaches coupled with molecular docking studies have been used to unveil that the Insulin-Degrading Enzyme, a ubiquitous and highly conserved Zn 2+ peptidase, often found to associate with proteasome in cell-based models, is targeted by carfilzomib in vitro. The drug behaves as a modulator of IDE activity, displaying an inhibitory effect over 10-fold lower than for the 20S. Notably, the interaction of IDE with the 20S enhances in vitro the inhibitory power of carfilzomib on proteasome, so that the IDE-20S complex is an even better target of carfilzomib than the 20S alone. Furthermore, IDE gene silencing after delivery of antisense oligonucleotides (siRNA) significantly reduced carfilzomib cytotoxicity in rMC1 cells, a validated model of Muller glia, suggesting that, in cells, the inhibitory activity of this drug on cell proliferation is somewhat linked to IDE and, possibly, also to its interaction with proteasome.

The anticoagulant therapy is widely used to prevent and treat thromboembolic events. Until the last decade, vitamin K antagonists were the only available oral anticoagulants; recently, direct oral anticoagulants (DOACs) have been developed. Since 55% to 95% of DOACs are bound to plasma proteins, the in silico docking and ligand-binding properties of drugs apixaban, betrixaban, dabigatran, edoxaban, and rivaroxaban and of the prodrug dabigatran etexilate to human serum albumin (HSA), the most abundant plasma protein, have been investigated. DOACs bind to the fatty acid (FA) site 1 (FA1) of ligand-free HSA, whereas they bind to the FA8 and FA9 sites of heme-Fe(III)- and myristic acid-bound HSA. DOACs binding to the FA1 site of ligand-free HSA has been validated by competitive inhibition of heme-Fe(III) recognition. Values of the dissociation equilibrium constant for DOACs binding to the FA1 site (ie, calc K DOAC ) derived from in silico docking simulations (ranging between 1.2 × 10 -8 M and 1.4 × 10 -6 M) agree with those determined experimentally from competitive inhibition of heme-Fe(III) binding (ie, exp K DOAC ; ranging between 2.5 × 10 -7 M and 2.2 × 10 -6 M). In addition, this study highlights the inequivalence of rivaroxaban binding to mammalian serum albumin. Given the HSA concentration in vivo (~7.5 × 10 -4 M), values of K DOAC here determined indicate that the formation of the HSA:DOACs complexes in the absence and presence of FAs and heme-Fe(III) may occur in vivo. Therefore, HSA appears to be an important determinant for DOACs transport., (© 2020 John Wiley & Sons Ltd.)

Motivation: Bringing a new drug to the market is expensive and time-consuming. To cut the costs and time, computer-aided drug design (CADD) approaches have been increasingly included in the drug discovery pipeline. However, despite traditional docking tools show a good conformational space sampling ability, they are still unable to produce accurate binding affinity predictions. This work presents a novel scoring function for molecular docking seamlessly integrated into DockingApp, a user-friendly graphical interface for AutoDock Vina. The proposed function is based on a random forest model and a selection of specific features to overcome the existing limits of Vina's original scoring mechanism. A novel version of DockingApp, named DockingApp RF, has been developed to host the proposed scoring function and to automatize the rescoring procedure of the output of AutoDock Vina, even to nonexpert users., Results: By coupling intermolecular interaction, solvent accessible surface area features and Vina's energy terms, DockingApp RF's new scoring function is able to improve the binding affinity prediction of AutoDock Vina. Furthermore, comparison tests carried out on the CASF-2013 and CASF-2016 datasets demonstrate that DockingApp RF's performance is comparable to other state-of-the-art machine-learning- and deep-learning-based scoring functions. The new scoring function thus represents a significant advancement in terms of the reliability and effectiveness of docking compared to AutoDock Vina's scoring function. At the same time, the characteristics that made DockingApp appealing to a wide range of users are retained in this new version and have been complemented with additional features.

Butylated hydroxytoluene (BHT) is one of the most commonly used synthetic antioxidants in food, cosmetic, pharmaceutical and petrochemical products. BHT is considered safe for human health; however, its widespread use together with the potential toxicological effects have increased consumers concern about the use of this synthetic food additive. In addition, the estimated daily intake of BHT has been demonstrated to exceed the recommended acceptable threshold. In the present work, using BHT as a case study, the usefulness of computational techniques, such as reverse screening and molecular docking, in identifying protein-ligand interactions of food additives at the bases of their toxicological effects has been probed. The computational methods here employed have been useful for the identification of several potential unknown targets of BHT, suggesting a possible explanation for its toxic effects. In silico analyses can be employed to identify new macromolecular targets of synthetic food additives and to explore their functional mechanisms or side effects. Noteworthy, this could be important for the cases in which there is an evident lack of experimental studies, as is the case for BHT.

Neonicotinoids are a widely used class of insecticides that target the acetylcholine recognition site of the nicotinic acetylcholine receptors in the central nervous system of insects. Although neonicotinoids display a high specificity for insects, their use has been recently debated since several studies led to the hypothesis that they may have adverse ecological effects and potential risks to mammals and even humans. Due to their hydrophobic nature, neonicotinoids need specific carriers to allow their distribution in body fluids. Human serum albumin (HSA), the most abundant plasma protein, is a key carrier of endogenous and exogenous compounds. The in silico docking and ligand binding properties of acetamiprid, clothianidin, dinotefuran, imidacloprid, nitenpyram, thiacloprid, and thiamethoxam to HSA are here reported. Neonicotinoids bind to multiple fatty acid (FA) binding sites, preferentially to the FA1 pocket, with high affinity. Values of the dissociation equilibrium constant for neonicotinoid binding FA1 of HSA (i.e., calc K n ) derived from in silico docking simulations (ranging between 3.9 × 10 -5 and 6.3 × 10 -4 M) agree with those determined experimentally from competitive inhibition of heme-Fe(III) binding (i.e., exp K n ; ranging between 2.1 × 10 -5 and 6.9 × 10 -5 M). Accounting for the HSA concentration in vivo (~7.5 10 -4 M), values of K n here determined suggest that the formation of the HSA:neonicotinoid complexes may occur in vivo. Therefore, HSA appears to be an important determinant for neonicotinoid transport and distribution to tissues and organs, particularly to the liver where they are metabolized., (© 2019 International Union of Biochemistry and Molecular Biology.)

In the current "genomic era" the number of identified genes is growing exponentially. However, the biological function of a large number of the corresponding proteins is still unknown. Recognition of small molecule ligands (e.g., substrates, inhibitors, allosteric regulators, etc.) is pivotal for protein functions in the vast majority of the cases and knowledge of the region where these processes take place is essential for protein function prediction and drug design. In this regard, computational methods represent essential tools to tackle this problem. A significant number of software tools have been developed in the last few years which exploit either protein sequence information, structure information or both. This review describes the most recent developments in protein function recognition and binding site prediction, in terms of both freely-available and commercial solutions and tools, detailing the main characteristics of the considered tools and providing a comparative analysis of their performance.

Introduction: In Chile, the prison system has a program that allows inmate mothers to live with their children un der two years of age. This could imply that these children are more exposed to stress conditions and a higher psychomotor developmental delay (PDD) risk., Objective: To compare the PDD and salivary cortisol concentrations (SCC) of children living in prison with their mothers and to compare the results with control children., Subjects and Method: Cross-sectional study in 42 infants, 12 of them are children of inmate mothers in the penitentiary center (CPF) of Santiago, and 30 controls from a Primary Care Family Health Center (CESFAM). PDD of infants was assessed through the ASQ-3 questionnaire and salivary cortisol was measured in infants and mothers using radioimmunoassay., Results: The median salivary cortisol level of the children of CPF and CESFAM mothers was 2.3 ng/ ml (IQR 1.1 to 2.7) and 2.1 ng/ml (IQR 1.6 to 2, 9) respectively. Maternal cortisol was 4.6 ng/ml (IQR 3.8 to 7.3) in the CPF and 3.7 ng/ml (IQR 2.4 to 4.7) in the CESFAM. The PDD deficit was 2.3% and 28.5% for children from the CPF and the CESFAM respectively, without statistical difference (p = 0.06)., Conclusions: There was no difference in the PDD and salivary cortisol between children of both groups.

In this work, the information contained in the contacts between fragments of small-molecule ligands and protein residues has been collected and its exploitability has been verified by using the scoring of docking simulations as a test case for bringing about a proof of concept. Contact statistics between small-molecule fragments and binding site residues were collected and analyzed using a dataset composed of 200,000+ binding sites and associated ligands, derived from the database of the LIBRA ligand binding site recognition software, as a starting point. The fragments were generated by applying the decomposition algorithm implemented in BRICS. A simple "potential" based on the contact frequencies was tested against the CASF-2013 benchmark; its performance was then evaluated through the rescoring of docking poses generated for the DUD-E dataset. The results obtained indicate that this approach, its simplicity notwithstanding, yields promising results that are comparable, and in some cases, superior, to those obtained with other, more complex scoring functions.

Multiple classical molecular dynamics simulations have been applied to the human LOX-1 receptor to clarify the role of the Trp150Ala mutation in the loss of binding activity. Results indicate that the substitution of this crucial residue, located at the dimer interface, markedly disrupts the wild-type receptor dynamics. The mutation causes an irreversible rearrangement of the subunits interaction pattern that in the wild-type protein allows the maintaining of a specific symmetrical motion of the monomers. The subunits dislocation determines a loss of linearity of the arginines residues composing the basic spine and a consequent alteration of the long-range electrostatic attraction of the substrate. Moreover, the anomalous subunits arrangement observed in the mutated receptor also affects the integrity of the hydrophobic tunnel, actively involved in the short-range hydrophobic recognition of the substrate. The combined effect of these structural rearrangements generates the impairing of the receptor function., (© 2017 Wiley Periodicals, Inc.)

The efficacy of microsurgical free-tissue transfer for the treatment of chronic nonhealing infected diabetic foot ulcers was evaluated in a retrospective study. Between January 1992-December 1997, 10 patients underwent surgery at the American University of Beirut. Muscular free flaps were used to salvage 8 feet, and fasciocutaneous free flaps were used in 2 feet. The flap survival rate was 90%, a result that is equivalent to other series of microvascular tissue transfer in nondiabetic patients; the postoperative morbidity rate was comparable to that of nondiabetic patients. Infection control was achieved in 87.5% of patients. Seven of the 9 surviving patients had bipedal gait and were ambulatory, with full weight-bearing on their flaps at the end of the 2-year follow-up period. Microvascular free-tissue transfer can be used successfully for the salvage of infected diabetic foot ulcers., (Copyright 2003 Wiley-Liss, Inc.)

Seventeen patients who underwent soft-tissue reconstruction of various anatomic regions of the foot and ankle, using the radial forearm fasciocutaneous free flap, are reported. The procedures were performed between January, 1992 and December, 1998. Indications for reconstruction included diabetes and/or vascular insufficiency (four patients), soft-tissue defects (six patients), and chronic osteomyelitis (seven patients). The weight-bearing surface of the foot was involved in 16 patients. Defects ranged in size from 35 to 206 cm2 (mean: 86.2 cm2). At a mean follow-up of 3.8 years, the radial forearm flap was successful in all cases (100 percent). Flap complications included superficial infection (three patients), and minor wound dehiscence at the flap-leg-skin interface (two patients). Recurrent ulceration occurred in two patients; both were diabetics with weight-bearing flaps. Donor-site complications included partial skin graft loss with tendon exposure in one patient, which healed with conservative management. Recurrent or persistent osteomyelitis was not demonstrated in any of the patients. Of the 16 patients with weight-bearing flaps, 12 were ambulatory, three had limited ambulation, and one was non-ambulatory. Three patients required modified shoes. No debulking of the transferred flaps was necessary. The radial forearm flap is one of the preferred flaps for reconstruction of moderate-sized ankle and foot defects, for weight-bearing surfaces, and in the treatment of osteomyelitic and diabetic wounds. It meets most of the anatomic prerequisites for an ideal foot coverage; it also facilitates the restoration of normal foot contour, allowing patients to wear ordinary shoes. The flap provides a durable and stable weight-bearing plantar surface during ambulation, and achieves excellent aesthetic results; when used as a neurosensory flap, it permits adequate reinnervation.

Over a period of 5 years, 65 children under 12 years of age were diagnosed as having "wrist sprain" at the American University of Beirut Medical Center, Emergency Department. Thirty-eight children were reevaluated; 33 patients (86.8%) were diagnosed as having a Salter-Harris I fracture of the distal radius that necessitated further treatment to relieve symptoms and allow early wrist function. The diagnosis of "wrist sprain" is often inadequate in establishing a proper treatment regimen. Rather, by taking a careful history, performing an exacting examination, and utilizing appropriate diagnostic aids, an accurate diagnosis of wrist injury can be established.

Forty patients who underwent rectus abdominis free-tissue transfer with split-thickness skin grafts for reconstruction of the lower extremity are reported. The procedures were performed between January, 1992 and December, 1998. Transfers were utilized for coverage of acute soft-tissue and bone defects (18 patients), defects following radical debridement of chronic osteomyelitis of the leg and foot (13 patients) or diabetic foot ulcers (eight patients), and for unstable scars (one patient). At a mean follow-up of 3.6 years, there was no donor-site morbidity; there were seven local complications--five superficial flap necroses and two flap congestions. Three flaps were totally lost. All patients but one were ambulatory and fully weight-bearing at the time of review, with consolidation of the fractures and bone defects and no evidence of recurrence of infection in the osteomyelitis or diabetic foot ulcer groups. The relatively high success rate (92.5 percent), the ease of surgical dissection, the consistency and size of the deep inferior epigastric pedicle, the absence of donor-site morbidity, and relatively low complication rates make the rectus abdominis muscle one of the preferable free-tissue transfers for these authors.

The self-study program has been a great success. Staff seized the opportunity for "hands-on," nonthreatening learning. The fear of asking questions and appearing less knowledgeable than peers in a group setting is removed, and new employees are grateful for the rapid accessibility of concise reference material. Everyone enjoys the freedom of fitting the in-service program into a routine day, rather than trying to adapt to a set time. Last, but not least, management reaps to the benefit of a program that satisfies the expectations of regulatory agencies and is virtually cost-free.