Comparative study of arterial and venous grafting for pedicle lengthening in head and neck microvascular reconstruction.

BACKGROUND: In the field of head and neck microvascular reconstruction, no previous study has compared arterial and venous grafting as methods of anterolateral thigh (ALT) pedicle lengthening. Therefore, we conducted this comparative study to compare the outcomes between the two pedicle lengthening techniques. METHODS: We performed comparative effectiveness research by conducting a retrospective chart review from January 2012 to December 2021 to identify patients who underwent head and neck reconstruction with non-descending branch ALT perforator flaps using either the in situ pedicle lengthening (ISPL) technique or the vein graft (VG) technique. A total of 26 patients were analyzed, including 14 who underwent ISPL, and 12 who underwent VG. The collected data, including patient demographics, surgical indications, history of prior free flap, prior neck dissection, radiation therapy, chemotherapy, graft length, and flap outcomes, were analyzed. The flap outcomes were categorized as total flap loss, partial flap loss, flap compromise that required operating room visits, or minor issues, including infection or dehiscence. The flap characteristics and postoperative outcomes were compared between the two groups. RESULTS: The VG group had two flap losses, whereas the ISPL group had none. Although the failure rate was higher in the VG group than that in the ISPL group, the difference was not statistically significant (0% vs. 16.7%, p = 0.203). Additionally, there were no significant differences in flap take-back (14.3% vs. 16.7%, p = 1) and minor complications between the two groups (35.7% vs. 33.3%, p = 1). CONCLUSIONS: If pedicle lengthening with vessel graft is inevitable in head and neck reconstruction, arterial graft may provide a reliable outcome and may be considered an effective alternative when compared to vein grafts.

Clinical predictors of early surgical intervention in patients with venomous snakebites.

BACKGROUND: Venomous snakebites induce tissue destruction and secondary infection; however, the optimal timing of surgical intervention for these complications remains unknown. This study assessed the clinical predictors of early surgical intervention in patients with snakebites. METHODS: This retrospective study included 63 patients (45 men and 18 women) with venomous snakebites. In addition to the snake species, the demographics, affected body parts, clinical characteristics, and ultrasound findings of the patients in the surgical (32 patients) and nonsurgical (31 patients) groups were analyzed and compared. RESULTS: A higher incidence of acute compartment syndrome, local ecchymosis, skin necrosis, bullae, blisters, and fever was found in the surgical group than in the nonsurgical group, and ultrasound findings of the absence of Doppler flow were more frequently noted in the surgical group than in the nonsurgical group. After adjustment using a multivariate logistic regression model, only advanced age, Naja atra bite, local ecchymosis, and bulla or blister formation remained significant factors for surgical intervention. Furthermore, comparison of the outcomes of patients who received early (≤ 24 h) and late (> 24 h) surgical intervention revealed that the duration of continuous negative pressure wound therapy (6 vs. 15 days; P = 0.006), duration of hospital stay (13 vs. 26 days; P = 0.002), and duration of outpatient follow-up (15 vs. 36 days; P < 0.001) were significantly lower in patients who received early surgical intervention. The final reconstructive surgery was simple among the patients who received surgical intervention within 24 h of being bitten (P = 0.028). CONCLUSION: In patients with snakebites, advanced age, high-risk clinical manifestations (e.g., local ecchymosis and bulla or blister formation), and Naja atra envenomation are predictors of surgical intervention within 24 h.

The role of vein grafts in reconstructive head and neck microsurgery

Abstract Objective: Free tissue transfer is widely used for head and neck reconstruction. In certain circumstances, vein grafting is required to elongate free flap pedicles to connect them to appropriate recipient vessels. Because of controversy regarding the use of interposition vein grafts in free tissue reconstruction, this paper reports vein graft indications, techniques, safety, and outcomes for head and neck microvascular surgery. Methods: Twenty-six patients (23 men and 3 women) who underwent interposition vein grafting concurrent with free tissue transfer were included in this study. The most common reason for head and neck reconstruction with vein graft was tumor recurrence, followed by flap salvage. The interposition vein grafts were applied in two manners as temporary arteriovenous (A-V) loop and conduit to extend the length of the free flap for venous drainage. Results: The most common reconstructions were anterolateral thigh flaps (15 cases), followed by vastus lateralis myocutaneous (3 cases) and radial forearm (2 cases) flaps. The common recipient vessels were superior thyroid artery, superficial temporal artery and external jugular vein. The free flap loss rate was 7.7% with vein grafts and 4.9 without vein grafts (p = 0.380). The free flap complication rate was 50.0% and 16.8% in patients with and without vein grafts, respectively (p < 0.001). Radiation therapy, chemotherapy, prior neck dissection, and prior free flap transfer were more common in the vein graft group (all p < 0.001). The hospital stay was significantly longer for the vein graft group than for the non-vein graft group (29.5 vs. 19.0 days; p = 0.001). Conclusion: Overall free flap survival rates of 92.3% and 95.1% in the vein and non-vein graft groups, respectively - indicating the reliability of the vein grafts in challenging head and neck reconstructions, particularly in salvage cases and patients with multiple reconstructions. Level of evidence: Level 3.

Invasive Candidiasis in Hospitalized Patients with Major Burns.

BACKGROUND: Invasive candidiasis (IC) is a major cause of morbidities and mortality in patients hospitalized with major burns. This study investigated the incidence of IC in this specific population and analyzed the possible risk factors. MATERIALS AND METHODS: We retrospectively analyzed data from the National Health Insurance Research Database (NHIRD) of Taiwan. We identified 3582 patients hospitalized with major burns on over 20% of their total body surface area (TBSA) during 2000-2013; we further analyzed possible risk factors. RESULT: IC was diagnosed in 452 hospitalized patients (12.6%) with major burns. In the multivariate analysis, patients older than 50 years (adjusted odds ratio (OR) = 1.96, 95% confidence interval (CI) 1.36-2.82), those of female sex (adjusted OR = 1.33, 95% CI 1.03-1.72), those with burns on the head (adjusted OR = 1.33, 95% CI 1.02-1.73), and those with burns over a greater TBSA had higher risks of IC. CONCLUSION: Treating IC is crucial in healthcare for major burns. Our study suggests that several risk factors are associated with IC in patients hospitalized with major burns, providing reliable reference value for clinical decisions.

The role of vein grafts in reconstructive head and neck microsurgery.

OBJECTIVE: Free tissue transfer is widely used for head and neck reconstruction. In certain circumstances, vein grafting is required to elongate free flap pedicles to connect them to appropriate recipient vessels. Because of controversy regarding the use of interposition vein grafts in free tissue reconstruction, this paper reports vein graft indications, techniques, safety, and outcomes for head and neck microvascular surgery. METHODS: Twenty-six patients (23 men and 3 women) who underwent interposition vein grafting concurrent with free tissue transfer were included in this study. The most common reason for head and neck reconstruction with vein graft was tumor recurrence, followed by flap salvage. The interposition vein grafts were applied in two manners as temporary arteriovenous (A-V) loop and conduit to extend the length of the free flap for venous drainage. RESULTS: The most common reconstructions were anterolateral thigh flaps (15 cases), followed by vastus lateralis myocutaneous (3 cases) and radial forearm (2 cases) flaps. The common recipient vessels were superior thyroid artery, superficial temporal artery and external jugular vein. The free flap loss rate was 7.7% with vein grafts and 4.9 without vein grafts (p = 0.380). The free flap complication rate was 50.0% and 16.8% in patients with and without vein grafts, respectively (p < 0.001). Radiation therapy, chemotherapy, prior neck dissection, and prior free flap transfer were more common in the vein graft group (all p < 0.001). The hospital stay was significantly longer for the vein graft group than for the non-vein graft group (29.5 vs. 19.0 days; p = 0.001). CONCLUSION: Overall free flap survival rates of 92.3% and 95.1% in the vein and non-vein graft groups, respectively - indicating the reliability of the vein grafts in challenging head and neck reconstructions, particularly in salvage cases and patients with multiple reconstructions. LEVEL OF EVIDENCE: Level 3.

In situ pedicle lengthening and perforator shifting technique for overcoming the perforator variation of the anterolateral thigh free flap during head and neck reconstruction.

BACKGROUND: Anterolateral thigh (ALT) free flap is one of the most popular options for surgeons when reconstructing head and neck defects. When the recipient vessels are located in a remote site, a flap with adequate pedicle length is essential. The conventional methods of either pedicle elongation or fabricating combined flap increase the total surgical time. We present the experience on the use of what in situ pedicle lengthening and perforator shifting technique to overcome these problems. METHODS: Fifteen patients with an age range of 38-65 years underwent in situ vascular transposition microsurgery of the ALT free flap harvest during head and neck reconstruction. Fourteen patients were male and one was female. Indications for reconstruction were malignant neoplasm in 14 patients and osteoradionecrosis in one patient. In this series, the descending branch of the lateral circumflex femoral vessels was used for interposition grafts. If the pedicle length was insufficient, the interposition grafts were used to lengthen the pedicle. The interposition grafts could also bridge different perforasomes in the thigh region in complex head and neck reconstruction. RESULTS: Of the 15 patients, 11 received the in situ pedicle lengthening technique, while four patients received in situ fabricated combined techniques. After surgery, all of the patients were followed up for at least 3 months. Two partial wounds involving poor healing occurred but finally healed after debridement. There were two major complications: one case involved venous thrombosis of the anastomosis and the other suffered from hematoma. Both cases were salvaged. All of the 15 free ALT flaps were successful. CONCLUSIONS: The alternative method employed in this series was able to solve the ALT flap perforator variation. Although the enrolled cases were confined to only head and neck reconstruction in the series, the in situ technique of the ALT flaps could be administered during reconstruction in other regions.

Recipient vessel selection for multiple free flap transfers in head and neck reconstruction at different periods.

BACKGROUND: Treatment decisions can be challenging in patients undergoing multiple oropharyngeal microsurgical reconstructions at different periods by various causes. We, retrospectively, reviewed patients with at least three consecutive free flap reconstructions to determine the optimal strategy for selecting recipient vessels. METHODS: Then, 36 patients (33 men and 3 women) who underwent at least 3 microsurgical reconstructions with a total of 51 free flap transfers for head and neck defects were included in this report. The most common reason for multiple microsurgical reconstructions was recurrent disease. For reconstructions, recipient vessel candidates on the same side of the head and neck were prioritized; if ipsilateral vessels were unavailable, contralateral recipient vessels, which might necessitate vein grafts, were used. RESULTS: The most common reconstructions were anterolateral thigh flaps (19 cases). The most commonly used contralateral recipient vessels were the superior thyroid artery, facial artery, and external jugular vein. All vessel anastomoses were performed using the end-to-end method. Postoperative complications occurred at the sites of 26 free flap reconstructions. The overall flap reconstruction success rate in patients with at least three surgeries was 90.2%. The median follow-up duration was 25.8 months. During follow-up, 26 patients survived until the end of follow-up. CONCLUSIONS: In patients undergoing multiple free flap reconstructions, recipient vessels on the ipsilateral side that have not been subjected to radiation should be selected first. Recipient vessels contralateral to the reconstruction side can then be selected; however, they may require vein grafts. Finally, distant healthy recipient vessels can be selected through vein grafting.

Robot-assisted microvascular anastomosis in head and neck free flap reconstruction: Preliminary experiences and results.

BACKGROUND: The da Vinci Surgical System has facilitated considerable advancements in surgery. The process and results of robot-assisted microvascular anastomosis in real clinical situations have rarely been reported. This study presents our experience of performing robot-assisted microvascular anastomosis in free flap reconstruction in patients with oropharyngeal cancer. PATIENTS AND METHODS: This was a retrospective study of reconstructive operations using a free radial forearm flap for oropharyngeal defects after tumor extirpation in 15 consecutive adult patients (12 men and 3 women). In total, 17 robot-assisted microvascular vessel anastomoses (2 arteries and 15 veins) were performed; moreover, 13 arteries and 13 veins were anastomosed using the standard operating microscope and hand-sewing technique. RESULTS: The recipient and donor vessel diameters were 2.5 ± 0.7 and 2.1 ± 0.8 mm, respectively. The donor blood vessel diameter selected for anastomosis using da Vinci Surgical System was significantly smaller (2.1 ± 0.8 vs. 2.5 ± 0.6 mm) than that for a standard operating microscope and hand-sewing technique (p = .021), the operating time spent (38.4 ± 10.4 vs. 28.0 ± 7.7 min) was significantly longer (p < .001). The vascular patency rate was 100%, and all flaps survived without requiring additional operation for revision. CONCLUSION: Robotic surgical systems can facilitate vascular microanastomosis and provide a blood vessel patency rate comparable to that of a standard operating microscope and hand-sewing technique.

Transposition of Duplicated Thumb for Reconstruction of Asymmetric Radial Polydactyly.

BACKGROUND: In this study, we present the long-term functional and aesthetic outcomes in patients with complicated asymmetric radial polydactyly treated with this surgical technique involving the transposition of a duplicated thumb. METHODS: We evaluated 6 thumbs in 6 patients who underwent radial polydactyly reconstruction using the transposition of duplicated thumb procedure between 2001 and 2017. The procedure was used when one of the thumbs was not obviously dominant over the other, with one having a better proximal portion and the other having a better distal portion. The average age at the time of surgery was 35 months, and at the final follow-up, average age was 86.5 months. Objective outcome values were obtained, and the Japanese Society for Surgery of the Hand evaluation form was adopted to assess functional and cosmetic outcomes. RESULTS: Neither soft tissue loss nor nonunion of the osteotomy was noted. No patients reported pain or difficulties in their activities. Mean flexion-extension arc for the metacarpophalangeal joint was 72.9° (range, 8.8° extension to 64.1° flexion), and that for the interphalangeal joint was 44.0° (range, 5.7° extension to 38.3° flexion). Mean key pinch, tip pinch, and grip strength of unaffected thumb were 75.1%, 68.7%, and 81.9%, respectively. Total scores using the Japanese Society for Surgery of the Hand scoring system averaged 18.2 points, and the results were excellent in 1 case and good in 5. CONCLUSIONS: Transposition of duplicated thumb can provide durable functional and cosmetic results for Rotterdam types IV and VI with asymmetric radial polydactyly in which neither thumb has adequate distal and proximal components.

Functional Outcomes and Complications of Robot-Assisted Free Flap Oropharyngeal Reconstruction.

BACKGROUND: Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction. MATERIALS AND METHODS: A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013-December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment. RESULTS: This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts. CONCLUSIONS: There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.

An eHealth education intervention to promote healthy lifestyles among nurses.

BACKGROUND: Nurses often do not adhere to health-promoting lifestyles, compromising their health status and quality of care. This study aimed to evaluate health-promoting effects of an eHealth intervention among nurses compared with conventional handbook learning. METHODS: This controlled before/after study enrolled 105 nurses, 55 in an experimental group and 60 in a control group, for 3 months of intervention. Both groups completed pre- and postintervention questionnaires of the Health-Promoting Lifestyle Profile and Short-Form Health Survey. Subjects' height, weight, and body mass index were recorded. DISCUSSION: The eHealth education intervention had the effect of significantly increasing nurses' postintervention Health-Promoting Lifestyle Profile total scores. No significant changes were observed in the postintervention scores of the control group subjects. The experimental group also had significant postintervention decreases in BMI, but no similar changes were observed in the control group. CONCLUSIONS: Tailored eHealth education is an effective and accessible intervention for enhancing health-promoting behavior among nurses.

Factors and symptoms associated with work stress and health-promoting lifestyles among hospital staff: a pilot study in Taiwan.

BACKGROUND: Healthcare workers including physicians, nurses, medical technicians and administrative staff experience high levels of occupational stress as a result of heavy workloads, extended working hours and time-related pressure. The aims of this study were to investigate factors associated with work stress among hospital staff members and to evaluate their health-promoting lifestyle behaviors. METHODS: We conducted a cross-sectional study from May 1, 2010 to July 30, 2010 and recruited 775 professional staff from two regional hospitals in Taiwan using purposive sampling. Demographic data and self-reported symptoms related to work-related stress were collected. Each subject completed the Chinese versions of the Job Content Questionnaire (C-JCQ) and The Health-Promoting Lifestyle Profile (HPLSP). Linear and binary regression analyses were applied to identify associations between these two measurements and subjects' characteristics, and associations between the two measurements and stress symptoms. RESULTS: Self-reported symptoms of work-related stress included 64.4% of subjects reporting nervousness, 33.7% nightmares, 44.1% irritability, 40.8% headaches, 35.0% insomnia, and 41.4% gastrointestinal upset. C-JCQ scores for psychological demands of the job and discretion to utilize skills had a positive correlation with stress-related symptoms; however, the C-JCQ scores for decision-making authority and social support correlated negatively with stress-related symptoms except for nightmares and irritability. All items on the HPLSP correlated negatively with stress-related symptoms except for irritability, indicating an association between subjects' symptoms and a poor quality of health-promoting lifestyle behaviors. CONCLUSIONS: We found that high demands, little decision-making authority, and low levels of social support were associated with the development of stress-related symptoms. The results also suggested that better performance on or a higher frequency of health-promoting life-style behaviors might reduce the chances of hospital staff developing stress-related symptoms. Our report may contribute to the development of educational programs designed to encourage members of high stress groups among the hospital staff to increase their health-promoting behaviors.

Mining subspace clusters from DNA microarray data using large itemset techniques.

Mining subspace clusters from the DNA microarrays could help researchers identify those genes which commonly contribute to a disease, where a subspace cluster indicates a subset of genes whose expression levels are similar under a subset of conditions. Since in a DNA microarray, the number of genes is far larger than the number of conditions, those previous proposed algorithms which compute the maximum dimension sets (MDSs) for any two genes will take a long time to mine subspace clusters. In this article, we propose the Large Itemset-Based Clustering (LISC) algorithm for mining subspace clusters. Instead of constructing MDSs for any two genes, we construct only MDSs for any two conditions. Then, we transform the task of finding the maximal possible gene sets into the problem of mining large itemsets from the condition-pair MDSs. Since we are only interested in those subspace clusters with gene sets as large as possible, it is desirable to pay attention to those gene sets which have reasonable large support values in the condition-pair MDSs. From our simulation results, we show that the proposed algorithm needs shorter processing time than those previous proposed algorithms which need to construct gene-pair MDSs.

The effectiveness of pelvic floor exercises, digital vaginal palpation and interpersonal support on stress urinary incontinence: an experimental study.

BACKGROUND/AIMS: The objective of this study is to examine if interpersonal support and digital vaginal palpation (DVP) as part of the pelvic floor muscle exercise (PFME) training is more effective for stress urinary incontinence (SUI) than PFME with a printed handout instruction. METHODS: 108 women who presented to the family medicine outpatient clinic without having urine leakage as a chief complaint were selected. They were randomized to either the group who received interpersonal support and DVP as part of the PFME training (experimental group), or the group who received PFME with a printed handout instruction (control group). The effects were assessed with 1-h pad tests. RESULTS: A total of 99 patients (50 experimental, 49 control) completed the study. The patients' mean age was 55.35+/-9.60 years, ranging from 20 to 80 years. All patients without urinary leakage listed as a chief complaint exhibited more or less urine leakage during the 1-h pad test. A significant decrease in the weight of 1-h pad test from baseline was observed in the experimental group (p<0.001) compared to the control group (p=0.514). CONCLUSION: Interpersonal support and DVP as part of the PFME training is more effective than PFME with a printed handout instruction. PFME, performed correctly and consistently, is effective even in patients who have very few symptoms of SUI.

Urinary incontinence among Taiwanese women: an outpatient study of prevalence, comorbidity, risk factors, and quality of life.

The objective of this study was to evaluate comorbidity and risk factors associated with female urinary incontinence and to assess quality of life for women with different types of urinary incontinence. Subjects included 551 consecutive females who attended the outpatient clinic from 9 March to 8 July 2006 and did not have a chief complaint of incontinence. A four-item incontinence questionnaire and a Chinese version of the Incontinence-Quality of Life (I-QOL) questionnaire were completed in the waiting room. Patient characteristics and medical conditions were summarized from outpatient electronic databases. A total of 371 females were included for statistical analysis. Among them, 114 patients (30.7%) did not indicate any urinary incontinence, while 257 (69.3%) patients indicated symptoms of urge incontinence, stress incontinence, or mixed incontinence. Comorbidities significantly associated with incontinence included osteoarthritis (P = 0.001), peptic ulcer disease (P = 0.031), obesity (P < 0.001), and cardiac disease (P < 0.001). After multiple logistic regression analysis, obesity (OR 3.38, 95% CI 1.94-6.98) and postmenstrual status (OR 2.17, 95% CI 1.35-3.50) were found to be risk factors of incontinence (P < 0.001). Mixed incontinence patients exhibited the least satisfaction in quality of life, while no significant differences were observed between patients with urge incontinence and stress incontinence. In conclusion, the incidence of urinary incontinence may be greater in the outpatient population than previously thought. Osteoarthritis, peptic ulcer disease, and cardiac disease are more common in women with urinary incontinence, obesity and postmenopausal status appear predictive of incontinence, and women with mixed incontinence exhibit the least satisfying quality of life.