The use of a skin paddle-containing vein graft for arteriovenous looping in two-stage free flap reconstruction of lower extremities.

BACKGROUND: Arteriovenous (AV) looping prior to the lower extremity free flap reconstruction enables better venous drainage in flap circulation, leading to less flap complications and better survival. A two-staged reconstruction including free tissue transfer after AV looping ensures a robust venous drainage of the flap. Arterialization of the AV loop results in less venous problems after the free flap reconstruction. However, major problems of this staged operation include AV loop kinking, heavy compression and loop exposure, leading to AV graft failure and interruption of surgical planning. The purpose of this article is to summarize probable flaws we noticed in conventional two-stage lower limb reconstruction and overcome those problems using the skin paddle-containing vein graft. METHOD: Eight patients with lower limb defects underwent lower limb reconstruction surgery using this technique at our institute. The mean age was 52 years old. Of the eight patients, three of them have the defect due to infection. Three of them was due to trauma and three of them was due to full-thickness burn. Five of the defects located at foot. The other three defects located at heel, knee, and pretibial region. All of them require AV looping because of unavailability of nearby recipient vessels. They all received a two-stage operation, including the first stage AV looping with a skin paddle-containing vein graft and the second stage definite free tissue transfer. RESULTS: The mean defect size was 140 cm2 (72-225). The mean length of AV loops was 17.1 cm (8-25). The mean size of skin paddles for vein grafts was 19.4 cm2 (15-24). The mean size of free ALT flaps 154.4 cm2 (105-252). All eight patients experienced a smooth postoperative course with no major or minor complications. There were no graft thrombosis or graft rupture complications during the vascular maturation period. All eight AV loops survived during maturation. All eight patients progressed to the second stage surgery. Maturation time ranged from 5 to 7 days. Free ALT flap was employed during the second stage reconstruction. All flaps survived at the last follow-up visit. There was no partial flap loss and complications. The mean follow-up time was 12.25 months, ranging from 8 to 17 months. CONCLUSION: The skin paddle-containing vein graft is an effective modification of the regular vein graft for AV looping procedure. The skin paddle prevents the underlying AV loop from compression, kinking and twisting during maturation. It also aids assessing patency of the AV loop and avoids the formation of adhesion between the AV loop and the surrounding tissue.

The abrogated role of premedication in the prevention of transfusion-associated adverse reactions in outpatients receiving leukocyte-reduced blood components.

BACKGROUND AND OBJECTIVES: Although it remains controversial, premedication before transfusion is a common clinical practice to prevent transfusion-associated adverse reactions (TAARs) in Taiwan. Thus, we aimed to investigate whether premedication prevented outpatients from developing TAARs and whether an educational programme could improve the understanding of physicians related to the unnecessary use of premedication, and this could elicit changes in their prescribing activities without affecting the occurrence of TAARs. MATERIALS AND METHODS: Clinical data from outpatients receiving transfusion therapy, including predisposing diseases, histories of transfusion and TAARs, premedication and the occurrence of TAARs in the period April 2017 to October 2018, were retrospectively obtained. The evidence-based transfusion programme implemented to educate physicians was started in January 2018. RESULTS: A total of 5018 blood units were transfused to 803 outpatients, with 2493 transfusion events reported in the study interval. The most frequently transfused component was leukocyte-reduced packed red cells (n = 4338), followed by leukocyte-reduced apheresis platelets (n = 540) and other blood components. The overall premedication rate significantly decreased from 92.4% to 76.7% after the educational programme (p < 0.001). There was no remarkable change in the occurrence of TAARs per patient event between the periods before and after the educational programme (1.11% vs. 1.14%, p = 0.964). Besides, it was shown that the occurrence of TAARs was associated with the history of TAARs and inversely related to multiple transfusions, but not premedication. CONCLUSION: Decreased premedication was not associated with increased incidence of TAARs in outpatients; these findings provide important evidence to support the need to revise clinical practices in the era of leukocyte-reduced blood products.

The role of pleural fluid lactate dehydrogenase-to-adenosine deaminase ratio in differentiating the etiology of pleural effusions.

Exudative pleural effusion includes tuberculous pleural effusion (TPE), parapneumonic pleural effusion (PPE), and malignant pleural effusion (MPE). An elevated pleural fluid adenosine deaminase (ADA) typically implies TPE, but the rule may not apply to every individual case. Recent studies proposed that the pleural fluid lactate dehydrogenase (LDH)-to-ADA ratio showed a higher diagnostic power than pleural fluid ADA alone in differentiating the etiology of pleural effusion. Hence, we aimed to investigate the performance of pleural fluid LDH-to-ADA ratio as a biomarker in assistance with the diagnosis of TPE, PPE, and MPE. All patients who underwent thoracentesis for the first time with a pleural fluid ADA >40 U/L were included in this retrospective study. The clinical data including pleural fluid ADA and LDH-to-ADA ratio were analyzed. A total of 311 patients were enrolled during the study interval. The pleural fluid LDH-to-ADA ratio <14.2 (sensitivity: 74.2%; specificity: 90.4%) favored TPE, while the pleural fluid LDH-to-ADA ratio >14.5 (sensitivity: 79.9%; specificity: 78.5%) favored PPE. Besides, the pleural fluid LDH-to-ADA ratio >46.7 (sensitivity: 56.3%; specificity: 78.3%) favored MPE owing to primary lung cancers. In conclusion, the pleural fluid LDH-to-ADA ratio was an effective indicator in differentiating the etiology of pleural effusions in the cases of high ADA level in the pleural fluid.

Giant Interpectoral Lipoma Causing Venous Thoracic Outlet Syndrome: A Rare Case Presentation.

Lipomas are the most prevalent type of benign soft tissue tumors, primarily composed of adipocytes, and typically remain asymptomatic unless they reach a significant size. Although giant lipomas are infrequent, their occurrence on the chest wall, particularly in the interpectoral region, is exceedingly rare. We present a unique case of a 48-year-old man with a massive interpectoral lipoma measuring 19.4 × 12.9 × 9.4 cm, which resulted in venous thoracic outlet syndrome by compressing the subclavian vein. This case highlights the clinical challenges in diagnosing deep-seated chest wall lipomas and underscores the necessity of considering thoracic outlet syndrome as a potential complication, even in the absence of direct neural or arterial compression. The presentation of thoracic outlet syndrome can vary, and a comprehensive evaluation is imperative for accurate diagnosis and management.

Application of multiple deep learning models for automatic burn wound assessment.

PURPOSE: Accurate assessment of the percentage of total body surface area (%TBSA) burned is crucial in managing burn injuries. It is difficult to estimate the size of an irregular shape by inspection. Many articles reported the discrepancy of estimating %TBSA burned by different doctors. We set up a system with multiple deep learning (DL) models for %TBSA estimation, as well as the segmentation of possibly poor-perfused deep burn regions from the entire wound. METHODS: We proposed boundary-based labeling for datasets of total burn wound and palm, whereas region-based labeling for the dataset of deep burn wound. Several powerful DL models (U-Net, PSPNet, DeeplabV3+, Mask R-CNN) with encoders ResNet101 had been trained and tested from the above datasets. With the subject distances, the %TBSA burned could be calculated by the segmentation of total burn wound area with respect to the palm size. The percentage of deep burn area could be obtained from the segmentation of deep burn area from the entire wound. RESULTS: A total of 4991 images of early burn wounds and 1050 images of palms were boundary-based labeled. 1565 out of 4994 images with deep burn were preprocessed with superpixel segmentation into small regions before labeling. DeeplabV3+ had slightly better performance in three tasks with precision: 0.90767, recall: 0.90065 for total burn wound segmentation; precision: 0.98987, recall: 0.99036 for palm segmentation; and precision: 0.90152, recall: 0.90219 for deep burn segmentation. CONCLUSION: Combining the segmentation results and clinical data, %TBSA burned, the volume of fluid for resuscitation, and the percentage of deep burn area can be automatically diagnosed by DL models with a pixel-to-pixel method. Artificial intelligence provides consistent, accurate and rapid assessments of burn wounds.

Minimal invasive fixation following with radiotherapy for radiosensitive unstable metastatic spine.

BACKGROUND: Minimally invasive surgery (MIS) has become a feasible option for patients with spinal metastasis, but the effectiveness of percutaneous pedicle screw fixation (PPSF) without decompression in patients with severe cord compression remains unknown. We compared PPSF without decompression with debulking surgery in patients with radiosensitive, unstable, metastatic thoracolumbar spinal cord compression. METHODS: A retrospective study of surgically treated spinal metastasis and spinal cord compression patients was conducted between October 2014 and June 2019. Demographic and pre- and postoperative data were collected and compared between patients treated with minimally invasive percutaneous fixation and external beam radiotherapy (EBRT) (the PPSF group) and those treated with debulking surgery (the debulking group). RESULTS: We included 50 patients in this study. The PPSF group had a significantly shorter operative time (143.56 ± 49.44 min vs. 181.47 ± 40.77 min; p < 0.01), significantly lower blood loss (116.67 ± 109.92 mL vs. 696.55 ± 519.43 mL; p < 0.01), and significantly shorter hospital stay (11.90 ± 9.69 vs. 25.35 ± 20.65; p < 0.01) than did the debulking group. No significant differences were observed between the groups in age, sex, spinal instability neoplastic score, ESCC, Tomita scores, numeric rating scale scores, American Spinal Injury Association Impairment Scale scores, survival rates, and complication rates. Postoperative neurologic function and decrease in pain were similar between the groups. CONCLUSION: The PPSF group had a shorter operation time, shorter length of hospital stay, and less blood loss than did the debulking group. PPSF followed by EBRT is pain relieving, relatively safe and appropriate as palliative therapy.