Immediate inguinal lymphaticovenous anastomosis following lymphadenectomy in skin cancer of lower extremities.

BACKGROUND: Secondary lymphedema following inguinal lymph node dissection in lower extremities skin cancer reduce the patients' quality of life. Immediate lymphaticovenous anastomosis (LVA) at groin is a procedure intended to prevent secondary lymphedema. The data regarding the long-term efficacy and safety of this procedure was limited. Therefore, we evaluated the long-term outcomes of immediate LVA in patients with melanoma and non-melanoma skin cancer of the lower extremities. METHODS: The retrospective data review of patients with melanoma or squamous cell carcinoma of the lower extremities underwent oncologic tumor resection with groin node dissection between December 2013 and December 2016 was performed. Seven patients underwent immediate LVA (intervention) at groin after node dissection and 22 acted as controls. The occurrence of lymphedema and oncologic outcomes were followed up to 7 years. RESULTS: Fifteen patients (51.7%) developed postoperative lymphedema, which were three patients in the intervention group and twelve patients in the control group (p = 0.68). The intervention group had significant lower 2-year (57.1% versus 77.3%) and 5-year overall survival (14.3% versus 54.5%) (p = 0.035). The intervention group had reduced 2-year (28.6% versus 86.4%) and 5-year (28.6% versus 68.2%) Recurrence Free Survival (RFS) (p = 0.013). The intervention group also had reduced 2-year (0% versus 90%) and 5-year (0% versus 70%) Metastasis Free Survival (MFS) (p = 0.003). CONCLUSION: Immediate inguinal LVA following groin node dissection in lower extremity skin cancer patients did not reduce the incidence of lymphedema. Unfortunately, it was associated with lower overall survival and an increase in tumor recurrence and metastasis.

Prospective study of Q-switched Nd:YAG laser treatment of hyperpigmented split-thickness skin grafts.

Hyperpigmentation of split-thickness skin grafts (STSGs) is commonly found among Asians, and it is also challenging to treat. Although the 1064-nm Q-switched Nd:YAG laser has been used as a standard treatment for skin hyperpigmented lesions, there are limited number of reports focusing on the treatment of hyperpigmentation of STSGs. We aimed to evaluate the efficacy of 1064-nm Q-switched Nd:YAG laser for treatment of hyperpigmented STSGs. Half of each STSGs was treated with the 1064-nm Q-switched Nd:YAG laser, while the remaining was left untreated as comparison. The laser was applied for 4 times with 2-4-week interval. The treatment outcomes were compared by measurement of melanin index, erythema index, and photographs of STSGs at prior to enrollment, before each treatment session, and after 1 month of treatment completion. Five patients with 11 skin graft lesions were enrolled. The melanin index was significantly improved after the 2nd session and after treatment completion in laser-treated area (p = 0.006 and p = 0.001, respectively). There was non-significant difference in erythema index. The photographic comparison showed brightened of laser-treated area after treatment completion and improved skin texture. The 1064-nm Q-switched Nd:YAG laser can significantly reduce melanin index of STSGs and can be an alternative treatment for hyperpigmentation of STSGs.

Clinical validation of a Cas13-based assay for the detection of SARS-CoV-2 RNA.

Nucleic acid detection by isothermal amplification and the collateral cleavage of reporter molecules by CRISPR-associated enzymes is a promising alternative to quantitative PCR. Here, we report the clinical validation of the specific high-sensitivity enzymatic reporter unlocking (SHERLOCK) assay using the enzyme Cas13a from Leptotrichia wadei for the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-the virus that causes coronavirus disease 2019 (COVID-19)-in 154 nasopharyngeal and throat swab samples collected at Siriraj Hospital, Thailand. Within a detection limit of 42 RNA copies per reaction, SHERLOCK was 100% specific and 100% sensitive with a fluorescence readout, and 100% specific and 97% sensitive with a lateral-flow readout. For the full range of viral load in the clinical samples, the fluorescence readout was 100% specific and 96% sensitive. For 380 SARS-CoV-2-negative pre-operative samples from patients undergoing surgery, SHERLOCK was in 100% agreement with quantitative PCR with reverse transcription. The assay, which we show is amenable to multiplexed detection in a single lateral-flow strip incorporating an internal control for ribonuclease contamination, should facilitate SARS-CoV-2 detection in settings with limited resources.

Concepts and Artistry in the Treatment of Scapholunate Ligament Injuries.

BACKGROUND: Scapholunate ligament injuries are highly challenging injuries to treat. Great uncertainly remains in determining which operative procedures are most effective. Furthermore, there is no consensus on whether surgical intervention changes the natural course of scapholunate injuries. METHODS: The authors present their assessment of scapholunate injuries and the senior author's preferred surgical techniques. Surgical videos are included. The authors' postoperative management is described. RESULTS: Operative procedures are selected based on the patient's timing and pattern of injury, degree of associated carpal changes and arthritis, and goals. CONCLUSION: Over the past 20 years, the senior author has had good success with these techniques, but prospective, longterm outcome studies are needed to critically assess whether these surgical techniques improve patients' long-term function and pain.

Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment.

Proximal interphalangeal joint injuries are one of the most common injuries of the hand. The severity of injury can vary from a minor sprain to a complex intra-articular fracture. Because of the complex anatomy of the joint, complications may occur even after an appropriate treatment. This article provides a comprehensive review on existing techniques to manage complications and imparts practical points to help prevent further complications after proximal interphalangeal joint injury.

Use and Associated Spending for Anesthesiologist-Administered Services in Minor Hand Surgery.

BACKGROUND: Evidence is lacking to support the use of specialized anesthesia providers in minor surgical operations for patients without medical necessity. The authors sought to estimate the extent of potentially discretionary service use (anesthesiologist-administered anesthesia services among low-risk patients). METHODS: The authors performed a retrospective claims analysis using the Truven MarketScan Database to estimate the prevalence and cost of anesthesiologist-administered anesthesia services provided to patients undergoing minor hand surgery (i.e., carpal tunnel release, trigger finger release, or de Quervain release) from 2010 to 2015. A predictive probability model was created to estimate patient risk status. The authors examined the relationship between patient risk status and anesthesia use using multivariable regression models. RESULTS: Of 441,579 eligible procedures, 352,779 (80 percent) involved anesthesiologist-administered anesthesia services. The total proportion of estimated anesthesiologist-administered anesthesia use in low-risk patients who did not need anesthesiologist support declined over the study period (from 69.7 percent in 2010 to 65.8 percent in 2015). Although total payments for these services remained steady between 2010 and 2014, the average payment per procedure increased regardless of procedure type (from $376.8 in 2010 to $427.9 in 2015 for a carpal tunnel release operation). Approximately 83.7 percent of payments ($133 million) to anesthesia providers is credited to services in low-risk patients. CONCLUSIONS: Anesthesiologist-administered anesthesia services are commonly rendered to low-risk surgical patients. Existing health care reform efforts do not adequately address discretionary services that can be a targeted area for cost saving. It is important to consider the implications of potentially discretionary use of specialized anesthesia providers, particularly with the advancement of bundled payment models.

Five-Year Review Outcome of Microvascular Free Flap in Siriraj Hospital.

BACKGROUND: Microvascular free flap operation has become the preferred reconstructive technique at many medical centers to cover complex defects from tumor ablative surgery or trauma and for reconstructive procedure such as functioning muscle transfer. There are many clinical reports about free tissue transfer since the beginning of microvascular technique in the early 1960s. The overall success rate is about 90 to 98% but there may be postoperative complications. OBJECTIVE: Retrospectively analyze outcome and complications of consecutive series of microvascular free flap procedures, and compare with series published by other center. MATERIAL AND METHOD: The chart review was conducted of all patients that underwent microvascular free tissue transfer in our hospital between January 2007 and December 2011. The age, gender underlying disease, other risk factors (smoking, obesity, pre-operative radiation on recipient site), American Society of Anesthesiologists (ASA) classification, indication for surgery, location of defect, type of flap, operative time, inflow and outflow vessel, type of anastomosis, vein graft usage, ischemic time, length of hospital stay, length of intensive unit stay, flap success rate, re-exploration surgery, salvage rate, and perioperative complications of all patient were noted. These data were collected in database and were available for statistical analysis. RESULTS: Between January 2007 and December 2011, 153 microvascular tissue transfers were performed to coverage and reconstruct various kind of defects and diseases. There were 102 men and 51 women, age ranged from 11 to 84 years (mean 48 years). There were 50 patients over 60 years old (33%). Among the 153 procedures, there were 124 defects from tumor ablation, 14 procedures for wound coverage including defect from acute trauma in five patients, and other procedure such as functioning muscle transfer and sex reassignment surgery. The microvascular free flap reconstruction of various kinds of indication all over the body showed success rate of 92.8%. Re-explorative surgery andASA class more than 1 were significant factors influence with flap failure rate. Only signficant factor associated with wound complication was age more than 60 years. ASA class more than 1 and age more than 60 years were significant factors that increasing general medical complication. CONCLUSION: Microvascular free flap was the versatile reconstructive option. The failure rate of them should not be more than 5%. Factors associated with flap failure were re-exploration, ASA classification and factors that affect complications were preoperative morbidity level (ASA) and elderly patient.

The efficacy of combined herbal extracts gel in reducing scar development at a split-thickness skin graft donor site.

BACKGROUND: The aim of this study was to evaluate the efficacy of combined herbal extracts in a gel preparation (Cybele(®) Scagel) in reducing scar development at a split-thickness skin graft donor site. METHODS: A prospective, randomized, double-blind control study was performed to evaluate the efficacy of Scagel in 15 patients who underwent a split-thickness skin graft operation. Both Scagel and placebo were applied equally to the donor site within 1 month after complete epithelialization. Scar assessments using the Vancouver Scar Scale (VSS) and patient self-evaluation were taken at 2, 4, 8, and 12 weeks. RESULTS: Of the 15 patients, 10 were enrolled and evaluated in this study. There was no significant difference in each parameter of the VSS. The total VSS was significantly lower in the Scagel group compared to the placebo group after 4 weeks (p = 0.003, 0.003, and <0.001 at 4, 8, and 12 weeks, respectively). The patient satisfaction score in the Cybele(®) Scagel group was significantly higher (p = 0.002) at the 12-week evaluation. CONCLUSION: Application of combined herbal extracts in gel preparation might reduce scar development at split-thickness skin graft donor sites. There was a positive trend in the reduction of postinflammatory hyperpigmentation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .