Fu's subcutaneous needling for subcutaneous adhesions and scar hyperplasia in the neck region: A case report.

RATIONALE: Lymphadenectomy for tongue cancer in the neck region is often accompanied by local impaired mobility, gland damage, difficult in swallowing, and postoperative complication and seriously affects patients life quality. We reported a case of subcutaneous adhesions and scar hyperplasia in the neck region after lymphadenectomy for tongue lesions accompanied by impaired neck mobility and difficult in swallowing was treated using Fu's subcutaneous needling (FSN) treatment. PATIENT CONCERNS: A 55-year-old male with tongue cancer received surgical intervention with lymphadenectomy 8 years ago was revealed a 15 cm-long curved surgical incision in the neck region and surrounded by numerous scar tissues. DIAGNOSIS: Post-operation subcutaneous adhesions and scar hyperplasia in the neck region after lymphadenectomy was diagnosed. INTERVENTIONS: FSN treatment was performed 2 to 3 times per week for 1 month to sway the affected tightened muscle and dissociate the superficial fascia beneath the scar resulted in a considerable improvement in neck movement. OUTCOMES: The Vancouver Scar Scale (VSS) was as follows: color (M) - 1; vascular distribution (V) - 0, thickness (H) - 2, and flexibility (P) - 4, with a total of 7 points before FSN treatment. The VSS after 1 month of FSN treatment was as follows: M1, V0, H2, and P2, with a total of 5 points. Neck mobility in different directions, i.e., stretching to the back of the neck and laterally bending the neck to the left and/or right side, was improved (P < .05). LESSONS: At present, treatment of chronic scar hyperplasia has certain side effects and limitations. FSN is safe and convenient, with minimal destruction of the superficial fascia, having evident effects of dissociating tissue adhesion under scars and compensating for deficiencies in scar hyperplasia treatment. It can provide new ideas for future treatments.

Physiological processes of inflammation and edema initiated by sustained mechanical loading in subcutaneous tissues: A scoping review.

Deep tissue injuries are pressure ulcers which initiate in the subcutaneous tissues and extend through a bottom-up pathway. Once deep tissue injuries are visual at skin level, serious irreversible tissue damage has already occurred. In pressure ulcer development, inflammation and edema are coupled physiological processes associated with tissue damage arising due to sustained mechanical loading. This study aimed to provide an in-depth overview of the physiological processes of inflammation and edema initiated by sustained mechanical loading in subcutaneous tissues, in the context of pressure ulceration. A scoping review was performed according to the framework by Arksey and O'Malley. The databases MEDLINE, EMBASE, Web of Science, and Scopus, and the reference lists of included studies were searched for in vivo (animal, human), and in vitro studies matching the study objectives (from inception to 28 May 2018). No restrictions for inclusion were applied for study design, setting, participants, and year of publication. A total of 12 studies were included, varying in study design, sample characteristics, amount and duration of mechanical loads that were applied, follow-up time, and assessment methods. Neutrophil infiltration and edema occur in the subcutaneous tissues nearly immediately after the application of load on soft tissues. The amount of neutrophils and edema increase in the first days after the mechanical insult and decrease once healing has been initiated and no supplementary mechanical load was applied. One study indicated that edema may extend up to the level of the dermo-epidermal junction. Further research should focus on how deep tissue inflammation and edema are reflected into unique tissue changes at skin level, and how abnormal inflammatory responses manifest (e.g. when the nervous system is not functioning normally).

Hypertension affects the biocompatibility and biomineralization of MTA, High-plasticity MTA, and Biodentine®.

This study evaluated the effect of hypertension on tissue response and biomineralization capacity of white Mineral Trioxide Aggregate (MTA), High-plasticity MTA (MTA HP), and Biodentine® (BDT) in rats. Polyethylene tubes filled with MTA, MTA HP, BDT, and the control group (empty tubes) were placed into the dorsal subcutaneous tissue of 32 male rats (16 normotensive (NT) and 16 hypertensive rats - 8 per group). After 7 and 30 days, the polyethylene tubes surrounded by connective tissue were removed, fixed, and embedded in histological resin. The mean number of inflammatory cells was estimated in HE-stained sections, biomineralization was quantified as area (µm2) by Kossa (VK) staining, and examination by polarized light (LP) microscopy was performed. The differences amongst the groups were analyzed statistically by the Mann-Whitney or Student's t test, according to Shapiro-Wilk test of normality (p < 0.05). The inflammatory responses to all materials were greater in hypertensive rats than in NT rats (p < 0.05). Positive VK staining in MTA and BDT were more pronounced in NT rats at 7 and 30 days (p < 0.05). Birefringent structures in LP for MTA, MTA HP, and BDT were more pronounced in NT rats at 7 days (p<0.05). In rats, hypertension was able to increase inflammatory infiltrate and decrease biomineralization of the tested materials.

Could calgranulins and advanced glycated end products potentiate acromegaly pathophysiology?

Growth hormone (GH) exerts a diverse set of effects across many tissues including fat, muscle, bone, kidney, heart, and liver. GH is also a diabetogenic hormone in that it inhibits the actions of insulin. Acromegaly, a condition traditionally characterized by increased levels of growth hormone secretion as a result of pituitary adenoma, results in increased tissue growth, lipolysis, and can result in patients with hyperglycemia and hyperinsulinemia. While current treatment modalities have greatly improved prognoses for most patients, a significant number present clinical symptoms of acromegaly with elevated levels of IGF-1 in the absence of increased GH levels, a phenomenon known as micromegaly. This condition presents a challenge to most currently used treatments since the high circulating IGF-1 levels are independent of elevated levels of GH. It has been previously shown that advanced glycation end products (AGE) can stimulate IGF-1 secretion by human monocytes in vitro, demonstrating a possible mechanism for increased IGF-1 levels. To further investigate AGE/GH/IGF-1 interaction, we have reanalyzed a publicly available RNAseq dataset from subcutaneous adipose tissue of patients with acromegaly. S100A1, a member of the calgranulin family of proteins and ligand of the AGE receptor, was shown to be significantly upregulated in patients with acromegaly. These findings identify an important consideration that may help explain the counterintuitive nature of micromegaly, while simultaneously providing new insight into the role of GH in diabetic, inflammatory, and immune pathologies.

Sternal Fracture Complicated by a Subcutaneous Abscess in a 5-Year-Old Boy and Diagnosed Using Point-of-Care Ultrasound.

BACKGROUND: Although fractures of the sternum are rare in young children, owing to the compliance of the chest wall, these fractures are still possible and require thorough examination. We present a case that emphasizes the usefulness of point-of-care ultrasound in the diagnosis of a pediatric sternal fracture complicated by a subcutaneous abscess. CASE REPORT: A 5-year-old boy presented with tenderness of the sternum, with diffuse swelling extending bilaterally to the anterior chest wall. Ultrasound imaging identified irregular alignment of the sternum with a subcutaneous abscess and swirling of purulent material within the abscess in the fracture area. These findings were confirmed on enhanced chest computed tomography and had not been visible at the time of the first evaluation 6 days prior. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case demonstrates the usefulness of point-of-care ultrasound for the diagnosis and appropriate management of a sternal fracture complicated by a subcutaneous abscess in a young child. As ultrasound imaging is easy to perform at the bedside, it is useful for examining pediatric patients with swelling of the anterior chest and local tenderness of the sternum to rule out a sternal fracture, even if these fractures are deemed to be uncommon in children.

Hypertension affects the biocompatibility and biomineralization of MTA, High-plasticity MTA, and Biodentine®

Abstract This study evaluated the effect of hypertension on tissue response and biomineralization capacity of white Mineral Trioxide Aggregate (MTA), High-plasticity MTA (MTA HP), and Biodentine® (BDT) in rats. Polyethylene tubes filled with MTA, MTA HP, BDT, and the control group (empty tubes) were placed into the dorsal subcutaneous tissue of 32 male rats (16 normotensive (NT) and 16 hypertensive rats - 8 per group). After 7 and 30 days, the polyethylene tubes surrounded by connective tissue were removed, fixed, and embedded in histological resin. The mean number of inflammatory cells was estimated in HE-stained sections, biomineralization was quantified as area (µm2) by Kossa (VK) staining, and examination by polarized light (LP) microscopy was performed. The differences amongst the groups were analyzed statistically by the Mann-Whitney or Student's t test, according to Shapiro-Wilk test of normality (p < 0.05). The inflammatory responses to all materials were greater in hypertensive rats than in NT rats (p < 0.05). Positive VK staining in MTA and BDT were more pronounced in NT rats at 7 and 30 days (p < 0.05). Birefringent structures in LP for MTA, MTA HP, and BDT were more pronounced in NT rats at 7 days (p<0.05). In rats, hypertension was able to increase inflammatory infiltrate and decrease biomineralization of the tested materials.

Ultrasound elastography reliably identifies altered mechanical properties of burned soft tissues.

Although burn injury to the skin and subcutaneous tissues is common in both civilian and military scenarios, a significant knowledge gap exists in quantifying changes in tissue properties as a result of burns. In this study, we present a noninvasive technique based on ultrasound elastography which can reliably assess altered nonlinear mechanical properties of a burned tissue. In particular, ex vivo porcine skin tissues have been exposed to four different burn conditions: (i) 200°F for 10s, (ii) 200°F for 30s, (iii) 450°F for 10s, and (iv) 450°F for 30s. A custom-developed instrument including a robotically controlled ultrasound probe and force sensors has been used to compress the tissue samples to compute two parameters (C10 and C20) of a reduced second-order polynomial hyperelastic material model. The results indicate that while the linear model parameter (C10) does not show a statistically significant difference between the test conditions, the nonlinear model parameter (C20) reliably identifies three (ii-iv) of the four cases (p<0.05) when comparing burned with unburned tissues with a classification accuracy of 60-87%. Additionally, softening of the tissue is observed because of the change in structure of the collagen fibers. The ultrasound elastography-based technique has potential for application under in vivo conditions, which is left for future work.

Chronic Expanding Hematoma in the Extremities: A Clinical Problem of Adhesion to the Surrounding Tissues.

Chronic expanding hematoma is characterized by continuous growth of a blood collection. We analyzed the clinical features of 7 patients with chronic expanding hematomas in the extremities, with an average age of 65.6 years. All lesions occurred in the lower extremities, with 4 seen in the thigh and 3 in the knee region. Six patients had subcutaneous hematomas, while 1 was deep-seated in the thigh. The magnetic resonance features of the lesion were compatible with those of a standard hematoma. A low signal intensity on T1- and T2-weighted imaging at the pseudocapsule was also characteristic. Cystic features were seen in 5 of 7 patients. All lesions were resected together with their pseudocapsule. In the subcutaneous lesions, it was necessary to resect adherent fascia, with or without involved skin. In the deep-seated thigh lesion, the common peroneal nerve was completely adherent to the pseudocapsule, a phenomenon from absence of the common peroneal nerve which appeared after resection. Chronic expanding hematomas of the extremities are predominantly located in the subcutaneous tissue of the lower extremity. The surrounding pseudocapsule is adherent to the adjacent tissues, and clinicians must be aware of this, especially when resecting a deep-seated lesion.

Panniculus morbidus: obesity-related abdominal wall lymphoedema.

A 52-year-old female patient presented with a massive abdominal wall swelling that adversely affected her lifestyle. Imaging revealed significant subcutaneous oedema and the presence of grossly distended veins. Subsequently, she underwent a 'toilet' panniculectomy and abdominoplasty. We describe the surgical technique used to retract the lymphoedematous tissue facilitating excisional surgery, and discuss the pathophysiology of this condition and the possible contribution of venous obstruction to the development of subcutaneous oedema.

Validity of a New Quantitative Evaluation Method that Uses the Depth of the Surface Imprint as an Indicator for Pitting Edema.

This study examined the validity of a practical evaluation method for pitting edema by comparing it to other methods, including circumference measurements and ultrasound image measurements. Fifty-one patients (102 legs) from a convalescent ward in Maruyama Hospital were recruited for study 1, and 47 patients (94 legs) from a convalescent ward in Morinaga Hospital were recruited for study 2. The relationship between the depth of the surface imprint and circumferential measurements, as well as the relationship between the depth of the surface imprint and the thickness of the subcutaneous soft tissue on an ultrasonogram, were analyzed using a Spearman correlation coefficient by rank. There was no significant relationship between the surface imprint depth and circumferential measurements. However, there was a significant relationship between the depth of the surface imprint and the thickness of the subcutaneous soft tissue as measured on an ultrasonogram (correlation coefficient 0.736). Our findings suggest that our novel evaluation method for pitting edema, based on a measurement of the surface imprint depth, is both valid and useful.

Using ultrasound elastography to monitor human soft tissue behaviour during prolonged loading: A clinical explorative study.

PURPOSE: Pressure ulcers are localized injuries to the skin or underlying tissues over a bony prominence, as a result of pressure, or pressure in combination with shear. Ultrasound imaging techniques are widely applied to detect and to investigate pressure ulcer pathogenesis and healing, but due to missing structural alterations, very early signs of tissue alterations are not detectable. Ultrasound elastography was proposed as a new method to measure very early signs of pressure ulcer development but this was not investigated in humans so far. The aim of this study was to investigate for the first time whether US elastography is able to measure potential changes in dermal and subcutaneous tissue stiffness during prolonged loading. MATERIALS AND METHODS: An exploratory study including nine healthy volunteers (mean age 70.1 (SD 4.8) years) was conducted. Study participants were requested to follow a standardized lying protocol, consisting of two loading phases of 90 and 150 min in supine position on a standard hospital mattress. Three pressure ulcer predilection sites (lateral heel over the calcaneus, sacral, and upper back area) were measured using B-mode and elastographic ultrasound system at baseline - immediately, after 90 min, and after 150 min loading. RESULTS: Mean baseline shear wave velocities were highest in the heel skin (2.7 m/s) and lowest in the upper back skin (1.9 m/s) indicating that heel skin was stiffest. Also the subcutaneous soft tissue stiffness was highest for the heel (2.7 m/s) and lowest for the upper back region (1.3 m/s). After 90 and 150 min loading there was a mean stiffness increase of the skin layers and a pronounced stiffness decrease of subcutaneous heel and sacral tissues. CONCLUSIONS: Continuous loading of skin and underlying subcutaneous soft tissues leads to dynamic changes of tissue stiffness which are considered to play key roles in pressure ulcer development. Superficial skin and deep tissues seem to react differently. Elastography is able to quantify the dynamic of skin and subcutaneous soft tissue stiffness changes non-invasively in vivo. Shear wave velocity might serve as a new parameter for quantifying pressure ulcer damage risk in superficial and deeper tissues prone to pressure ulcer development.

Model study of the pressure build-up during subcutaneous injection.

In this study we estimate the subcutaneous tissue counter pressure during drug infusion from a series of injections of insulin in type 2 diabetic patients using a non-invasive method. We construct a model for the pressure evolution in subcutaneous tissue based on mass continuity and the flow laws of a porous medium. For equivalent injection forces we measure the change in the infusion rate between injections in air at atmospheric pressure and in tissue. From a best fit with our model, we then determine the flow permeability as well as the bulk modulus of the tissue, estimated to be of the order 10-11-10-10 m2 and 105 Pa, respectively. The permeability is in good agreement with reported values for adipose porcine tissue. We suggest our model as a general way to estimate the pressure build-up in tissue during subcutaneous injection.

Immunohistochemical analysis of the expression of TNF-alpha, TGF-beta, and caspase-3 in subcutaneous tissue of patients with HIV lipodystrophy syndrome.

INTRODUCTION: HIV Lipodystrophy Syndrome (HIVLS) is a multifactorial clinical expression that presents alterations in the metabolism and distribution pattern of body fat via immunological changes capable of disrupting homeostasis. This study aimed to analyze the degree of inflammatory, anti-inflammatory, and apoptosis activity in the subcutaneous tissue of patients, based on the expression of Tumor Necrosis Factor-α (TNF-α), Transforming Growth Factor-ß (TGF-ß), and caspase-3, respectively, and correlate them with clinical data and with each other. METHODS: This is a cross-analytical study. The biopsy of subcutaneous cellular tissue was performed on the right thigh of 19 patients with HIVLS who were attended to at a university hospital, and four people without HIV and lipodystrophy, for comparison. The type of lipodystrophy and the estimation of body fat were obtained during the consultation or obtained from medical charts. The cytokine expression was observed in the adipose tissue through the streptavidin-biotin peroxidase method, and analyzed by optical microscopy. RESULTS: Despite the mixed clinical form having been prevalent in both genders, men were more lipoatrophic and women were more lipohypertrophic. Men showed higher expression of TNF-α and caspase-3 than women. Patients with lipodystrophy had higher expression of TNF-α and caspase-3 and lower TGF-ß, compared to the control group. The percentage of body fat was negatively correlated with the expression of TNF-α and caspase-3. Longer durations of infection and use of antiretroviral therapy (ARVT) were positively associated with the levels of TNF-α. The expression of caspase-3 and TGF-ß was associated with higher levels of TNF-α. CONCLUSION: Regardless of the clinical form, HIVLS is characterized by a chronic inflammatory process associated with the male gender, the percentage of body fat, and lipoatrophy manifestations. There is increased apoptotic activity in more inflamed tissues and there is correlation between TNF-α and TGF-ß, which suggests a possible negative feedback mechanism between the inflammatory and anti-inflammatory activity.

Real-time tissue elastography assessment of skin and subcutaneous tissue strains in legs with lymphedema.

PURPOSE: To confirm the feasibility of assessing strains of the skin and subcutaneous tissue in normal legs and legs with lymphedema via free-hand real-time tissue elastography (RTE) using a phantom. METHODS: After placing a phantom on the skin, we measured the strains of the phantom (S p), skin (S sk), and subcutaneous tissue (S sc) of the inner thigh and calf by free-hand RTE in 35 healthy volunteers. A reference S p was set using these data. We then assessed S sk and S sc in each leg of 15 patients with unilateral stage II lymphedema. RESULTS: In the healthy volunteers, the strain was largest in the subcutaneous tissue of the thigh, followed by the subcutaneous tissue of the calf, skin of the thigh, and skin of the calf. These differences were each significant. In the patients with unilateral lymphedema, S sk and S sc in the thigh and calf were not different between the affected and unaffected legs. CONCLUSION: It was feasible to assess the strains of the skin and subcutaneous tissue using free-hand RTE and standardization of the compression force using a phantom. We failed to demonstrate decreased strains of the skin and subcutaneous tissue in legs with stage II lymphedema compared with healthy legs.

Subcutaneous interstitial pressure and volume characteristics in renal impairment associated with edema.

The kidneys and the interstitial compartment play a vital role in body fluid regulation. The latter may be significantly altered in renal dysfunction, but experimental studies are lacking. To help define this we measured the subcutaneous interstitial pressure, bioimpedance volumes, and edema characteristics in 10 healthy subjects and 21 patients with obvious edema and chronic kidney disease (CKD). Interstitial edema was quantified by the time taken for a medial malleolar thumb pit to refill and termed the edema refill time. Interstitial pressure was significantly raised in CKD compared to healthy subjects. Total body water (TBW), extracellular fluid volume (ECFV), interstitial fluid volume, the ratio of the ECFV to the TBW, and segmental extracellular fluid volume were raised in CKD. The ratio of the ECFV to the TBW and the interstitial fluid volume were the best predictors of interstitial pressure. Significantly higher interstitial pressures were noted in edema of 2 weeks or less duration. A significant nonlinear relationship defined interstitial pressure and interstitial fluid volume. Edema refill time was significantly inversely related to interstitial pressure, interstitial compartment volumes, and edema vintage. Elevated interstitial pressure in CKD with obvious edema is a combined function of accumulated interstitial compartment fluid volumes, edema vintage, and tissue mechanical properties. The edema refill time may represent an important parameter in the clinical assessment of edema, providing additional information about interstitial pathophysiology in patients with CKD and fluid retention.

The time-course of hindbrain neuronal activity varies according to location during either intraperitoneal or subcutaneous tumor growth in rats: single Fos and dual Fos/dopamine ß-hydroxylase immunohistochemistry.

Neuronal activity in the nucleus of the solitary tract, ventrolateral medulla, area postrema, and parabrachial nucleus was studied in rats with intraperitoneal or subcutaneous tumors on the 7th, 14th, 21st, and 28th day after injection of fibrosarcoma tumor cells. We found that the number of Fos and dopamine ß-hydroxylase immunopositive neurons differs between animals with intraperitoneal and subcutaneous tumors and also between tumor-bearing rats at different times following injection. Our data indicate that responses of the brainstem structures to peripheral tumor growth depend on the localization as well as the stage of the tumor growth.

[MR lymphangiography for assessment of focal dermal backflow for presurgical work-up in patients with peripheral lymphoedema]. / Die MR-Lymphangiografie in der präoperativen Diagnostik des fokalen "dermal backflow" bei peripheren Lymphödemen.

BACKGROUND: MR lymphangiography might provide valuable morphological information in the diagnosis of peripheral lymphedema in addition to lymphoscintigraphy. Even patients with focal dermal backflow can benefit from surgical intervention. The purpose of this study was to assess the feasibility of MR-Lymphangiography for assessment of focal dermal backflow for pre-surgical work-up. PATIENTS/MATERIALS & METHODS: 50 patients with peripheral lymphedema were included in this study. Patients showing focal dermal backflow in MR-Lymphangiography were reviewed and analyzed separately. The MR findings were correlated to lymphoscintigraphy. Concordance of the 2 modalities regarding existence and distribution of dermal backflow were examined. Furthermore the feeding vessels of the dermal backflow were assessed and visualized. RESULTS: Dermal backflow was diagnosed with MR lymphangiography in 13 patients. Dermal backflow was confirmed by lymphoscintigraphy in 12 patients (92.3%). The feeding vessels of the dermal backflow configuration could be visualized in 9 patients (69.2%) and could be visualized with 3-dimensional reconstructions. The latter is not possible with lymphoscintigraphy. CONCLUSION: MR lymphangiography provides important supplementary diagnostic information in patients with peripheral lymphedema additional to lymphoscintigraphy. Particularly in patients with focal dermal backflow and intended surgery, MR lymphangiography holds high potential for pre-surgical work-up.

Microdialysis--a versatile technology to perform metabolic monitoring in diabetes and critically ill patients.

Continuous subcutaneous glucose monitoring has been tested in type 1 diabetes (T1D). Since in critically ill patients vascular access is granted vascular microdialysis may be preferential. To test this hypothesis comparative accuracy data for microdialysis applied for peripheral venous and subcutaneous glucose monitoring was obtained in experiments in T1D patients. Twelve T1D patients were investigated for up to 30 h. Extracorporeal vascular (MDv) and subcutaneous microdialysis (MDs) was performed. Microdialysis samples were collected in 15-60 min intervals, analyzed for glucose and calibrated to reference. MDv and MDs glucose levels were compared against reference. Median absolute relative difference was 14.0 (5.0; 28.0)% (MDv) and 9.2 (4.4; 18.4)% (MDs). Clarke Error Grid analysis showed that 100% (MDv) and 98.8% (MDv) were within zones A and B. Extracorporeal vascular and standard subcutaneous microdialysis indicated similar performance in T1D. We suggest microdialysis as a versatile technology for metabolite monitoring in subcutaneous tissue and whole blood.

Relative contribution of tissue oedema and the presence of an A2 pulley to resistance to flexor tendon movement: an in vitro and in vivo study.

Increases in the resistance to tendon during movement may lead to rupture or gapping of the repaired tendon. The relative contribution of these factors-tissue oedema, tendon oedema, and the intact A2 pulley-to resistance to tendon gliding is unclear. In in vitro chicken models, we created oedema in subcutaneous tissue or tendon. The work of digital flexion (WOF) increased significantly after creation of oedema in those tissues. WOF decreased significantly after division of the A2 pulley. Preservation of the integrity of the A2 pulley significantly increased WOF at post-operative weeks 1 and 2 in the in vivo chicken model; increases in WOF were greater than those due to the presence of oedematous subcutaneous tissue. Pulley division at the time of surgery reduced WOF more drastically than the removal of volar subcutaneous tissue. Presence of an intact A2 pulley adds greater resistance to the movement of the repaired flexor tendon than volar oedematous subcutaneous tissue.