Surgical outcomes of suprafascial and subfascial radial forearm free flaps in head and neck reconstruction

Background@#Conventional radial forearm free flaps (RFFFs) are known to be safe, but can result in donor site complications. Based on our experiences with suprafascial and subfascial RFFFs, we evaluated the safety of flap survival and surgical outcomes. @*Methods@#This was a retrospective study of head and neck reconstructions using RFFFs from 2006 to 2021. Thirty-two patients underwent procedures using either subfascial (group A) or suprafascial (group B) dissection for flap elevation. Data were collected on patient characteristics, flap size, and donor and recipient complications, and the two groups were compared. @*Results@#Thirteen of the 32 patients were in group A and 19 were in group B. Group A included 10 men and three women, with a mean age of 56.15 years, and group B included 16 men and three women, with a mean age of 59.11 years. The mean defect areas were 42.83 cm² and 33.32 cm², and the mean flap sizes were 50.96 cm² and 44.54 cm² in groups A and B, respectively. There were 13 donor site complications: eight (61.5%) in group A and five (26.3%) in group B. Flexor tendon exposure occurred in three patients in group A and in none in group B. All flaps survived completely. A recipient site complication occurred in two patients (15.4%) in group A and three patients (15.8%) in group B. @*Conclusions@#Complications and flap survival were similar between the two groups. However, tendon exposure at the donor site was less prevalent in the suprafascial group, and the treatment period was shorter. Based on our data, suprafascial RFFF is a reliable and safe procedure for reconstruction of the head and neck.

Unusual anomaly of the radial artery encountered during the elevation of a radial forearm free flap: a case report

The radial forearm free flap (RFFF) has become popular for head and neck reconstructions. Owing to a constant anatomy the RFFF is relatively easy to dissect. Nevertheless, anatomical variations of the radial artery have been reported. Some variations could affect the survival of the flap. This paper reports an unusual anomaly of the radial artery where the radial artery was not located between the brachioradialis (BR) and flexor carpi radialis. The radial artery was observed above the BR and on the radial side of the BR. The survival of the elevated flap was deemed questionable because it had only few perforators. So we decided to discard the flap and to elevate another free flap for the head and neck defect. The donor area on the forearm was covered using the original skin of the first flap as a full-thickness skin graft. This case highlights a means to deal with anomalies of the radial artery encountered during the elevation of RFFF and the checking process for variations of the radial artery before RFFF.

Reconstruction of a large chest wall defect using bilateral pectoralis major myocutaneous flaps and V-Y rotation advancement flaps: a case report

Bilateral pectoralis major myocutaneous (PMMC) flaps are commonly used to reconstruct large chest wall defects. We report a case of large chest wall defect reconstruction using bilateral PMMC flaps augmented with axillary V-Y advancement rotation flaps for additional flap advancement. A 74-year-old male patient was operated on for recurrent glottic squamous cell carcinoma. Excision of the tumor resulted in a 10×10 cm defect in the anterior chest wall. Bilateral PMMC flaps were raised to cover the chest wall defect. For further flap advancement, V-Y rotation advancement flaps from both axillae were added to allow complete closure. All flaps survived completely, and postoperative shoulder abduction was not limited (100° on the right side and 92° on the left). Age-related skin redundancy in the axillae enabled the use of V-Y rotation advancement flaps without limitation of shoulder motion. Bilateral PMMC advancement flaps and the additional use of V-Y rotation advancement flaps from both axillae may be a useful reconstructive option for very large chest wall defects in older patients.

Biological Characterization of Marssonina coronaria Associated with Apple Blotch Disease

Marssonina coronaria associated with apple blotch disease causes severe premature defoliation, and is widely distributed in Korea. Thirteen isolates were collected from orchards located in Gyeongbuk Province from 2005~2007. All isolates displayed over 99.6% and 99.2% sequence similarity to each other in internal transcribed spacer regions and partial sequences of 28S rDNA, respectively. The isolates were phylogenetically closely related to Chinese isolates. Selected isolates did not differ in their pathogenicity. The optimum conditions for fungal growth were 20degrees C and pH 6 on peptone potato dextrose agar (PPDA). Peptone and mannose were the best nitrogen and carbon source, respectively. Fungal growth was better on PPDA than on common potato dextrose agar. This study provides valuable information for integrated disease management program and facilitates the routine culturing of M. coronaria.

Cerebral Air Embolism after Removal of Subclavian Venous Catheter: A case report

We experienced a patient who developed a cerebral air embolism after subclavian venous catheter removal. The patient underwent gastric antrectomy under impression of gastric cancer. After surgery, right subclavian venous catheter was removed while the patient was kept in supine position for 15 minutes. When he changed to sitting position, he became agitated and O2 saturation was dropped to 72%. Im-mediately 100% O2 was administered via air mask. Computed tomography of brain showed multiple focal air densities in the cerebral vessels. Three days after the event, he slowly regained consciousness with persistent left hemipareis. After rehabilitation, he was able to walk with quadcane and gained functional improvement.

The Effect of Hyperglycemia at Admission on Clinical Outcomes after Acute Stroke

OBJECTIVE: To clarify the issues about the importance of hyperglycemia in the acute stage of stroke as a poor predictor of clinical outcome, we analyzed the relationship between the glucose level in admission and clinical outcome in the acute stroke patients. METHOD: Twenty-five patients with sudden onset of acute stroke with focal neurological deficit were included in this study. Clinical assessments consisted of the National Institutes of Health Stroke Scale (NIHSS) for neurological impairment and the Korean modified Bathel index (KMBI) for functional status. NIHSS and K-MBI were assessed at admission and at discharge. Plasma glucose level was measured at admission in all patients. Acute hyperglycemia at admission was defined as fasting plasma glucose level more than 140 mg/dl. Statistical analysis were used to compare variables and clinical outcome scores between the normoglycemic and hyperglycemic groups. RESULTS: For the patient with hyperglycemia at admission, the odds ratio for neurological improvement decreased (beta=-0.604) and the odds ratio for functional improvement decreased (beta=-0.553). However, control of the glucose level during the acute stroke was not significantly related to neurological and functional recovery (p>0.05). CONCLUSION: In patients with acute stroke, hyperglycemia at admission was associated with neurological and functional impairments. Therefore, we expect that strict control of hyperglycemia during the acute stroke would improve clinical outcomes.

Mean Platelet Component Change according to Stage in Stroke Patients

OBJECTIVE: Decrease of platelet density by degranulation of activated platelet is well correlated with decrease of mean platelet component (MPC) value. We intended to investigate the change of MPC, mean platelet volume, and platelet count according to the stroke stage and difference between ischemic and hemorrhagic infarction. METHOD: Thirty eight patients (ischemic stroke 28 men, hemorrhagic stroke 10 men) and twenty age-matched healthy persons were included in this study. They were divided into acute stage group and subacute stage group. Each of them were sampled by venously and investigated about mean platelet component, mean platelet volume, and platelet counts. RESULTS: In ischemic stroke, there was statically (p <0.05) meaningful decrease of MPC value in acute stage (27.5+/-1.7) compared to control group (28.8+/-0.9). And MPC value in subacute stage showed meaningful increase (28.1+/-1.3) compared to acute stage but still remained in statically lower value compared to control value. In hemorrhagic stroke, there was no meaningful difference of MPC value in acute stage group (28.6+/-2.0) and subacute stage group (27.9+/-1.1) compared to control group. CONCLUSION: In ischemic stroke patients, MPC value in acute stage decreased meaningfully and this change might be useful as a landmark in predicting the activity of infarction.

The Effect of Vacuum-Assisted Closure (V.A.C.) Therapy in Pressure Ulcer

OBJECTIVE: To evaluate the effect of Vacuum-Assisted Closure (V.A.C.) therapy in stage 3 or 4 pressure ulcers refractory to traditional saline wet gauze dressing. METHOD: Ten patients who had stage 3 or 4 pressure ulcers which were failed to heal with saline wet gauze dressing over 4 weeks were investigated. We treated these subjects with V.A.C. therapy. The length, width and depth of pressure ulcers were evaluated every week for 3 weeks. Soft tissue biopsy from pressure ulcer was taken before starting V.A.C. therapy and after the scheduled therapy was done. RESULTS: The sizes of length, width and depth in pressure ulcer were significantly decreased after one week of V.A.C. application. And then healthy granulation tissue was formed. The length, width and depth of the pressure ulcer were decreased of 40.2%, 42.7% and 79.8% of their original size. Soft tissue biopsy in pressure ulcers was taken in 4 cases, the number and size of capillaries were more increased and inflammatory cells were decreased. CONCLUSION: V.A.C. therapy promoted wound healing and revealed favorable histological changes in pressure ulcers refractory to traditional dressing. We suggest that V.A.C. therapy can be used for the effective management of pressure ulcer.

Early Detection of Human Cytomegalovirus DNA by PCR-ELISA / 대한임상병리학회지

BACKGROUND: Human cytomegalovirus (CMV) infections are common and occasionally severe in newborns, immunocompromised hosts, cancer patients, and recipients of organ transplant. Consequently, sensitive and rapid methods for CMV detection are of great diagnostic value since antiviral drugs have become available, which might be more effective upon early administration. We evaluated a polymerase chain reaction and enzyme-linked immunosorbent assay (PCR- ELISA) to detect human CMV infection as an aid in making a prompt diagnosis and a determination of therapeutic efficacy. METHODS: CMV DNA was amplified by single PCR, using primers chosen from genomic regions (major immediate-early [MIE] protein coding region), and the microwell plate hybridization assay was performed for specific detection of 5'-biotinylated PCR products using CMV-specific probes labeled with digoxigenin. A total of 35 clinical specimens from 14 patients who were suspected CMV infectious state was analyzed by PCR-ELISA and its results were compared with those of serum anti-CMV IgM, shell vial culture assay and PCR. RESULTS: The sensitivity for detection of PCR-amplified CMV DNA by the ELISA was 102 copies, which was ten-fold greater than ethidium bromide staining of agarose gels. The positive rates of 35 clinical specimens by serology, shell vial culture assay, PCR and PCR-ELISA were 37.9%, 40.0%, 60.0% and 68.6%, respectively. The OD ranges of 24 positive specimens by PCR-ELISA were from 0.042 to above 2.5. In follow-up studies of two patients with bone marrow transplantation, positive CMV results by PCR-ELISA earlier than by other methods including serologic method, shell vial culture assay and PCR. CONCLUSIONS: These results reveal that PCR-ELISA may show higher sensitivity and positive rate than serologic method, shell vial culture assay and conventional PCR. PCR-ELISA can be useful to manage CMV infection rapidly in patients at risk.

The Clinical Significance of the Detection of Human Papilloma Virus in the Patients with ASCUS in the Cervical Pap Smear / 대한산부인과학회잡지

OBJECTIVE: Our purpose was to determine the clinical value of human papilloma virus deoxyribonucleic acid testing with the hybrid capture test, specifically to examine whether human papillomavirus testing could identify which women with Papanicolaou smears read as atypical squamous cells of undetermined significance were most likely to have histologically confirmed cervical intraepithelial neoplasia. STUDY DESIGN: Hybrid capture testing for high-risk human paillomavirus types(type 31, 33, 35, 45, 51, 52, 56), repeat Papanicolaou smears and colposcopically directed biopsies were performed concurrently on 55 women refered to chosun university hospital with a previous Papanicolaou smear read as atypical squamous cells of undetermined significance. RESULTS: Human papillomavirus eoxyribonucleic acid positivity was associated with a six fold increased likelihood of histologic confirmation of cervical intraepithelial neoplasia. The sensitivity of hybrid capture for any cervical intraepithelial neoplasia was 92% (12/13) and specificity was 86%(36/42), whereas the corresponding values for the repeat Papanicilaou smear was 85%(11/13) and 38%(16/42), respectively. CONCLUSIONS: Testing for human papillomavirus deoxyribonucleic acid with hybrid capture appears to offer an effective means by which patients whose cervical Papanicolaou smears have been read as atypical squamous cells of undetermined significance could be triaged for colposcopy. In particular, high sensitivity and specificity for cervical intraepithelial neoplasia could be maintained.

Intraoperative Management of Myocardial Ischemia with Transesophageal Echocardiography during Coronary Bypass Surgery / 대한마취과학회지

BACKGROUND; Regional wall motion abnormalities(RWMA) detected by intraoperative transesophageal echocardiography(TEE) are thought to be sensitive indicators of myocardial ischemia. The present study was undertaken to elucidate management of RWMA with an immediate regraft in the area of RWMA or conventional drug therapy. METHOD; Twenty-six patients undergoing coronary artery bypass graft surgery were examined with TEE. After induction of anesthesia, TEE probe was inserted into esophagus and connected to Echo system. LV short axis views at the mid-papillary muscle level were viewed and recorded. TEE showed postbypass RWMA in 6 cases and one patient who did not have the TEE developed postbypass RWMA viewed by the epicardial echocardiography. Regraft was performed at the area of RWMA in 3 patients. The remainder was treated with intraaortic balloon pump(IABP) and/or inotropics. RESULTS; The patients with regraft showed an immediate improvement of the new RWMAs. The patients treated with IABP and/or inotropics had improvement of hemodynamics but did not show any improvement of the RWMAs. All seven patients developed hypotension and ST segment changes. All patients with the conventional treatment and two out of 3 regraft patients developed the postoperative myocardial infarctions. CONCLUSIONS; In conclusion this study demonstrated that patients experiencing persistent RWMA would be more likely to have myocardial infarction than those having only transient changes and that TEE would be an excellent tool for early detection of myocardial ischemia and might improve treatment of ischemic events.

The Use of Pressure-Limit Control Accessary for Anesthetic Drager Infant Ventilator in Pediatric Patients with Congenital Heart Disease / 대한마취과학회지

Pressure-limit ventilators are used because it is believed that they decrease the incidence of pulmonary gas leaks and chronic lung disease. The disadvantage of pressurelimit ventilators is that there is no automatic compensation for changes in compliance and resistance of the lung and the chest wall. Consequently, if lung compliance decreases, tidal volume will decrease and blood gases will worsen. The aim of this study is to find the adequacy for the oxygenation and ventilation of volume-limit ventilator with pressure-limit control accessary in pediatric patient with congenital heart disease. The pressure-limit control accessary for anesthetic ventilator(AV-E, North America Drager, Bedford, USA) in 36 pediatric patients undertaken open heart surgery and thoracotomy, retrospectively, were employed. The patients were divided into 3 groups according to their body weights. The respiratory rate of group I ( or = 5, or = 10, < 20 kg, n=8) was 15/min. The patients were divided into another 2 groups, A(n=30) or B(n=6), with the supine or lateral, respectively according to the operation position. The results showed all the values of arterial blood gases almost within normal limits, except one patient in each group. We concluded that anesthetic Drager infant ventilator with pressure-limit control accessary was useful during controlled ventilation, and this is suitable for the prolonged operation in pediatric patients with the supine or lateral position.