Nationwide time-series surveys of pressure ulcer prevalence in Japan.

OBJECTIVE: The Japanese Society of Pressure Ulcers (JSPU) has two purposes: first, to improve knowledge and skills among health professionals related to preventing and managing pressure ulcers (PUs); and second, to represent those in the field managing PUs, including with government and health authorities. Since 2006, JSPU has conducted fact-finding surveys about every four years to identify PU prevalence in Japan (2006, 2010, 2013 and 2016). Based on the prevalence identified by these surveys, an attempt was made to validate the achievements of JSPU's activities. METHOD: Information from one-day surveys of hospitals, long-term care health facilities, long-term care welfare facilities, and home visit nursing care stations was analysed. We used generalised estimating equations to estimate the proportions of PUs and their 95% confidence intervals (CIs) for each survey. RESULTS: A total of 662,419 patients in 2631 facilities participated in the surveys. The estimated proportions for all facilities (95% CI) in chronological order, from the first to the fourth survey, were: 2.67% (2.52-2.83); 2.61% (2.43-2.80); 1.99% (1.83-2.17); and 1.79% (1.65-1.94), respectively. In all facility types, the proportion of PUs was lower in the fourth survey than the first survey. CONCLUSION: The proportion of PUs showed a decreasing trend and was low according to global standards, demonstrating the efficacy of JSPU's activities.

Facial asymmetry with enlarged frontal sinus and hyperplasia of the cranial, nasal, and mandible bones.

The conditions of facial asymmetry are caused by congenital or acquired diseases, and several unclassifiable syndromes with unknown etiologies exist. In this report, a case of facial asymmetry with enlarged frontal sinus and hyperplasia of the frontal cranial bone and nasal bone is presented. Although the etiology of the facial malformation was clear, it was thought that the cause of the enlarged frontal sinus was related to the unidentified bony hyperplasia and facial asymmetry related to hemimandibular hyperplasia.

Troubleshooting distraction osteogenesis for craniosynostosis.

PURPOSE: We previously reported that distraction osteogenesis is less invasive and gives greater skull advancement compared to conventional cranioplasty [Akai et al: Pediatr Neurosurg 2006;42:288-292]. In this study, we analyzed the distraction osteogenesis process and tried to identify and solve various technical problems. PATIENTS AND RESULTS: We operated on 22 patients, 5 syndromic and 17 nonsyndromic. During treatment, we encountered several problems: (i) dural laceration during craniotomy (2 cases), solution: repair by suturing with fascia; (ii) skull fracture at sphenofrontal or coronal sutures (2 cases), solution: completed distraction; (iii) device dislocation during distraction (1 case), solution: the device was secured to the skull with stainless wire; (iv) wound issues around shaft and device (3 cases), solution: treated with antibiotic ointment. DISCUSSION: (1) Extra caution is needed to avoid dural damage at frontal bottom burr holes. (2) Completion of craniotomy should be confirmed by checking if the bone flap moves in sync with brain pulsation. The craniotomy line should be placed forward of coronal sutures. (3) For patients younger than 2 years, employ clamp-type devices. (4) Shafts should be cut short enough to prevent their tips from exerting pressure or puncturing the scalp from beneath. CONCLUSIONS: The distraction osteogenesis technique has complications that may not occur in conventional one-stage cranioplasty. In this study, neither age at operation nor distraction distance were significant causes of complications during distraction osteogenesis.

The estimation of tissue loss during tangential hydrosurgical debridement.

The preservation of healthy tissue during surgical debridement is desirable as this may improve clinical outcomes. This study has estimated for the first time the amount of tissue lost during debridement using the VERSAJET system of tangential hydrosurgery. A multicenter, prospective case series was carried out on 47 patients with mixed wound types: 21 (45%) burns, 13 (28%) chronic wounds, and 13 (28%) acute wounds. Overall, 44 (94%) of 47 patients achieved appropriate debridement after a single debridement procedure as verified by an independent photographic assessment. The percentage of necrotic tissue reduced from a median of 50% to 0% (P < 0.001). Median wound area and depth increased by only 0.3 cm (6.8%) and 0.5 mm (25%), respectively. Notably, 43 (91%) of 47 wounds did not progress into a deeper compartment, indicating a high degree of tissue preservation.

Low-grade central osteosarcoma of the orbit.

Low-grade central osteosarcoma is a rare type of osteosarcoma, representing fewer than 2% of all osteosarcomas. Approximately 80% of these tumors are located in the long bones, and they are particularly common in the distal and proximal tibia. However, they are rare in the craniofacial bones, and this tumor type has never been reported to occur in the orbit. In this report, a case of low-grade central osteosarcoma arising from the orbit is presented. The differential diagnoses of this tumor and the surgical results of radical resection and reconstruction are also presented.

[Two episodes of cardiac arrest in a boy receiving sclerotherapy with polydocanol--a case report].

A 4-year-old boy, weighing 15.6 kg, experienced two episodes of cardiac arrest during the eight sessions of sclerotherapy under general anesthesia. Although cardiac arrest had been documented after accidental extubation during the seventh procedure, the specific cause had not been identified. For the eighth procedure, anesthesia was again induced and maintained with nitrous oxide and sevoflurane. A total of 10 ml of 3% polydocanol was injected. Approximately five minutes after the injection, his heart rate slowed and asystole developed. External cardiac massage was started immediately and atropine was injected intravenously. His heart started to beat again very soon. From the clinical course, the two episodes of cardiac arrest could be attributable to polydocanol overdose. It was concluded that severe circulatory derangement might follow an injection of polydocanol during sclerotherapy.

Use of skin staples to fix film dressings on scalp donor wounds in patients with burns.

Split-thickness skin grafts (STSGs) from the scalp have been used in large burns. The donor site wounds are usually covered using occlusive dressings, such as film dressings because they contribute to reduce donor site pain and infection under exudative crust and to enhance re-epithelialization. However, it is not always easy to fix such film dressings to the scalp because of the presence of hair. In this paper, we report the use of skin staplers to fix the film dressings. Eight donor sites in four patients were dressed in this way. The patients had 50-78% of the body burned, all of them survived. The mean healing time for the donor sites was 6.8 days. Three patients had their scalps re-harvested several times (range two to three times). There were no infections nor secondary skin ulcers at the donor sites. The technique of this dressing is very simple and speedy, thus we recommend the use of skin staplers to fix the film dressing to scalp donor wounds in patients with burns.

Recurrent meningioma with metastasis to the skin incision--case report.

A 70-year-old woman presented with meningioma with metastasis to the skin incision. Neuroimaging demonstrated a tumor of the falx extending to the frontal bone. The tumor was grossly totally resected through a coronal skin incision. The histological diagnosis was meningotheliomatous meningioma. The tumor recurred in the ethmoid sinus 2 years later, and was resected through the transfacial approach. One year later, the tumor recurred in the ethmoid sinus and orbit, and was resected through the transcranial approach. Six months later, she noticed an isolated small mass under the skin incision, distant from a further recurrence of the tumor. Both tumors were resected. The histological diagnosis was atypical meningioma. Resection of atypical meningioma carries the risk of iatrogenic metastasis. Surgeons should wash out the operative field carefully and change surgical tools frequently.

[Food residues identified in the pharynx of a patient with a cleft palate].

Solid food residues were identified in the pharynx of a 17-month-old infant with a cleft palate at the time of anesthesia induction, although nothing-by-mouth directions for more than four hours had been strictly followed. Preoperative airway management, e.g. gargling and nose blowing, is necessary in patients with a cleft palate even after an appropriate period of fasting because food residues may remain in the nose due to the anatomical abnormality.

Nipple- or skin-sparing mastectomy and immediate breast reconstruction by the "moving window" operation.

BACKGROUND: Endoscope-assisted skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) has been developed to minimize the skin incision and to improve the cosmetic outcome of reconstructed breast for patients with breast cancer. However, this procedure can be performed without using endoscopic instruments. METHODS: We have performed SSM or NSM via a small periareolar incision with axillary incision using wound retractors without disposable endoscopic instruments. After the entire breast tissue was removed, immediate breast reconstruction (IBR) using tissue expanders was performed through the axillary incision. RESULTS: Twelve patients (13 cases: 1 patient had synchronous bilateral primary cancer) underwent NSM, and 8 had SSM because of involvement of the nipple-areola complex. IBR was performed with tissue expanders in 18 patients, while 2 patients refused to have IBR because of small breast size. When 3 patients with synchronous or metachronous bilateral breast cancer were excluded, the average length of surgery was 267 min in 15 patients who underwent SSM or NSM followed by IBR with implants, while it was only 120 min in 2 patients who underwent NSM alone. Average blood loss was 135 mL (range 40-350 mL). CONCLUSION: We have described a novel technique using the wound retractor for SSM or NSM followed by IBR in treating breast cancer patients. This technique can minimize skin incisions without using disposable endoscopic instruments and improve the cosmetic outcome of the reconstructed breast.

Aggressive remodelling with pedicled skin flaps of the volar surface for the release of contractures of the fingers.

We treated contractures of fingers with one or several pedicled skin flaps on one or both sides of the scar, depending on the site and spread of the scar. The length of the flap was equivalent to half the circumference of the unaffected finger, or the distance between bilateral midlateral lines. The width of the flap was the same as the distance between the scar and the midlateral line. A subcutaneous pedicle including one or several vessels is left at the proximal or distal end of each flap. After the scar has been excised the flaps are rotated about 90° and both ends of the flaps are sutured on the bilateral midlateral line. The skin defect that remains between the flaps is covered with a full-thickness skin graft from the non-weight-bearing area of the sole. In all cases, the flaps and skin grafts survived perfectly. Because of the flexibility of the subcutaneous flaps, the skin defects are effectively divided to avoid recontraction without disadvantages such as excess trimming of normal skin, extensive dog ears, or formation of scars on the dorsal surface. The method seems to be less invasive than the procedures used currently, and to yield a satisfactory aesthetic appearance.

Toxic shock syndrome toxin-1 (TSST-1) antibody levels in Japanese children.

Children with burns have a greater risk of developing toxic shock syndrome (TSS) than adults. This risk is thought to be associated with colonisation by toxic shock syndrome toxin-1 (TSST-1)-producing Staphylococcus aureus in children with insufficient antibody titers. The diagnosis of TSS is difficult because, in the early stages, its signs and symptoms resemble those of other common childhood illnesses such as scarlet fever. If the condition is not treated promptly, the mortality rate is high. This study was designed to determine the titers of TSST-1 serum antibody in Japanese children, in order to prevent TSS and facilitate its early diagnosis. Between May 2006 and May 2007, we studied 119 patients who were treated in the Department of Plastic and Reconstructive Surgery of Kanazawa Medical University Hospital. An enzyme-linked immunosorbent assay (ELISA) was used to test the level of the IgG antibody to TSST-1 in the patients' serum samples. The percentage of cases testing for TSST-1 antibody in the patients under 6 months old was 78.6%, and it was lowest (21.3%) in the age group from 6 to 12 months old. The group of patients older than 41 years showed the highest rate of positivity (100.0%) for TSST-1 antibody. Higher titers of TSST-1 antibody were found within the first 6 months after birth, and lower titers were found between 6 months and 2 years old. The titers began to increase again after age three. The high morbidity of TSS in children around 2 years of age was proven to be related to changes in the titers of TSST-1 antibody. Infants under 6 months old are protected from TSS because of the high level of TSST-1 antibody they receive from their mother. Children are at risk of developing staphylococcal toxic shock syndrome when their immune system is immature and they have no protective circulating anti-TSS antibodies.

Treatment for chronic abscess after cranioplasty: reconstruction of dura maters using the anterolateral thigh flap with fascia lata.

Although artificial dura maters such as Gore-Tex are used in cranioplasty, the use of artificial products occasionally results in the formation of infectious lesions. Recently, we encountered two patients who underwent brain surgery and contracted infection from artificial dura maters used for cranioplasty. To treat the postoperative infection, we prepared a vascularized fascia lata attached anterolateral thigh flap that could be applied to the infected wounds in the reconstruction of dura maters and obtained satisfactory results. The present study demonstrated that fascia lata attached anterolateral thigh flaps were useful for reconstructing intractable cranial fistulae complicated by infection. The disadvantages of our surgical technique were the impossibility of simultaneous bone reconstruction and the difficulty in creating a watertight closure of fascia and dura mater, although leakage of cerebrospinal fluid was not observed so far.

Treatment of craniosynostosis by distraction osteogenesis.

PURPOSE: Craniosynostosis patients treated with one-stage cranioplasty often have bleeding from the dura mater, fluid collection in the extradural space, and poor wound healing due to skin overstretching. To avoid these complications, we began using distraction osteogenesis. To determine the advantages and disadvantages of the procedure, we retrospectively compared distraction osteogenesis with conventional cranioplasty. PATIENTS AND RESULTS: We treated 24 patients with fronto-orbital advancement. Fifteen had one-stage cranioplasty; 9 received distraction osteogenesis. The one-stage operation patients averaged 25.5 months of age at surgery, 289 min of operating time, and 154 ml of intraoperative blood loss. For the distraction group, the average age was 16.6 months, average operating time was 196 min, and average blood loss was 76 ml. CONCLUSIONS: Compared with one-stage cranioplasty patients, distraction osteogenesis patients had significantly less intraoperative bleeding and shorter operating times. The disadvantages of distraction treatment were the need for multiple surgeries, prolonged hospitalization, wound infection, and dislocation of the distraction device.

Syndromic craniosynostosis with elbow joint contracture.

This paper reports a new type of syndromic craniosynostosis that was diagnosed by DNA analysis of the patient's fibroblast growth factor receptor (FGFR) genes. At birth, a male infant had ocular proptosis, a pseudotail, and obstructed respiration. He developed craniosynostosis, craniofacial dysmorphism, hydrocephalus, and bilateral contracture of his elbow joints. His treatment included fronto-orbital advancements and a ventriculoperitoneal shunt. Genetic analysis revealed that he was heterozygous for a missense mutation in exon 9 of the FGFR2 gene that resulted in an amino acid substitution of cysteine for serine at residue 351 (Ser351Cys). Seven cases with this mutation had previously been reported. All had severe craniosynostosis with midface hypoplasia, elbow joint contracture, developmental retardation, and early death.

A case of Beare-Stevenson cutis gyrata syndrome confirmed by mutation analysis of the fibroblast growth factor receptor 2 gene.

This paper reports a case of Beare-Stevenson cutis gyrata syndrome confirmed by DNA analysis of the patient's fibroblast growth factor receptor (FGFR) genes. At birth, the patient had ocular proptosis, a red nevus with skin tags on her forehead and an umbilical stump. She developed craniosynostosis, craniofacial dysmorphism and hydrocephalus. Her treatment included forehead and facial advancement and a ventriculoperitoneal shunt. Analysis of the FGFR genes revealed that she was heterozygous for a missense mutation in exon 10 for the FGFR2 protein, resulting in an amino acid substitution of cysteine for tyrosine at residue 375 (Tyr375Cys). This is the fourth case of Beare-Stevenson cutis gyrata syndrome confirmed by mutation analysis of the FGFR genes.