Culturally adapted translation of LYMPH-Q upper extremity module from English to Mandarin Chinese.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is one of the debilitating complications after breast cancer treatment. Several forms of patient-reported outcome measures (PROMs) were developed to evaluate the severity of BCRL based on the patients' perspective. LYMPH-Q Upper Extremity Module is a newly developed questionnaire for BCRL. This study aimed to demonstrate the process of translation and cultural adaption from English to Mandarin Chinese. METHODS AND RESULTS: The translation process followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) best-practice guidelines for the translation and cultural adaption of PROM. The process included four steps: forward translation, back translation, back translation review, and patient interviews. In total, five patients with BCRL were recruited for patient interviews. The forward translation step involved two professional translators whose native language was Mandarin Chinese. A reconciled translated version was produced. In the back translation step, the reconciled translated version in Mandarin Chinese was sent to another professional translator whose native language was English. The back-translated version in English was sent back to the developer of LYMPH-Q for review. In this step, 22 items were revised. In the final step of patient interviews, 15 items were revised based on the patients' feedback. CONCLUSION: The development of Mandarin Chinese version of LYMPH-Q Upper Extremity Module and its utilization in conjunction with the existing objective measures could provide a more well-rounded picture of the status of patients with BCRL worldwide.

2024 TSOC/TSPS Joint Consensus: Strategies for Advanced Vascular Wound Management in Arterial and Venous Diseases.

The Taiwan Society of Cardiology (TSOC) and Taiwan Society of Plastic Surgery (TSPS) have collaborated to develop a joint consensus for the management of patients with advanced vascular wounds. The taskforce comprises experts including preventive cardiologists, interventionists, and cardiovascular and plastic surgeons. The consensus focuses on addressing the challenges in diagnosing, treating, and managing complex wounds; incorporates the perfusion evaluation and the advanced vascular wound care team; and highlights the importance of cross-disciplinary teamwork. The aim of this joint consensus is to manage patients with advanced vascular wounds and encourage the adoption of these guidelines by healthcare professionals to improve patient care and outcomes. The guidelines encompass a range of topics, including the definition of advanced vascular wounds, increased awareness, team structure, epidemiology, clinical presentation, medical treatment, endovascular intervention, vascular surgery, infection control, advanced wound management, and evaluation of treatment results. It also outlines a detailed protocol for assessing patients with lower leg wounds, provides guidance on consultation and referral processes, and offers recommendations for various wound care devices, dressings, and products. The 2024 TSOC/TSPS consensus for the management of patients with advanced vascular wounds serves as a catalyst for international collaboration, promoting knowledge exchange and facilitating advancements in the field of advanced vascular wound management. By providing a comprehensive and evidence-based approach, this consensus aims to contribute to improved patient care and outcomes globally.

Pediatric Mandibular Reconstruction With Free Serratus Anterior-Rib Composite Flap: A Case Report.

ABSTRACT: Reconstruction of children's mandibles after mandibular resection for benign or malignant tumors is challenging. Microvascular flap reconstruction is a common treatment option for restoring mandibular continuity after the resection of oral cavity neoplasms.We presented 2 cases of childhood mandibular reconstruction after tumor wide excision and segmental mandibulectomy, one for malignant cancer and one for benign ossifying fibroma, with serratus-rib composite free flap. All 2 patients had a favorable facial profile, functional outcome, and dental occlusion at the last follow-up. The development of children's mandible and donor site needs to be considered compared with adult's mandibular reconstruction. Given its reliability and utility, this flap can be an alternative for pediatric mandibular reconstruction compared with the free fibular flap and other candidates.

The effect of immediate lymphatic reconstruction on the post-operative drain output after axillary lymph node dissection for breast cancer: A retrospective comparative study.

INTRODUCTION: Axillary lymph node dissection (ALND) for breast cancer has been considered to be associated with a variety of complications, such as excessive postoperative wound drainage, prolonged drain placement, or seroma formation in the short term, or arm lymphedema in the long run. Immediate lymphedema reconstruction (ILR) has been proposed to reduce the occurrence of arm lymphedema by anastomosing the transected arm lymphatics to nearby branches of the axillary vein immediately after ALND. This study aims to demonstrate that ILR can also reduce the postoperative drainage amount. PATIENTS AND METHODS: Between April 2020 and January 2022, a total of 76 breast cancer patients receiving ALND were reviewed. Forty four of them also received ILR immediately after ALND. The assignment of ILR surgery was non-random, based on patients' willingness and plastic surgeons' availability. The lymphatic vessels in the axillary wound were anastomosed with nearby terminal branches of the axillary vein under surgical microscope. Patients' characteristics, including age, body mass index (BMI), neoadjuvant therapy, type of breast surgery, the occurrence of seroma formation, number of removed lymph nodes, number of positive nodes, and the drainage amount from the operative wounds were compared between ILR and non-ILR groups. RESULTS: No statistically significant difference was noted between groups in terms of age (56.5 ± 9.8 vs. 60.9 ± 10.7, p = .09), BMI (22.6 ± 3.7 vs. 23.7 ± 3.8, p = .27), type of breast surgery (p = .32), the occurrence of seroma formation (p = 1.0), the likelihood of receiving neoadjuvant therapy (p = .12), number of lymph nodes removed (17.5 ± 7.6 vs. 17.4 ± 8.3, p = .96), or number of positive nodes on final pathology (3.7 ± 5.4 vs. 4.8 ± 8.5, p = .53) except the ILR group had statistically significantly less drainage amount than non-ILR group (39.3 ± 2.6 vs. 48.3 ± 3.7, p = .046). CONCLUSION: For breast cancer patients receiving ALND, the immediate lymphatic reconstruction can reduce the postoperative drainage amount from the operative wound.

A pressure ulcers assessment system for diagnosis and decision making using convolutional neural networks.

BACKGROUND/PURPOSE: Pressure ulcers are a common problem in hospital care and long-term care. Pressure ulcers are caused by prolonged compression of soft tissues, which can cause local tissue damage and even lead to serious infections. This study uses a deep learning algorithm to construct a system that diagnoses pressure ulcers and assists in making treatment decisions, thus providing additional reference for first-line caregivers. METHODS: We performed a retrospective research of medical records to find photos of patients with pressure ulcers at National Taiwan University Hospital from 2016 to 2020. We used photos from 2016 to 2019 for training and after removing the photos which were vague, underexposed, or overexposed, 327 photos were obtained. The photos were then labeled as "erythema" or "non-erythema" for the first classification task and "extensive necrosis", "moderate necrosis" or "limited necrosis" for the second, by consensus of three recruited physicians. An Inception-ResNet-v2 model, a kind of Convolutional Neural Network (CNN), was applied for training these two classification tasks to construct an assessment system. Finally, we tested the model with the photos of pressure ulcers taken from 2019 to 2020 to verify its accuracy. RESULTS: For the task of classification of erythema and non-erythema wounds, our CNN model achieved an accuracy of about 98.5%. For the task of classification of necrotic tissue, our model achieved accuracy of about 97%. CONCLUSION: Our CNN model, which was based on Inception-ResNet-v2, achieved high accuracy when classifying different types of pressure ulcers, making it applicable in clinical circumstances.

Resuming Oral Feeding in Patients With Oral Squamous Cell Carcinoma With Free Anterolateral Thigh Flap Reconstruction.

BACKGROUND: Quality of life and functional improvement have emerged as important goals for patients with oncologic disease. For patients with head and neck cancer, free anterolateral thigh (ALT) flaps serve as reliable reconstruction and provide functional restoration. Nevertheless, factors affecting the resumption of oral feeding are rarely described. This study aimed to evaluate and compare the functional outcomes of oral feeding for patients with different oncologic defect patterns and reconstructive ALT flap designs. METHODS: We retrospectively reviewed patients with head and neck cancer undergoing oncologic ablation and free ALT reconstruction between January 2016 and April 2018 at National Taiwan University Hospital. Patients were categorized into 2 groups as through-and-through (T&T) and non-through-and-through (non-T&T) according to the defect pattern. We further subgrouped T&T patients into lip resection/lip sparing according to lip involvement. Reconstructive ALT flaps were of 2 designs, folded (F-ALT) and chimeric (C-ALT). Outcomes of oral feeding were analyzed using descriptive statistics, and differences between groups were compared using the Student t test. RESULTS: We identified 233 patients who received oncologic ablation and free ALT flap reconstruction. There was no significant difference in functional recovery between the T&T and non-T&T groups (81.2% vs 73%, P = 0.137). However, among patients who succeeded in resuming oral feeding, lip-sparing patients had better functional recovery in terms of early oral feeding within 6 months and nasogastric tube removal compared with lip-resection patients (100% vs 83.3%, P = 0.001). Moreover, the F-ALT design resulted in a higher success rate in resuming oral feeding compared with the C-ALT design (90.5% vs 54.6%, P = 0.032). CONCLUSIONS: Patients with head and neck cancer with T&T defects were associated with higher rates of secondary flap revision and a trend of delayed oral feeding. In the long term, improved oral feeding outcome with the F-ALT design was observed compared with the C-ALT design in the specific group with T&T defect.

Prognostic significance of positive surgical margins for scalp angiosarcoma.

BACKGROUND: Scalp angiosarcomas (AS) are aggressive soft tissue sarcomas that present with outcomes different from other AS of the head and neck region. Due to the rarity of the disease, limited data on the clinical outcome of scalp AS are available. In particular, the prognostic significance of surgical margins remains controversial and the impact of margin status on survival has not been documented. METHODS: We retrospectively reviewed 41 scalp AS patients, including 30 patients with localized disease and 11 patients with initial distant metastasis, treated in our institution between 1997 and 2017. Survival was determined by Kaplan-Meier analysis. In the 30 patients without distant metastasis (localized disease), univariate and multivariate analysis using the Cox proportional hazards model were used to determine clinicopathologic characteristics associated with recurrence free survival (RFS), locoregional control (LRC), and overall survival (OS). RESULTS: Totally 41 patients diagnosed with scalp AS were identified, including 30 patients with localized disease and 11 patients with initial distant metastasis on diagnosis. Overall, the median follow-up period was 19.3 (range 0.3-128.5) months. The median survival time was 16.6 (range 0.3-144.3) months and the 5-year OS (95% Confidence Interval (CI)) rate was 22% (12%-42%). In the 30 patients with localized disease, univariate analysis showed that positive margins, either lateral-side or deep-side, were significant prognostic factors for RFS, LRC, and OS (p < 0.05). On multivariate analysis, positive margins emerged as adverse prognostic factors for RFS (Hazard Ratio (HR) 4.29, 95% CI, 1.71-10.75, p = 0.002), LRC (HR 6.35, 95% CI, 2.19-18.37, p = 0.001), and OS (HR 4.73, 95% CI, 1.71-13.07, p = 0.003). CONCLUSION: Scalp AS is associated with high local recurrence rates and poor survival outcomes. Positive surgical margins are adverse prognostic factors for survival.

Predisposing factors of necrotizing fasciitis with comparison to cellulitis in Taiwan: A nationwide population-based case-control study.

BACKGROUND: Necrotizing fasciitis (NF) is a life-threatening soft tissue infection with low incidence that requires prompt surgery. In the initial stage, it is difficult to distinguish NF and cellulitis, and limited population-based reports are available. METHODS: We queried inpatient data sets of National Health Institute Research Database in Taiwan from 2002 to 2011 for all patients with diagnoses of NF. Of them, only patients who underwent surgeries and had been admitted to intensive care units were included as the study group. Age and gender-matched patients with admission diagnoses of cellulitis were enrolled in a ratio of 1:4 as the control group. We calculated annual incidence, mortality rate, risk factors and predictors of mortality of NF. RESULTS: The study group consisted of 7391 NF patients. Among them, 4715 patients (64%) were man and 2676 (36%) were women. The overall annual incidence of NF was 3.26 hospitalizations per 100,000 person-years, which rose with age with male predominance. The in-hospital mortality rate, which also rose with age, was 32.2%. Diabetes mellitus (adjusted odds ratio, 2.93; 95% confidence interval, 2.77-3.11; P value < 0.0001), alcoholism (2.64; 2.27-3.08; P < .0001), and chronic kidney disease (1.98; 1.84-2.14; P < .001) were identified as risk factors. Chronic kidney disease (1.86; 1.64-2.10; P < .001) and liver cirrhosis (1.68; 1.50-1.88; P < .001) were identified as predictors of in-hospital mortality. CONCLUSION: Age and the presence of chronic diseases are major risk factors as well as prognostic factors of NF in Taiwan. Diabetes mellitus increases the risk of NF, but does not adversely affect the outcome.

The impacts of intra-arterial chemotherapy on head and neck microvascular reconstruction.

BACKGROUND: For locally advanced head and neck cancers, intra-arterial (IA) chemotherapy is utilized for locoregional control with favorable results. The study aimed to evaluate the surgical outcomes of microsurgical reconstruction in head and neck cancer patients with IA chemotherapy METHODS: This cohort study retrospectively reviewed patients who underwent head and neck microsurgical reconstruction from January 2014 to August 2018. Patients with prior history of chemotherapy were included and categorized into two groups according to history of IA chemotherapy (IA group)/intravenous chemotherapy (IV group). Flap survival was evaluated along with microsurgical revision rates and complications. Recipient vessel specimens were analyzed by histological examination. A 1:1 propensity score matched analysis was performed. RESULTS: The study cohort included 45 patients with IA chemotherapy and 201 patients with IV chemotherapy. After propensity score matching, the difference in total flap loss and microsurgical revision rates were nonsignificant between two groups. However, the IA group had significantly higher rates of arterial thrombosis (Odds ratio [OR] 4.98; 95%CI, 1.28-19.38; p = 0.021), wound-related complications (OR 3.30; 95%CI, 1.21-9.02; p = 0.02) and revision surgery within one month (OR 3.73; 95%CI, 1.10-12.64; p = 0.035). Based on histology, IA group vessels showed a higher intima/media ratio than the IV group (0.45 ± 0.06 versus 0.23 ± 0.03, p = 0.02) CONCLUSION: Despite treating local advanced head and neck cancers with good results, IA chemotherapy may cause subsequent deleterious effects on local tissue due to the high concentration of cytotoxic chemotherapeutic agents. Surgeons should be cautious in selection of recipient vessels when performing microvascular reconstruction.

Chronic wound assessment and infection detection method.

BACKGROUND: Numerous patients suffer from chronic wounds and wound infections nowadays. Until now, the care for wounds after surgery still remain a tedious and challenging work for the medical personnel and patients. As a result, with the help of the hand-held mobile devices, there is high demand for the development of a series of algorithms and related methods for wound infection early detection and wound self monitoring. METHODS: This research proposed an automated way to perform (1) wound image segmentation and (2) wound infection assessment after surgical operations. The first part describes an edge-based self-adaptive threshold detection image segmentation method to exclude nonwounded areas from the original images. The second part describes a wound infection assessment method based on machine learning approach. In this method, the extraction of feature points from the suture area and an optimal clustering method based on unimodal Rosin threshold algorithm that divides feature points into clusters are introduced. These clusters are then merged into several regions of interest (ROIs), each of which is regarded as a suture site. Notably, a support vector machine (SVM) can automatically interpret infections on these detected suture site. RESULTS: For (1) wound image segmentation, boundary-based evaluation were applied on 100 images with gold standard set up by three physicians. Overall, it achieves 76.44% true positive rate and 89.04% accuracy value. For (2) wound infection assessment, the results from a retrospective study using confirmed wound pictures from three physicians for the following four symptoms are presented: (1) Swelling, (2) Granulation, (3) Infection, and (4) Tissue Necrosis. Through cross-validation of 134 wound images, for anomaly detection, our classifiers achieved 87.31% accuracy value; for symptom assessment, our classifiers achieved 83.58% accuracy value. CONCLUSIONS: This augmentation mechanism has been demonstrated reliable enough to reduce the need for face-to-face diagnoses. To facilitate the use of this method and analytical framework, an automatic wound interpretation app and an accompanying website were developed. TRIAL REGISTRATION: 201505164RIND , 201803108RSB .

Generation of GGTA1 Mutant Pigs by Direct Pronuclear Microinjection of CRISPR/Cas9 Plasmid Vectors.

This study was conducted to confirm that 1-site and 4-site ppU6-GGTA1-gRNA CRISPR vectors together with the pCX-Flag2-NLS1-Cas9-NLS2 plasmid can both generate KO pigs by direct pronuclear microinjection. In total, 41 and 53 fertilized eggs were microinjected on 1-site and 4-site strategies, respectively. The 1-site construction generated a litter of 8 piglets, and 2 were mono-allelic mutant (mMt). The injection of 4-site constructions resulted in one biallelic mutant (bMt) and one mMt piglet in a litter of 7. Those 3 mMt pigs had a 4 bp deletion, 5 bp insertion, or 7 bp insertion at site I, and the bMt pig had 5 types of mutations at cleavage sites I and III. The expression of alpha-Gal on the bMt peripheral blood mononuclear cells (PBMCs) was reduced, and survival rate of bMt PBMCs was maintained as indicated by results of cultivation with sera of humans or Formosan Macaques. We concluded that mutant pigs could be generated by direct pronuclear microinjection of ppU6-GGTA1-gRNA CRISPR vectors with the pCX-Flag2-NLS1-Cas9-NLS2 plasmid and that the 4-site strategy has a better mutant efficiency. Porcine U6 promoter was firstly used to express KO vectors and effectively generate mutant pigs, worthily to adopt for future KO studies.

Evaluation of a laminin-alginate biomaterial, adipocytes, and adipocyte-derived stem cells interaction in animal autologous fat grafting model using 7-Tesla magnetic resonance imaging.

Biomaterials are often added to autologous fat grafts both as supporting matrices for the grafted adipocytes and as cell carrier for adipose-derived stem cells (ADSCs). This in vivo study used an autologous fat graft model to test a lamininalginate biomaterial, adipocytes, and ADSCs in immune-competent rats. We transplanted different combinations of shredded autologous adipose tissue [designated "A" for adipose tissue]), laminin-alginate beads [designated "B" for bead], and ADSCs [designated "C" for cell]) into the backs of 15 Sprague-Dawley rats. Group A received only adipocytes, Group B received only laminin-alginate beads, Group AB received adipocytes mixed with laminin-alginate beads, Group BC received laminin-alginate beads encapsulating ADSCs, and Group ABC received adipocytes and laminin-alginate beads containing ADSCs. Seven-tesla magnetic resonance imaging was used to evaluate the rats at the 1st, 6th, and 12th weeks after transplantation. At the 12th week, the rats were sacrificed and the implanted materials were retrieved for gross examination and histological evaluation. The results based on MRI, gross evaluation, and histological data all showed that implants in Group ABC had better resorption of the biomaterial, improved survival of the grafted adipocytes, and adipogenic differentiation of ADSCs. Volume retention of grafts in Group ABC (89%) was also significantly greater than those in Group A (58%) (p < 0.01). Our findings support that the combination of shredded adipose tissue with ADSCs in laminin-alginate beads provided the best overall outcome.

Risk factors for complications following immediate tissue expander based breast reconstruction in Taiwanese population.

BACKGROUND/PURPOSE: Breast cancer patients in Asia show considerable disparities from Caucasian patients, such as younger age of onset and lower rates of smoking, obesity, and diabetes. Findings of prior studies regarding risk factors associated with complications in tissue expander may not hold for Asian populations, since most of these studies involved Caucasian patients. In this study, we surveyed risk factors in the Taiwanese population, providing additional evidence about the important differences and discuss the implications for clinical practice. METHODS: Patients who underwent immediate, two-stage, tissue expander breast reconstruction from December 2008 to August 2014 in the National Taiwan University Hospital, Taipei, Taiwan were included. Follow-up observations of all patients were conducted until December 2014. Complications occurring during the tissue expander stage were evaluated. Multivariate regression modeling was used to identify risk factors for complications. RESULTS: A total of 246 consecutive, immediate, smooth round tissue expander placements were performed for breast reconstruction. The most common complication was skin necrosis (4.9%), followed by wound dehiscence (4.1%). In the multivariate model, body mass index (BMI) ≥ 24 kg/m2 was the only risk factor that reached statistical significance (odds ratio: 2.41, 95% confidence interval: 1.17-4.96). CONCLUSION: We provided evidence that racial disparities have an impact on the risk factors for complications associated with tissue expander breast reconstruction. BMI≥24 kg/m2 was the only risk factor significantly associated with complications. Clinically, BMI≥24 kg/m2, rather than the standard definition of obesity (BMI > 30 kg/m2), may be a more suitable cutoff point for risk in patients of Asian ethnicity.

Chen's Double Eyelid Fold Illusion: An Eye Size Assimilation Illusion Induced by a Supratarsal Fold in the Brow-Eye Unit, A Preliminary Report.

BACKGROUND: Double eyelidplasty can enhance the eye size and facial attractiveness of Asian individuals with single eyelids. The authors hypothesize that a supratarsal fold can induce an eye size assimilation illusion to enhance eye dimensions and aesthetics, and seek to define the optimum vertical proportion between a supratarsal fold and the eye fissure associated with maximal induction of the size assimilation illusion. METHODS: A photometric study of the replicated photographs of ten female Taiwanese patients after double eyelidplasty was designed. Each photograph was edited by shifting the supratarsal folds vertically at a regular fold/eye ratio increment of 0.1. The perceived attractiveness of edited photographs of each patient was rated by 100 adult observers using a score of 1-5. The palpebral parameters were measured and analyzed. RESULTS: The mean rating score increased gradually when a supratarsal fold was added and peaked when the fold/eye ratio was 0.3 and the mean Chen's double eyelid fold ratio was 0.631 ± 0.023. After the peak, the mean score decreased gradually and was lower than the photograph without a fold when the fold/eye ratio exceeded 0.5 and the mean Chen's ratio exceeded 0.729 ± 0.027. CONCLUSION: Within the optimal ranges of the fold/eye ratio and Chen's double eyelid fold ratio, eyes are perceived as larger and more attractive due to a hybrid presentation of two interdependent eye size assimilation illusions induced by a supratarsal fold in the brow-eye unit. "Chen's double eyelid fold illusion" is proposed to describe this complex visual phenomenon. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postoperative Showering for Clean and Clean-contaminated Wounds: A Prospective, Randomized Controlled Trial.

OBJECTIVE: To evaluate wound infection rates, pain scores, satisfaction with wound care, and wound care costs starting 48 hours after surgery. BACKGROUND: Showering after surgery is a controversial issue for wound care providers and patients. We investigated the benefits and detriments of showering for postoperative wound care. METHODS: Patients undergoing thyroid, lung, inguinal hernia, and face and extremity surgeries with clean or clean-contaminated wounds were included. The patients were randomized to allow showering (shower group) or to keep the wound dry (nonshower group) for postoperative wound care starting 48 hours after surgery. The primary endpoint was the rate of surgical wound infection. The secondary endpoints included the wound pain score, satisfaction with wound care, and cost of wound care. RESULTS: Between May 2013 and March 2014, there were 222 patients randomized to the shower group and 222 to the nonshower group. Two patients in each group were lost to follow-up. There were 4 superficial surgical site infections in the shower group and 6 in the nonshower group (4/220, 1.8% vs 6/220, 2.7%, P = 0.751). Postoperative pain scores were comparable between the 2 groups. Patients in the shower group were more satisfied with their method of wound care, and their wound care costs were lower when compared with the nonshower group. CONCLUSIONS: Clean and clean-contaminated wounds can be safely showered 48 hours after surgery. Postoperative showering does not increase the risk of surgical site complications. It may increase patients' satisfaction and lower the cost of wound care.

Necrotizing fasciitis in patients with diabetes mellitus: clinical characteristics and risk factors for mortality.

BACKGROUND: Necrotizing fasciitis (NF) is a rapidly progressive and life-threatening infection. This study aimed to investigate the clinical characteristics and mortality- associated factors in diabetic patients. METHODS: Detailed clinical information of 165 NF cases was retrospectively collected and analyzed in National Taiwan University Hospital between January 1997 and February 2013. We documented and compared the clinical features according to the presence of underlying diabetes mellitus, and we identified risk factors associated with mortality. RESULTS: There were 84 patients (51 %) with diabetes. The overall case fatality rate was 29.7 %, and we found no significant difference between the patients with or without diabetes. Compared with the nondiabetic patients, diabetic patients were older and exhibited higher serum levels of glucose and potassium on admission. Polymicrobial infection and monomicrobial NF caused by Klebsiella pneumoniae were also more frequently associated with diabetic patients. Moreover, diabetic NF patients exhibit a significantly higher chance of limb loss during hospitalization. In the combined diabetic and nondiabetic cohort, a high serum level of potassium (odds ratio, 2.2; 95 % confidence interval, 1.2 to 4.02; P = 0.011) on admission was independently associated with mortality, whereas positive blood culture on admission was associated with mortality in the diabetic cohort (odds ratio, 7.36; 95 % confidence interval, 1.66 to 32.54; P = 0.009). CONCLUSIONS: Diabetic patients are more susceptible to NF caused by polymicrobial infection or K. pneumoniae, and they are more likely to receive limb amputation for infection control. Bacteraemia on admission is a significant risk factor for mortality in diabetic NF patients.

Reconstruction for osteoradionecrosis of the mandible: superiority of free iliac bone flap to fibula flap in postoperative infection and healing.

BACKGROUND: Osteoradionecrosis (ORN) of the mandible is not an uncommon complication after radiotherapy for head and neck cancers. Although definitive treatment has been confirmed as radical excision of the necrotic bone with simultaneous vascularized osteocutaneous flap reconstruction, it remains a unique challenge. In this study, we compare our results of reconstruction with free iliac and fibula flaps in flap survival, bony union, and postoperative complications. PATIENTS AND METHODS: From 1986 to 2011, there were 153 mandibular ORN cases in our center that were treated with radical resection of the necrotic bone and reconstruction with either vascularized iliac (n=108) or fibula flaps (n=45). Data collected for analysis included patient demographics, flap survival rate, postoperative infection rate, nonunion/malunion rate, mean hospital stay, and antibiotics use. RESULTS: All patients healed eventually without recurrence of ORN. However, we observed difference in the complication rate between the iliac flap group and fibula flap group. In the group with iliac flap reconstruction, patients required less days of hospital stay for intravenous antibiotics treatment postoperatively. The average days required for intravenous antibiotics in the iliac flap group were 10.46 (2.28) versus 16.09 (3.88) days in the fibula group (P<0.01). In the group with fibula flap reconstruction, 9 (20.0%) patients had subsequent neck infection due to healing problem, compared to 8 (7.4%) patients in the iliac flap group (P=0.04). In the iliac flap group, the nonunion and malunion rates were 4.6% and 2.8% respectively; whereas in the fibula group, the rates were 15.5% and 6.6%, respectively (P=0.04 and 0.36, respectively). CONCLUSIONS: For ORN patients, vascularized iliac bone flap provides more reliable results compared to fibula flap. The merits of vascularized iliac flap include the following: (1) its natural curve mimics the shape of mandible and does not need osteotomy; (2) it offers more volume of bone that matches better to the native mandible to allow later osteointegration as well as faster bony union, due to the nature of being a membranous bone; and (3) it carries more abundant soft tissue to obliterate possible dead space. The only disadvantages are short pedicle and requiring special management of skin paddle, which can be overcome by training in microsurgery.

Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery.

This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.

A modified free chimeric osteocutaneous fibular flap design for head and neck reconstruction: experience on a series of 10 cases.

BACKGROUND: We have previously described a modified chimeric fibular osteocutaneous flap design based on a combination of a traditional fibular flap and a peroneal artery perforator fasciocutaneous flap for mandible and adjacent soft tissue reconstruction. The purpose of this article is to share our experience with a larger case series utilizing this new technique for mandible and adjacent soft tissue reconstruction after cancer wide excision surgery and a more detailed description on these flaps harvesting procedures. PATIENTS AND METHODS: Ten patients (age range from 32 to 63 years), who had segmental defect of mandible and adjacent soft tissue defect after cancer wide excision surgery, received mandible and adjacent soft tissue reconstruction based on the modified chimeric fibular flap design. RESULTS: The skin paddle based on peroneal perforators ranged from 9 cm × 3.5 cm to 10 cm × 10 cm and the mean pedicle length was 8.9 cm. Four patients underwent primary closure of the donor site. Three flap salvage procedures were performed due to vascular thrombosis and all flaps survived well. Nine patients had acceptable outer appearance, and one patient complained of cheek sunken. All patients had at least 3-cm interincisor distance during a mean of 12-month follow-up period. CONCLUSION: The modified chimeric osteocutaneous fibula flaps were feasible design with few intermuscular septum problems during bone fixation. Furthermore, it provided larger skin paddles with few restrictions to reconstruct the cheek skin defect.

Automatic segmentation and measurement of pressure injuries using deep learning models and a LiDAR camera.

Pressure injuries are a common problem resulting in poor prognosis, long-term hospitalization, and increased medical costs in an aging society. This study developed a method to do automatic segmentation and area measurement of pressure injuries using deep learning models and a light detection and ranging (LiDAR) camera. We selected the finest photos of patients with pressure injuries, 528 in total, at National Taiwan University Hospital from 2016 to 2020. The margins of the pressure injuries were labeled by three board-certified plastic surgeons. The labeled photos were trained by Mask R-CNN and U-Net for segmentation. After the segmentation model was constructed, we made an automatic wound area measurement via a LiDAR camera. We conducted a prospective clinical study to test the accuracy of this system. For automatic wound segmentation, the performance of the U-Net (Dice coefficient (DC): 0.8448) was better than Mask R-CNN (DC: 0.5006) in the external validation. In the prospective clinical study, we incorporated the U-Net in our automatic wound area measurement system and got 26.2% mean relative error compared with the traditional manual method. Our segmentation model, U-Net, and area measurement system achieved acceptable accuracy, making them applicable in clinical circumstances.