Noninvasive Risk Prediction Models for Heart Failure Using Proportional Jaccard Indices and Comorbidity Patterns.

Background: In the post-coronavirus disease 2019 (COVID-19) era, remote diagnosis and precision preventive medicine have emerged as pivotal clinical medicine applications. This study aims to develop a digital health-monitoring tool that utilizes electronic medical records (EMRs) as the foundation for performing a non-random correlation analysis among different comorbidity patterns for heart failure (HF). Methods: Novel similarity indices, including proportional Jaccard index (PJI), multiplication of the odds ratio proportional Jaccard index (OPJI), and alpha proportional Jaccard index (APJI), provide a fundamental framework for constructing machine learning models to predict the risk conditions associated with HF. Results: Our models were constructed for different age groups and sexes and yielded accurate predictions of high-risk HF across demographics. The results indicated that the optimal prediction model achieved a notable accuracy of 82.1% and an area under the curve (AUC) of 0.878. Conclusions: Our noninvasive HF risk prediction system is based on historical EMRs and provides a practical approach. The proposed indices provided simple and straightforward comparative indicators of comorbidity pattern matching within individual EMRs. All source codes developed for our noninvasive prediction models can be retrieved from GitHub.

Integrated Approaches for Reconstruction of Facial Paralysis.

BACKGROUND: Facial paralysis can affect periorbital muscles, oral competence, and facial expressions with significant facial deformities, which could occur in either children or adults with variable severity, duration, and degree of recovery. OBJECTIVE: The present study was aimed to delineate treatment plans for facial paralysis with different clinical scenarios and to report the results of these patients. METHODS: Patients were grouped according to different presentations as follows: (1) facial paralysis with incomplete recovery; (2) young patients of facial paralysis without recovery; (3) senile patients of facial palsy without recovery; (4) combined facial palsy with mandibular deficiency, vascularized bone reconstruction for mandible with (a) subsequent muscle transfer or (b) simultaneous sling operation or (c) simultaneous facial nerve exploration and cross nerve grafting; (5) palsy of frontal branch of facial nerve; (6) palsy of zygomatic-buccal branch of facial nerve; (7) palsy of marginal mandibular branch of facial nerve; (8) partial recovery with dyskinesia; and (9) facial paralysis with dynamic asymmetry and muscle atrophy. According to clinical scenarios, different treatment plans were provided, and clinical outcomes were evaluated and presented. RESULTS: All patient groups achieved fair or satisfactory outcomes. Revisions using sling procedures, botulinum toxin injection, and filler or fat graft as supplement further refined the ultimate outcomes. CONCLUSIONS: For reconstruction of facial paralysis, individualized integrated treatment plans are mandatory according to the presentation and condition of the patient. Comprehensive considerations and strategic solutions for the existing disabilities have been appreciated by the patients. The least numbers of operations with considerate correction of asymmetry were the major concerns of the patients.

Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm.

BACKGROUND: Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm. METHODS: From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery. RESULTS: The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants. CONCLUSION: Immediate reexploration is mandatory to salvage the flap.

Fronto-naso-orbital Reconstructions.

BACKGROUND: Significant defects at the fronto-naso-orbital area always present with severe facial disfigurement for the afflicted individuals. It may occur after tumor ablations, compound comminuted fractures, or craniofacial surgeries at this area. PATIENTS AND METHODS: Reconstructions of 11 patients with this problem had been performed by the authors, with follow-up for 3 to 25 years. The modes of reconstruction involved carved cartilage block with fascia grafts in 3 patients, split calvarial bone grafting covered with fascia grafts in 2 patients, drilled bone chips harvested from outer table of calvarial bone encased with fascia for smaller defects in 2 patients, 3-dimensional computed tomographic reconstruction and reformation of replica to replace the destroyed framework in 4 patients. RESULTS: Patients in this series all achieved good results, with symmetric face, acceptable facial contour, and being willing to attend social activities with deliberate evaluation and planning, selection of proper method, with proficient skills in reconstruction. One patient who received cartilage block grafting came back for refining facial contour 18 years later. CONCLUSIONS: Midline fronto-naso-orbital defects could be reconstructed with carved cartilage graft or bone graft, overlaid with fascia graft, intricate asymmetric defects can be reconstructed with the aid of 3-dimensional computed tomographic image reconstruction and reformation of the defect replica to achieve symmetric esthetic result with individualized approaches.

Clinical Application of Different Surgical Navigation Systems in Complex Craniomaxillofacial Surgery: The Use of Multisurface 3-Dimensional Images and a 2-Plane Reference System.

BACKGROUND: Intraoperative navigation is a tool that provides surgeons with real-time guidance based on patients' preoperative imaging studies. The application of intraoperative navigation to neurosurgery and otolaryngology has been well documented; however, only isolated reports have analyzed its potential in the field of craniomaxillofacial surgery. METHODS: From November 2010 to July 2014, 15 patients were operated on for complex craniomaxillofacial surgery with assistance by 3 different navigation systems, which used either infrared or electromagnetic technologies. We imported fine-cut (0.625-mm) computed tomographic scan images of the patients to the navigation systems whose software processed them into multisurface 3-dimentional models used as guiding material for the surgical navigation. We also developed a simple "2-plane reference system" to ensure that the final results were symmetric to the normal half of the face. Appearance outcome was evaluated by questionnaire. RESULTS: Of these 15 cases, 3 cases were performed with infrared-based navigation, and the remaining 12 cases were accomplished by electromagnetic technology. Most of these cases resulted in satisfactory outcomes after tumor resection, posttraumatic reconstruction, and postablative reconstruction. CONCLUSION: Navigation systems offer highly valuable intraoperative assistance in complex craniomaxillofacial surgery. Not only can these systems pinpoint deep-seated lesions as neurosurgeons or otolaryngologists do, but they can also use a simple 2-plane reference system for accurate bone alignment. Moreover, advancements in multisurface 3-D models provide us more reliable intuitive image guidance. The application of electromagnetic technology, with its smaller reference obviation of the line-of-sight problem, makes the manipulation of craniomaxillofacial surgery more comfortable.

An unusual electrical burn caused by alkaline batteries.

Electrical burns caused by low-voltage batteries are rarely reported. We recently encountered a male patient who suffered from a superficial second-degree burn over his left elbow and back. The total body surface area of the burn was estimated to be 6%. After interviewing the patient, the cause was suspected to be related to the explosion of a music player on the left-side of his waist, carried on his belt while he was painting a bathroom wall. Elevated creatine kinase levels and hematuria indicated rhabdomyolysis and suggested an electrical burn. Initial treatment was done in the burn intensive care unit with fluid challenge and wound care. The creatine kinase level decreased gradually and the hematuria was gone after 4 days in the intensive care unit. He was then transferred to the general ward for further wound management and discharged from our burn center after a total of 11 days without surgical intervention.

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.

Supercharge end-to-side nerve transfer from anterior interosseous nerve to augment intrinsic recovery in high ulnar nerve injuries of varying magnitudes.

BACKGROUND: High ulnar nerve injuries result in intrinsic muscle weakness and are inconvenient for patients. Moreover, conventional surgical techniques often fail to achieve satisfactory motor recovery. A potential reconstructive solution in the form of the supercharge end-to-side (SETS) anterior interosseous nerve (AIN) transfer method has emerged. Therefore, this study aims to compare surgical outcomes of patients with transected and in-continuity high ulnar nerve lesions following SETS AIN transfer. METHODS: Between June 2015 and May 2023, patients with high ulnar palsy in the form of transection injuries or lesion-in-continuity were recruited. The assessment encompassed several objective results, including grip strength, key pinch strength, compound muscle action potential, sensory nerve action potential, and two-point discrimination tests. The muscle power of finger abduction and adduction was also recorded. Additionally, subjective questionnaires were utilized to collect data on patient-reported outcomes. Overall, the patients were followed up for up to 2 years. RESULTS: Patients with transected high ulnar nerve lesions exhibited worse baseline performance than those with lesion-in-continuity, including motor and sensory functions. However, they experienced greater motor improvement but less sensory recovery, resulting in comparable final motor outcomes in both groups. In contrast, the transection group showed worse sensory outcomes. CONCLUSIONS: Our findings suggest that SETS AIN transfer benefits patients with high ulnar nerve palsy, regardless of the lesion type. Nonetheless, improvements may be more pronounced in patients with transected lesions.

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.

Technical details for inset of flaps in transfer of double-level gastroepiploic lymph node flaps for lower extremity lymphedema.

BACKGROUND: In this study, the method that can be followed to ensure rapid and uncomplicated recovery of lymph node flap (LNF) applied in the medial of the ankle for lymphedema treatment was investigated. METHODS: Thirty-seven patients with class II of lower limb lymphedema underwent transfer of gastroepiploic LNF to the medial ankle and popliteal fossa areas. At the popliteal fossa region, the wound could always be closed primarily by the advancement of neighboring skin. The wound closure could be classified into three types at the medial ankle area (A) The partially exposed LNF was covered with a split-thickness skin graft (STSG) (n = 9). (B) A larger local flap was elevated, and the donor site of the local flap was covered with STSG (n = 18). (C) The skin flap's donor site was treated with pre-tie sutures (n = 10). RESULTS: In the popliteal region, there was no complication of wound healing. In the ankle region, the wound was coated by a thin layer of hematoma over the exposed LNF in 5 patients of group A. It healed secondarily except for one patient who needed a secondary skin graft. The healing was perfect in group B. In group C the healing was good, but there was a hypertrophic scar in 7 patients and required steroid injection later. CONCLUSION: To avoid complications of the gastroepiploic LNF at the medial ankle, it should be entirely covered by an anteriorly-based local flap, and the donor site defect of the local flap can be treated with either pre-tie sutures or a skin graft.

Prospective outcome analysis of ulnar tunnel syndrome: Comparing traumatic versus non-traumatic etiologies.

BACKGROUND: Ulnar tunnel syndrome (UTS) is relatively uncommon compared to the carpal tunnel or cubital tunnel syndromes. Few reports dedicated to the functional outcomes after surgical intervention of the UTS exist. Herein we compare the outcomes of patients with UTS of different etiologies. METHODS: Patients diagnosed with UTS between 2016 and 2020 were recruited. Ulnar tunnel release was performed in all patients, along with other necessary osteosynthesis or reconstructive procedures in the traumatic group. Patients were followed-up every six months post-operatively. Outcomes measured include: objective evaluations, subjective questionnaires, records of clinical signs, and grading of the British Medical Research Council scale for intrinsic muscle strength. RESULTS: 21 patients were recruited, and favorable results were noted in all of them after surgery. Traumatic UTS patients had a worse initial presentation than the non-traumatic cases, but had a greater improvement after surgery and yielded outcomes comparable with those of the patients without trauma. Patients with aberrant muscles in their wrists had better outcomes in some objective measurements than those without aberrant muscles. CONCLUSIONS: Ulnar tunnel release improves the outcome of patients regardless of the etiology, especially in patients with trauma-induced UTS. Thus, a proper diagnosis of the UTS should be alerted in all patients encountering paresthesia in the ulnar digits, ulnar-sided pain, weakness of grip strength, or intrinsic weakness to ensure good outcomes.

The treatment of bone exposure in burns by using artificial dermis.

BACKGROUND: The treatment of bone-exposed wounds with artificial dermis is not widely accepted in burn patients because of uncertain clinical results. This article aimed to review our clinical experience with this technique. METHODS: We implanted artificial dermis in 11 bone-exposed burns. Implantation was directly performed on bones with periosteum, whereas bones without periosteum were trephinated or burred before implantation. All wounds were closed by secondary skin grafting. RESULTS: The mean patient age was 49 years. Lower extremity is the most common site of bone exposure. The mean bone exposed area was 55.6 cm, whereas the mean Integra-implanted area was 86.7 cm. The overall implant take rate was 91%, and the skin grafting success rate was 80%. No secondary breakdown was noted after a 2-year follow-up. CONCLUSIONS: This study confirms that artificial dermis can be an alternative treatment tool for burns with exposed bones, especially in patients with limited donor sites.

Free and pedicled appendix transfer for various reconstructive procedures.

INTRODUCTION: The appendix has a constant vascular anatomy and provides a small lumen that always maintains its patency because of mucosal secretion and motility; thus, it serves as an ideal conduit structurally. The appendix has been used in urologic surgeries as a pedicled flap and as a free flap in isolated case reports for the reconstruction of the urethra. However, this study proposes more extended applications of the appendix in different kinds of reconstruction. METHODS: From 2002 to 2011, 11 patients were included in this study retrospectively. Of these cases, 8 were transferred as free flaps, whereas the other 3 were pedicle flaps. Among the 8 free appendix transfers (A and B), 5 of them were used for voice reconstruction by creating a tracheoesophageal fistula; the other 3 were transferred to reconstruct the male urethra. Among the 3 pedicled appendix transfer, 2 were used for reconstruction of cervix and vagina, whereas the other was used for reconstruction of esophagus and voice tube simultaneously after ablation of cancers in the hypopharynx and esophagus. RESULTS: All cases showed successful results not only structurally but also functionally. As for voice reconstruction, the appendix serves as an autologous fistula between the trachea and the esophagus with minimal complications and no aspirations. The intelligibility and loudness were fair to excellent, whereas fluency required persistent training and practice.For patients who underwent urethral reconstruction, their micturition was smooth with ease postoperatively. Two of the patients also received penile reconstruction with fibula osteocutaneous flap simultaneously during the urethral reconstruction.As for reconstruction of cervix and vagina, pedicled appendix-cecum-colon-complex is a great option offering long-term patency with an expandable diameter up to 2.5 cm. CONCLUSIONS: Appendix has a reliable vascularity and a unique structure for reconstruction of conduit-like organs, and combining its adjacent bowel segments, including ileum, cecum, and colon, during tissue transfer not only increases its length but provides more applications and possibilities for reconstruction of different parts of the body. Removal of the appendix carries minimal morbidity. Our study proved the applicability and reliability of free and pedicled appendix transfer.

Quality improvement of microsurgery through telecommunication--the postoperative care after microvascular transfer of intestine.

The purpose of this report is to describe the use of telecommunication to improve the quality of postoperative care following microsurgery, especially following microvascular transfer of intestinal transfer for which shortening of ischemia time is of utmost importance to achieve high success rate. From 2003 to 2009 microvascular transfer of intestinal flaps had been performed in 112 patients. After surgery the patients were put in intensive care unit and the flaps were checked every 1 hour. The image for circulatory status of the flaps was sent directly to the attending surgeon for judgment. The information was sent through intranet and the surgeon can get access to the intranet through internet if necessary. Among the 112 cases, there were 9 cases of reexploration. The average duration between the time of problem detection and the time of starting reexploration was 54 min in 7 cases, and other 2 cases were delayed to enter the operating room which had been occupied by other cases of major trauma. Only two flaps were lost completely, two patients developed narrowing at the junction of cervical esophagus and thoracic esophagus. The rate of salvage for intestinal flap is apparently higher than those reported in the literature. In the postoperative management of microsurgery in ICU, telecommunication can help to reduce the ischemia time after vascular compromise in the transfer of free intestinal flap. Telecommunication is really an easy and effective tool in improving the outcome of reconstructive surgery.

IGFBP-6 plays a role as an oncosuppressor gene in NPC pathogenesis through regulating EGR-1 expression.

Nasopharyngeal carcinoma (NPC) is prevalent in south-eastern Asia, particularly southern China, Singapore and Taiwan. The aim of this study was to identify the pivotal genes that may be altered during NPC progression. Using cDNA microarray analysis, we compared the expression of 18 genes between NPC and normal nasomucosal cells. qRT-PCR analysis found the expression of IBFBP-6 in NPC cell lines and immunolocalization of IGFBP-6 in NPC to be very weak. To explore the effects of IGFBP-6 on NPC tumour growth, we constructed inducible plasmids containing full-length IGFBP-6 cDNA (pBIG2i-IGFBP-6) and established pBIG2i-IGFBP-6-transfected NPC stable cell lines (NPC-TW01-pBIG2i-IGFBP-6). We then performed functional analysis of the IGFBP-6 in cell lines in vitro and in vivo. Over-expression of IGFBP-6 significantly suppressed the proliferation, invasion and metastatic activity of NPC cells and increased their apoptosis. We found the EGR-1, caspase-1 and TSP-1 genes to be markedly up-regulated when NPC-pBIG2i-IGFBP-6 was treated with doxycycline. Knocking down EGR-1 with EGR-1 siRNA resulted in a decrease in expression of caspase-1, TSP-1 and EGR-1 but not the expression of IGFBP-6. However, in knockdown cells the unchanged expression of IGFBP-6 did not inhibit the migration of NPC cells. Chromatin immunoprecipitation and luciferase reporter assay experiments showed that IGFBP-6 bound the EGR-1 promoter regions and activated EGR-1 promoter. We conclude that IGFBP-6 can regulate the progression of NPC by regulating the expression of EGR-1. These results suggest that IGFBP-6 could be used as a new target in NPC therapy.

Combined first dorsal metacarpal artery flap and dorsal transposition flap for correction of extensive first web space contracture: a case report and literature review.

First web space contracture is a common sequela after hand trauma and exerts tremendously negative effects on hand function. To restore hand function, it is mandatory to release contracted first web structures, which usually results in a large skin defect. Dorsal transposition flaps sometimes are not sufficient to cover the whole defect. Microvascular flaps provide abundant soft tissue, but they are lengthy procedures and exhibit risks of complete flap failure. In this study, we present an alternative approach to address this difficult clinical problem. A 25-year-old man developed extensive contracture over the first web space after trauma. After release of the contracted structures, the extensive skin defect was covered by a dorsal transposition flap with an extension to the territory of the first dorsal metacarpal artery flap. The functional and cosmetic results were excellent, without recurrence of contracture postoperatively. The combined first dorsal metacarpal artery flap and dorsal transposition flap appeared to be an effective and relatively simple method for the reconstruction of severe first web space contracture.

Necrotizing fasciitis caused by Staphylococcus aureus: the emergence of methicillin-resistant strains.

Staphylococcus aureus is an uncommon causative agent of monomicrobial necrotizing fasciitis, but we have noted several cases over the years. The patients treated for necrotizing fasciitis between January 1998 and December 2008 in our institution were identified, and their medical records were reviewed. Of 105 necrotizing fasciitis cases during the study period, 18 were caused by monomicrobial S. aureus infection (17%). The median age was 62 years (range, 12-81 years). Among this cohort, 10 patients had coexisting medical conditions or risk factors, including diabetes and hypertension. Lower limbs and upper limbs are the most commonly involved sites. Among the bacterial isolates from these cases, 8 were methicillin-sensitive S. aureus (MSSA) and 10 were methicillin-resistant S. aureus (MRSA). One patient died in the MSSA group, and 5 patients died in the MRSA group. The mortality rate and other clinical characteristics were not significantly different between the 2 groups. However, all MRSA necrotizing fasciitis developed after the year 2000, and it was significantly different from MSSA necrotizing fasciitis that predominantly took place before the year 2000. In conclusion, S. aureus is an important pathogen of monomicrobial necrotizing fasciitis, and MRSA has emerged as the predominant causative agent in recent years. Therefore, MRSA-directed antibiotic therapy should be considered when treating patients suspected with necrotizing fasciitis in endemic areas.

Combination of a free jejunal flap and a Roux-en-Y colojejunostomy for reconstruction of esophageal stricture secondary to a distant blast injury: a case report.

Pneumatic perforation of the esophagus caused by blast injury is very rare. Our patient presented with esophageal stricture in the context of a previous reconstruction of an esophageal rupture secondary to a distant air-blast injury. The ruptured esophagus was initially reconstructed with a left pedicled colon interposition in an antiperistaltic pattern. However, dysphagia developed 4 years later because of severe reflux-induced stenosis at the junction of the cervical esophagus and the left pedicled colon segment. A free isoperistaltic jejunal flap was performed to replace the cervical esophagus, with an anti-reflux Roux-en-Y colojejunostomy between the caudal segment of the left pedicled colon and the jejunum. The patient was discharged uneventfully 29 days later with smooth esophageal transit and no further reflux, as shown by scintigraphic scan. Esophageal reconstruction in an isoperistaltic pattern using a free isoperistaltic jejunal flap combined with an anti-reflux Roux-en-Y colojejunostomy has never been reported in the literature and appears to be an effective method to provide smooth passage of food and prevent restenosis of the esophagus.

Using intestinal segments during secondary salvage procedures after failed reconstructions of the cervical oesophagus.

OBJECTIVES: The free anterolateral thigh (ALT) flap is commonly used for the reconstruction of the cervical oesophagus with satisfactory results. Its convenience and popularity make it a popular flap for reconstructive surgeons. The use of intestinal flaps, however, carries a higher level of technical difficulty and is normally performed as a primary reconstructive procedure. This report investigates the feasibility of intestinal flaps for the reconstruction of the cervical oesophagus and strategies to optimize its success when used as a secondary flap after primary ALT flap failure. METHODS: We retrospectively reviewed 22 patients (age 39-72 years) who were men, between April 2013 and January 2015, with intestinal segments (free and pedicled ileocolon, jejunal and colon flaps) that were used secondarily to salvage failed primary free ALT flap reconstructions after hypopharyngeal cancer resection. Ten patients presented with leakage and 2 with tracheo-oesophageal fistulae as complications from the primary flap failure. RESULTS: Oral intake commenced around 1-month postoperatively. One case of flap failure was observed. The majority had no major postoperative complications. Patients were followed up (6-27 months), and 21 cases of a secondary intestinal flap were successful with the restoration of oesophageal continuity and oral intake. CONCLUSIONS: Intestinal flaps, free or pedicled, can be used secondarily after failed ALT flap reconstructions with minimal complications or morbidity. Intestinal flaps successfully allow restoration of gastrointestinal continuity with early commencement of oral intake and swallowing function.

Caveolin-1 sensitizes rat pituitary adenoma GH3 cells to bromocriptine induced apoptosis.

BACKGROUND: Prolactinoma is the most frequent pituitary tumor in humans. The dopamine D2 receptor agonist bromocriptine has been widely used clinically to treat human breast tumor and prolactinoma through inhibition of hyperprolactinemia and induction of tumor cell apoptosis, respectively, but the molecular mechanism of bromocriptine induction of pituitary tumor apoptosis remains unclear. Caveolin-1 is a membrane-anchored protein enriched on caveolae, inverted flask-shaped invaginations on plasma membranes where signal transduction molecules are concentrated. Currently, caveolin-1 is thought to be a negative regulator of cellular proliferation and an enhancer of apoptosis by blocking signal transduction between cell surface membrane receptors and intracellular signaling protein cascades. Rat pituitary adenoma GH3 cells, which express endogenous caveolin-1, exhibit increased apoptosis and shrinkage after exposure to bromocriptine. Hence, the GH3 cell line is an ideal model for studying the molecular action of bromocriptine on prolactinoma. RESULTS: The expression of endogenous caveolin-1 in GH3 cells was elevated after bromocriptine treatment. Transiently expressed mouse recombinant caveolin-1 induced apoptosis in GH3 cells by enhancing the activity of caspase 8. Significantly, caveolin-1 induction of GH3 cell apoptosis was sensitized by the administration of bromocriptine. Phosphorylation of caveolin-1 at tyrosine 14 was enhanced after bromocriptine treatment, suggesting that bromocriptine-induced phosphorylation of caveolin-1 may contribute to sensitization of apoptosis in GH3 cells exposed to bromocriptine. CONCLUSION: Our results reveal that caveolin-1 increases sensitivity for apoptosis induction in pituitary adenoma GH3 cells and may contribute to tumor shrinkage after clinical bromocriptine treatment.