An ingenious deep learning approach for pressure injury depth evaluation with limited data.

BACKGROUND: The development of models using deep learning (DL) to assess pressure injuries from wound images has recently gained attention. Creating enough supervised data is important for improving performance but is time-consuming. Therefore, the development of models that can achieve high performance with limited supervised data is desirable. MATERIALS AND METHODS: This retrospective observational study utilized DL and included patients who received medical examinations for sacral pressure injuries between February 2017 and December 2021. Images were labeled according to the DESIGN-R® classification. Three artificial intelligence (AI) models for assessing pressure injury depth were created with a convolutional neural network (Categorical, Binary, and Combined classification models) and performance was compared among the models. RESULTS: A set of 414 pressure injury images in five depth stages (d0 to D4) were analyzed. The Combined classification model showed superior performance (F1-score, 0.868). The Categorical classification model frequently misclassified d1 and d2 as d0 (d0 Precision, 0.503), but showed high performance for D3 and D4 (F1-score, 0.986 and 0.966, respectively). The Binary classification model showed high performance in differentiating between d0 and d1-D4 (F1-score, 0.895); however, performance decreased with increasing number of evaluation steps. CONCLUSION: The Combined classification model displayed superior performance without increasing the supervised data, which can be attributed to use of the high-performance Binary classification model for initial d0 evaluation and subsequent use of the Categorical classification model with fewer evaluation steps. Understanding the unique characteristics of classification methods and deploying them appropriately can enhance AI model performance.

Factors Associated with Complications after Total Pharyngo-Laryngo-Esophagectomy and Free Jejunal Flap Reconstruction.

INTRODUCTION: Free jejunal flap (FJF) reconstruction is a standard procedure for pharyngeal and cervical esophageal defects resulting from head and neck cancer resection. However, improvements in patients' quality of life after surgery require a further statistical approach. METHODS: An observational, retrospective, multivariate analysis was designed to report the incidence of postoperative complications and their association with clinical factors in 101 patients who underwent total pharyngo-laryngo-esophagectomy and FJF reconstruction for head and neck cancer at a university hospital between January 2007 and December 2020. RESULTS: Postoperative complications were observed in 69% of patients. In the reconstructive site, anastomotic leak, observed in 8% of patients was associated with vascular anastomosis in the external jugular vein system (age-adjusted odds ratio [OR]: 9.05, p = 0.044) and anastomotic stricture, observed in 11% of patients was associated with postoperative radiotherapy (age-adjusted OR: 12.60, p = 0.02). Cervical skin flap necrosis was the most common complication (34%) and was associated with vascular anastomosis on the right cervical side (age- and sex-adjusted OR: 4.00, p = 0.005). CONCLUSION: Although FJF reconstruction is a useful procedure, 69% of patients suffer a postoperative complication. We suppose that anastomotic leak is related to the low blood flow resistance of the FJF and inadequate drainage of the external jugular venous system, and anastomotic stricture is related to the vulnerability of the intestinal tissue to radiation. Furthermore, we hypothesized that the location of the vascular anastomosis may affect the mesenteric location of the FJF and the dead space in the neck, leading to the development of cervical skin flap necrosis. These data contribute to increasing our knowledge about postoperative complications related to FJF reconstruction.

Reconstruction for Bilateral Internal Jugular Vein Perfusion Disruption.

When resecting the internal jugular veins bilaterally in surgery for head and neck cancer, it is necessary to perform neck dissection in two stages or to reconstruct the internal jugular veins in one stage. Reconstruction of the internal jugular vein using grafting or direct anastomosis to the external jugular vein have both been reported. We report the case of a 53-year-old man with accidental injury to the left internal jugular vein after resection of the right internal jugular vein for supraglottic cancer. The left internal jugular vein was damaged near the inflow of the subclavian vein, making vein grafting difficult. Therefore, internal jugular venous return was reestablished by end-to-side anastomosis of the left internal jugular vein to the left external jugular vein system. In this surgical procedure, by incising the internal jugular vein obliquely, it was not necessary to match the calibers of the internal jugular vein and the external jugular vein system, and a smooth hemodynamic body was reconstructed. In addition, we were able to reconstruct the internal jugular vein while preserving blood flow in the external jugular vein system. End-to-side anastomosis of the internal jugular vein to the external jugular system is an option for internal jugular vein reconstruction.

Comparison of Antera 3D® and TcPO2 for Evaluation of Blood Flow in Skin.

Background: There is a need for quick skin blood flow tests that can be performed in the wound healing field. Antera 3D® is a compact scanner using multispectral imaging. It can perform quick assessment of skin conditions. The purpose of the present study was to investigate the ability of the Antera 3D® to assess skin blood flow in comparison with transcutaneous partial pressure of oxygen (TcPO2) measurements. Methods: This study was conducted on 13 patients with a history of lower extremity ulcers. Measurements of hemoglobin average level (hereafter, Hb score) measured by Antera 3D® and TcPO2 measured by a transcutaneous blood gas monitor were obtained at the same sites on the dorsal foot and lower leg. Differences in Hb score and TcPO2 were analyzed by t-test for each measurement site and for the presence of peripheral arterial disease (PAD). The correlation between TcPO2 and Hb score was analyzed by Pearson's correlation coefficient. Results: Twenty-four limbs were tested. Hb score was higher (P < 0.001) and TcPO2 was lower (P = 0.056) in the dorsal foot compared to the lower leg. In the dorsal foot, Hb score was higher (P = 0.023) and TcPO2 was lower (P = 0.046) in patients with PAD compared to those without PAD. A significant negative correlation (r = -0.68; 95% confidence interval -0.85 to -0.38, P < 0.001) between TcPO2 and Hb score was observed in the dorsal foot. Conclusion: The negative correlation between TcPO2 and Hb score may reflect compensatory peripheral vasodilation due to occlusion or stenosis of central arteries. This study showed that Hb score measured by Antera 3D® may be related to skin blood flow.

Effects of Conditioned Medium of Adipose-Derived Stem Cells Exposed to Platelet-Rich Plasma on the Expression of Endothelial Nitric Oxide Synthase and Angiogenesis by Endothelial Cells.

ABSTRACT: Platelet-rich plasma (PRP) and adipose-derived stem cells (ADSCs) are known to secrete angiogenic factors that contribute to the treatment of intractable ulcers. The combination of PRP and ADSCs may enhance their angiogenic effects. However, it remains unclear whether treatment of ADSCs with PRP influences angiogenesis. We studied whether the conditioned medium from PRP-treated ADSCs under hypoxic conditions exerts angiogenic effects. Although PRP stimulated the proliferation of ADSCs obtained from rats, it decreased the mRNA levels of vascular endothelial growth factor, hepatocyte growth factor, and TGF-ß1, but not of basic fibroblast growth factor, under hypoxia. The conditioned medium of PRP-treated ADSCs inhibited endothelial nitric oxide synthase phosphorylation, decreased NO production, and suppressed tube formation in human umbilical vein endothelial cells. Transplantation of ADSCs alone increased both blood flow and capillary density of the ischemic limb; however, its combination with PRP did not further improve blood flow or capillary density. This suggests that both conditioned medium of ADSCs treated with PRP and combination of PRP with ADSCs transplantation may attenuate the phosphorylation of endothelial nitric oxide synthase and angiogenesis.

Analysis of the Optimum Tapering Angle in Microanastomosis Using Computational Fluid Dynamics.

Background: In free flap transfer, size discrepancy between the vascular pedicle and recipient vessel can create a problem for microsurgeons and sometimes induces postoperative thrombus formation. When there is a major difference between the diameters of the vascular pedicle and the recipient vessel, the larger vessel is often tapered to perform the anastomosis properly. However, the decision on the tapering angle used depends mostly on the operator's experience. In this study, computational fluid dynamics (CFD) was used to investigate the optimum tapering angle. Methods: Using ANSYS ICEM 16.0 (ANSYS Japan, Tokyo, Japan), simulated vessels of diameters 1.5 mm and 3.0 mm were designed and then used to produce four anastomosis models with the 3.0-mm vessel tapered at angles of 15º, 30º, 60º, and 90º (no tapering). Venous perfusion with a mean value of 13.0 mL/min was simulated, and this was passed through the four anastomosis models in both the forward direction (F), from the smaller to the larger vessel, and the retrograde direction (R), from the larger to the smaller vessel. The velocity, wall shear stress (WSS), and oscillatory shear index (OSI) were measured in these eight patterns and then analyzed using OpenFOAM version 5. Results: The decrease in velocity was limiting. The WSS was greater in the R direction than the F direction at every tapering angle. The OSI also tended to be almost the same in the F direction, and lower at smaller tapering angles in the R direction. And, it was greater in the F direction than in the R direction at every tapering angle. The OSI values for 15º and 30º were almost identical in the R direction. Conclusion: The risk of thrombus formation is thought to be lower when tapering is used for anastomosis if the direction of flow is from the larger to the smaller vessel, rather than vice versa. These results also suggest that the optimum tapering angle is approximately 30º in both directions.

Risk Factors of Free Flap Complications in Reconstruction for Head and Neck Cancer.

Background: Although head and neck reconstruction using free flaps has become a common procedure, flap complications remain a concern. This study aimed to analyze the risk factors of free flap complications and to identify the causes of these complications. Methods: We studied 97 patients with head and neck cancer with intraoral defects who underwent reconstruction using free flaps at Tottori University Hospital between 2011 and 2020. We used a retrospective cohort study design to investigate whether flap complications, including flap necrosis (total and partial) and flap dehiscence, were related to various factors, including the underlying disease condition, treatment status, and surgical factors. Results: Of the 97 patients analyzed, total flap necrosis was observed in one patient (1.0%). The incidence rate of flap complications, including flap necrosis and flap dehiscence, was 29.9%. When the time taken to perform one vascular anastomosis, including preparation of the recipient vessel and flap vessel, exceeded 30 min, the incidence rates of flap necrosis (total and partial) (odds ratio, 8.30; 95% confidence interval, 1.91-36.00; P = 0.005) and flap dehiscence (odds ratio, 3.46; 95% confidence interval, 1.05-11.36; P = 0.041) increased significantly. Conclusion: The time taken to perform one vessel anastomosis was the factor that contributed the most to the incidence of flap complications. Reconstructive surgeons should reduce the incidence of flap complications by keeping the known risk factors of the surgery in mind and by aiming to complete a vascular anastomosis time, including the time taken for the preparation of vessels, of ≤ 30 min per vessel during surgery.

Preventing recurrence after surgical repair of pressure injuries in patients with spinal cord injury: Effects of a presurgical and postsurgical wheelchair seating intervention by experts.

OBJECTIVE: Pressure injuries in people with spinal cord injury or dysfunction (SCI/D) are known to have a high recurrence rate. As a countermeasure, we perform surgery after adjusting the wheelchair and cushion with the intervention of a seating expert. The effectiveness of seating interventions in postsurgical recurrence prevention was examined. MATERIALS AND METHODS: In this retrospective analysis, the participants were 19 patients with SCI/D who underwent pressure injury surgical treatment in the gluteal region from 2005 to 2018. The patients with conventional rehabilitation were assigned to Group 1 (n = 8), and those with seating intervention by experts in addition to conventional rehabilitation were assigned to Group 2 (n = 11). The main outcome measure was the presence or absence of recurrence 3 years after the surgery. The recurrence rate was compared between the two groups. RESULTS: The recurrence rates were 18% with seating intervention and 75% without; there was a significant difference (p = 0.025). The recurrence odds ratio was 13.5. CONCLUSION: This study suggests that presurgical seating evaluation and assessment by experts, postsurgical rehabilitation based on presurgical evaluation and assessment, and routine follow-up and seating adjustment according to changes are efficacious for preventing postsurgical pressure injury recurrence in patients with SCI/D.

Effect of Subcutaneous Adrenaline/Saline/Lidocaine Injection on Split-Thickness Skin Graft Donor Site Wound Healing.

BACKGROUND: Subcutaneous injection of tumescent solution, which contains local anesthetic, adrenaline, and saline, before split-thickness skin graft harvesting, shows a significant hemostatic effect. This method can reduce the initial bleeding from the donor site. The aim of this study is to assess the benefits of controlling the bleeding from donor sites by tumescent injection. A randomized, controlled trial was performed to compare the wound healing of split-thickness skin graft donor sites treated with or without tumescent injection. METHODS: This randomized, controlled trial examined donor site healing days as the main measure of outcome. postoperative pain, donor site ulceration, and scar quality were evaluated as secondary outcome measures. Patients planned for split-thickness skin graft harvest were randomly assigned to receive either pre-harvest subcutaneous injection of local anesthetic, adrenaline, and saline solution (tumescent solution) (Group 1) or post-harvest application of adrenaline solution-soaked gauze to the skin graft donor sites (Group 2). Donor sites were treated with calcium alginate dressings after graft harvesting. On the 10th postoperative day, the dressings were removed and donor site healing were measured. Follow-up evaluation of scar quality was performed 6 months after surgery. Postoperative pain was evaluated on the 1st day after operating. RESULTS: Forty-five patients (26 males; average age 61.8 years) completed the late follow-up evaluation (6 months postoperatively), with 26 patients in group 1 and 19 in group 2. There were no significant differences between the two groups in any of the outcome measures. CONCLUSION: Tumescent technique provides sufficient hemostasis in split skin graft donor sites, especially the initial bleeding just after graft harvesting, without any negative effects. Larger series should be studied to evaluate the effect in donor site wound healing.

Hemodynamic Analysis of a Microanastomosis Using Computational Fluid Dynamics.

BACKGROUND: Technical issues in free flap transfer, such as the selection of recipient vessels and the positioning and method of anastomosis of the vascular pedicle, have been the subject of vigorous debate. Recent developments in computational fluid dynamics (CFD) have enabled the analysis of blood flow within microvessels. In this study, CFD was used to analyze hemodynamics in a microanastomosis. METHODS: In the fluid calculation process, the fluid domain modelizes microvessels with anastomosis. The inlet flow conditions were measured as venous waveform, and the fluid is simulated as blood. Streamlines (SL), wall shear stress (WSS), and oscillatory shear index (OSI) at the anastomosis were visualized and analyzed for observing effects from the flow field. RESULTS: Some flow disruption was evident as the SL passed over the sutures. The maximum recorded WSS was 13.37 Pa where the peak of a suture was exposed in the lumen. The local maximum value of the OSI was 0.182, recorded at the base of the anastomosis on the outflow side. CONCLUSION: In the ideal anastomosis, the SL is disrupted as little as possible by the sutures. The WSS indicated that thrombus formation is unlikely to occur at suture peaks, but more likely to occur at the base of sutures, where the OSI is high. Tight suture knots are important in microanastomosis.

Considering the Better Donor-side in Reconstruction of Composite Radius After Resection of Spindle Cell Sarcoma Using Free Fibular Osteocutaneous Flap: A Case Report.

Reconstruction of bone and soft-tissue defects in the forearm is a surgery that often proves unsuccessful. Free fibular osteocutaneous flaps are a useful material for reconstruction that enable simultaneous reconstruction of bone, skin, and soft tissues. However, in free fibular osteocutaneous flaps, the fibula, skin, and vascular pedicle are tightly bound together by the posterior intermuscular septum and the perforators that pass through the septum, giving the disadvantage of a low degree of freedom when setting these structures in place. We take into account the 3-dimensional structure of the free skin flap when selecting which lower leg to use as the donor. We report here the case of a 61-year-old man with defects in the radius, skin, and soft tissues after resection of spindle cell carcinoma of the right forearm, which was reconstructed using a free fibular osteocutaneous flap harvested from the left lower leg. Two years postoperatively, recovery has been uneventful with no complications. Donor-side selection of free fibular osteocutaneous flap is an important factor for safely completing composite radius reconstruction.

Clinicopathological significance of EGFR pathway gene mutations and CRTC1/3-MAML2 fusions in salivary gland mucoepidermoid carcinoma.

AIMS: Mucoepidermoid carcinoma (MEC) is one of the most common salivary gland carcinomas. Epidermal growth factor receptor (EGFR) signalling pathway gene mutations are important in predicting a patient's prognosis, selecting molecularly targeted drugs and estimating the efficacy of a molecular therapy. However, their significance in MEC have been poorly clarified. CRTC1/3-MAML2 fusions are specific to MEC and may be associated with favourable characteristics in these patients. METHODS AND RESULTS: We looked for CRTC1/3-MAML2 fusions and gene alterations in the EGFR, RAS family (KRAS, HRAS and NRAS), PIK3CA, BRAF and AKT1 in 101 MEC cases. We also examined mutations in TP53. CRTC1/3-MAML2 fusions were found in 62.4% of the cases. KRAS, HRAS and PIK3CA mutations were detected in 6.9%, 2.0% and 6.9%, respectively, but other EGFR pathway genes were not mutated. In total, gene mutations (RAS/PIK3CA) in the EGFR pathway were detected in 14.9% of the cases. TP53 mutations were found in 20.8%. CRTC1/3-MAML2 fusions were associated with a better prognosis and RAS/PIK3CA mutations a worse prognosis of the patients, respectively, and both were selected as independent prognostic factors for the overall survival of the patients. TP53 mutations had no prognostic impact. CRTC1/3-MAML2 fusion-positive rates were inversely associated with the patients' age and the fusions were found in 82% of patients aged < 30 years. CONCLUSIONS: RAS/PIK3CA mutations were frequently detected, and may be a biomarker for a poorer prognosis in MEC patients. CTRC1/3-MAML2 fusions were positive in most of the young MEC patients.

ß-Adrenergic Blocker, Carvedilol, Abolishes Ameliorating Actions of Adipose-Derived Stem Cell Sheets on Cardiac Dysfunction and Remodeling After Myocardial Infarction.

BACKGROUND: Treatment of myocardial infarction (MI) includes inhibition of the sympathetic nervous system (SNS). Cell-based therapy using adipose-derived stem cells (ASCs) has emerged as a novel therapeutic approach to treat heart failure in MI. The purpose of this study was to determine whether a combination of ASC transplantation and SNS inhibition synergistically improves cardiac functions after MI.Methods and Results:ASCs were isolated from fat tissues of Lewis rats. In in vitro studies using cultured ASC cells, mRNA levels of angiogenic factors under normoxia or hypoxia, and the effects of norepinephrine and a ß-blocker, carvedilol, on the mRNA levels were determined. Hypoxia increased vascular endothelial growth factor (VEGF) mRNA in ASCs. Norepinephrine further increased VEGF mRNA; this effect was unaffected by carvedilol. VEGF promoted VEGF receptor phosphorylation and tube formation of human umbilical vein endothelial cells, which were inhibited by carvedilol. In in vivo studies using a rat MI model, transplanted ASC sheets improved contractile functions of MI hearts; they also facilitated neovascularization and suppressed fibrosis after MI. These beneficial effects of ASC sheets were abolished by carvedilol. The effects of ASC sheets and carvedilol on MI heart functions were confirmed by Langendorff perfusion experiments using isolated hearts. CONCLUSIONS: ASC sheets prevented cardiac dysfunctions and remodeling after MI in a rat model via VEGF secretion. Inhibition of VEGF effects by carvedilol abolished their beneficial effects.

General Anesthetic Management of a Patient With Hypertrophic Cardiomyopathy for Oral Surgery: Did Digitalis Contribute to Bradycardia?

Stabilization of circulatory dynamics is a critical issue in the anesthetic management of patients with hypertrophic cardiomyopathy (HCM). In this report, we managed general anesthesia for a 74-year-old male patient with nonobstructive HCM who developed circulatory instability intraoperatively. Severe bradycardia measuring 35 beats/min and hypotension measuring 78 mm Hg systolic were observed during surgery. Using stroke volume variation and stroke volume from the FloTrac as indices, successful circulatory management was performed with dopamine. The hypotension and bradycardia were thought to be the result of methyldigoxin and possibly associated with our perioperative management. Cardiology consult should have been obtained. We demonstrated that the FloTrac can be beneficial in diagnosing and managing cardiovascular instability and administration of dopamine in the anesthetic management of nonobstructive HCM patients.

General Anesthetic Management of a Child With Horseshoe Lung and Left Lung Hypoplasia for Cheiloplasty: A Case Report.

Horseshoe lung is an extremely rare congenital malformation in which the right and left lungs are fused due to stenosis of the lung parenchyma. In anesthetic management, it is important to avoid hypoxemia and hypercapnia caused by a decline in lung capacity and functional residual capacity. A 3-year-old boy with horseshoe lung and left lung hypoplasia was scheduled to undergo cheiloplasty. Regarding respiratory management, to prevent hypoxemia and hypercapnia, we avoided intraoperative peripheral airway obstruction with positive end-expiratory pressure, set a long inspiratory phase time for sufficient alveolar expansion, and maintained sufficient gas exchange in lungs with low reserve capacity.

Application of the cis-regulatory region of a heat-shock protein 70 gene to heat-inducible gene expression in the ascidian Ciona intestinalis.

Temporally controlled induction of gene expression is a useful technique for analyzing gene function. To make such a technique possible in Ciona intestinalis embryos, we employed the cis-regulatory region of the heat-shock protein 70 (HSP70) gene Ci-HSPA1/6/7-like for heat-inducible gene expression in C. intestinalis embryos. We showed that Ci-HSPA1/6/7-like becomes heat shock-inducible by the 32-cell stage during embryogenesis. The 5'-upstream region of Ci-HSPA1/6/7-like, which contains heat-shock elements indispensable for heat-inducible gene expression, induces the heat shock-dependent expression of a reporter gene in the whole embryo from the 32-cell to the middle gastrula stages and in progressively restricted areas of embryos in subsequent stages. We assessed the effects of heat-shock treatments in different conditions on the normality of embryos and induction of transgene expression. We evaluated the usefulness of this technique through overexpression experiments on the well-characterized, developmentally relevant gene, Ci-Bra, and showed that this technique is applicable for inferring the gene function in C. intestinalis.