Free tissue transfer using bidirectional recipient veins in traumatic extremity reconstruction.

BACKGROUND: Reverse-flow flaps rely on retrograde or reverse flow for drainage and have shown success in reconstructive surgery. However, limited studies have been conducted on the use of reverse-flow recipient veins. Our study proposed bidirectional venous anastomoses within a single recipient vein to optimize venous outflow and evaluated the outcomes of an additional retrograde venous anastomosis group in traumatic extremity reconstruction. METHODS: We performed a retrospective analysis of 188 patients with traumatic extremity free flap using two venous anastomoses, which were divided into the antegrade and bidirectional venous anastomosis groups. We analyzed the basic demographic information, flap type, duration between injury and reconstruction, recipient vessels, postoperative flap outcomes, and complications. Propensity score matching was used for the additional analysis. RESULTS: Of the 188 patients analyzed, 63 free flaps (126 anastomoses, 33.5%) and 125 free flaps (250 anastomoses, 66.5%) were included in the bidirectional venous anastomosis and antegrade groups, respectively. In the bidirectional vein group, the median time between trauma and reconstruction was 13.0 ± 1.8 days and the mean flap area was 50.29 ± 7.38 cm2 . Radial artery superficial palmar branch perforator flap was most frequently performed (60.3%). In the antegrade vein group, the median time until surgery was 23.0 ± 2.1 days and the mean flap area was 85.0 ± 8.5 cm2 . Thoracodorsal artery perforator flap surgery was the most frequently performed surgery. The two groups were similar in terms of basic characteristics, but the bidirectional group demonstrated significantly higher success rate (98.4% vs. 89.7%, p = .004) and lower complication rate (6.3% vs. 22.4%, p = .007) than the antegrade group. However, these results were not observed after propensity score matching. CONCLUSIONS: Our study demonstrated successful results with the recipient vein using reverse flow. Additional retrograde venous anastomosis is a useful option for augmenting venous drainage for reconstruction of distal extremities in cases where dissection of additional antegrade vein is not feasible.

Surgical Considerations of One-Stage Reconstruction of Large Extremity Defects Using a Thin Deep Inferior Epigastric Perforator Flap.

Background One-stage reconstruction with "thin perforator flaps" has been attempted to salvage limbs and restore function. The deep inferior epigastric perforator (DIEP) flap is a commonly utilized flap in breast reconstruction (BR). The purpose of this study is to present the versatility of DIEP flaps for the reconstruction of large defects of the extremities. Methods Patients with large tissue defects on extremities who were treated with thin DIEP flaps from January 2016 to January 2018 were included. They were minimally followed up for 36 months. We analyzed the etiology and location of the soft tissue defect, flap design, anastomosis type, outcome, and complications. We also considered the technical differences in the DIEP flap between breast and extremity reconstruction. Results Overall, six free DIEP flaps were included in the study. The flap size ranged from 15 × 12 to 30 × 16 cm 2 . All flaps were transversely designed similar to a traditional BR design. Three flaps were elevated with two perforators. Primary closure of the donor site was possible in all cases. Five flaps survived with no complications. However, partial necrosis occurred in one flap. Conclusion A DIEP flap is not the first choice for soft tissue defects, but it should be considered for one-stage reconstruction of large defects when the circulation zone of the DIEP flap is considered. In addition, this flap has many advantages over other flaps such as provision of the largest skin paddle, low donor site morbidity with a concealed scar, versatile supercharging technique, and a long pedicle.

Association of Dual Venous Anastomosis with Reduced Risks for Flap Congestion in Microsurgical Lower Extremity Reconstruction: A Multicenter Study.

BACKGROUND: Flap congestion related with venous thrombosis is a major cause for microsurgical lower extremity reconstruction failure. Conducting dual venous anastomosis has been suggested to reduce risks for the adverse outcomes; however, its efficacy remains controversial. This study evaluated a potential association of dual venous anastomosis with the development of flap congestion in diverse clinical situations. METHODS: This multicenter study included patients who underwent microsurgical lower extremity reconstruction at two institutions. They were divided into two groups based on the number of venous anastomoses-single and dual groups. Their perfusion-related complications (PRCs), including total/partial flap loss, arterial or venous insufficiency, and emergent reoperation, were compared. Independent association of the number of venous anastomoses with the outcomes was evaluated. Further analyses were conducted using propensity score matching. RESULTS: In total, 225 cases were analyzed, of which 92 were included in the single group and the other 133 in the dual group. The two groups had generally similar baseline characteristics. The dual group presented significantly lower rates of PRC, including total/partial flap loss, flap congestion, and emergent reoperation. Multivariable analyses showed that conducting dual venous anastomoses was associated with reduced risks for the development of overall PRC and flap congestion. These associations were more prominent when restricting analyses for cases with chronic wound and trauma (vs. oncologic defects). Similar associations were observed in the propensity score matching analysis. CONCLUSION: Conducting dual venous anastomosis seems associated with reduced risks for flap congestion in microsurgical lower extremity reconstruction, especially for cases with unfavorable conditions.

Video recording of hand surgeries using a field of view (FOV) matching USB camera module and smartphone in the era of COVID-19.

BACKGROUND: As the online medium has gained in popularity due to the recent coronavirus disease (COVID-19) pandemic, video recording of surgical procedures has become crucial in medical education. Various methods for recording are available but many require professional equipment and experienced personnel. Here, we propose a feasible and acceptable method for video recording of surgeries. METHODS: An M12 mount USB camera, which is based on an Android micro-USB, was utilized. The device was purchased from a website for $32-$40. The camera was mounted between the eyes of the binocular loupes. Surgical procedures were recorded with the camera. The optimal settings were determined according to the types of surgeries. RESULTS: We recorded the following surgical procedures: radial artery superficial palmar branch (RASP) free flap harvest, carpal tunnel release, and free flap operation. The default values were retained for all settings, but the highest image quality (1080 p) was selected with an 8 mm lens. The camera battery was sufficient to record each surgery in its entirety. CONCLUSIONS: The USB camera produced high-quality videos that perfectly matched the surgeon's field of view without the need for additional staff for recording. This low-cost equipment could be widely employed for the recording of educational videos for surgeons, especially in the era of COVID 19.

Reoperation of epicanthal reconstruction using a modified reverse skin-redraping method.

With the increasing adoption of medial epicanthoplasty or reconstruction procedures, the number of patients undergoing reoperations is also increasing. However, the surgical techniques useful for reoperations and the potential difficulties during reoperations have not been adequately elucidated. We aimed to describe the use of our modified reverse skin-redraping technique to improve cosmetic outcomes in patients who had previously undergone epicanthal reconstruction. From January 2014 to January 2021, we performed reoperations using our modified reverse skin-redraping technique in patients who had previously undergone epicanthal reconstruction. The main reason for the reoperations was cosmesis. The patients' ages ranged from 21 to 46 years (average, 28.7 years), and the follow-up periods ranged from 6 to 12 months. A total of 389 patients (311 females and 78 males) underwent reoperations, of which 324 patients (83%) underwent 1 reconstructive surgery and 65 (17%) underwent reconstructive surgeries more than twice after primary epicanthoplasty. The postoperative intercanthal distances could be increased or decreased depending on the preoperative design. After reoperation, 22 patients (5.6%) required additional reoperation. Reoperation of epicanthoplasty is technically challenging. The scarred round shape of the medial epicanthus during the reoperation poses difficulties, and the optimal technique to be used remains unknown. We believe that selection of an individualized restoration method that suits the purpose of surgery is important for patients who require reoperations. In this respect, we suggest that our modified reverse skin-redraping method is a suitable option for improving esthetic outcomes.

When is the Critical Time for Soft Tissue Reconstruction of Open Tibia Fracture Patients?

BACKGROUND: The timing of soft tissue reconstruction for soft-tissue defect in patients with open fractures in the lower extremity is known to be critical for successful outcomes. However, medical advances, including development of dressing materials and refinement in the microsurgical techniques, might have undergone modifications in this "critical period." There have been no studies on the role of timing on reconstructive outcomes. Thus, we have analyzed the effect of reconstruction timing on optimal surgical outcomes and complication rates in a single type of lower extremity injury. METHODS: Data of patients who underwent microvascular free tissue transfer with an open fracture in the lower extremity from 2014 through 2016 were retrospectively reviewed (n = 103). Surgical outcomes, including flap complication rate, flap revision rate, and long-term bony complications, were analyzed serially in accordance with time interval until coverage using the receiver operating characteristic (ROC) curve analysis. Significant factors with a p < 0.05 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. RESULTS: A total of 46 patients (33 males and 13 females) were finally included in the study. Based on the association between surgical timing and flap-related complication rate, the best cutoff period for surgery was 33 days, with an area under the curve of 0.658 (p = 0.040). Further, in the revision rate, the cutoff period was identified as 10 days (p = 0.016). Regarding the incidence of bony complications, ROC curve showed that the maximal period until operation was 91 days with no influence on the occurrence of bony complications (p = 0.029). CONCLUSION: Although the best method is an early reconstruction, many modalities such as negative pressure wound therapy play a role as a temporary measure. Our study suggests that the acute or early period for successful reconstruction might be extended compared with previous studies.

A Novel Method to Differentiate Tonsil-Derived Mesenchymal Stem Cells In Vitro into Estrogen-Secreting Cells.

BACKGROUND: The advantages of tonsil-derived mesenchymal stem cells (TMSCs) over other mesenchymal stem cells (MSCs) include higher proliferation rates, various differentiation potentials, efficient immune-modulating capacity, and ease of obtainment. Specifically, TMSCs have been shown to differentiate into the endodermal lineage. Estrogen deficiency is a major cause of postmenopausal osteoporosis and is associated with higher incidences of ischemic heart disease and cerebrovascular attacks during the postmenopausal period. Therefore, stem cell-derived, estrogen-secreting cells might be used for estrogen deficiency. METHODS: Here, we developed a novel method that utilizes retinoic acid, insulin-like growth factor-1, basic fibroblast growth factor, and dexamethasone to evaluate the differentiating potential of TMSCs into estrogen-secreting cells. The efficacy of the novel differentiating method for generation of estrogen-secreting cells was also evaluated with bone marrow- and adipose tissue-derived MSCs. RESULTS: Incubating TMSCs in differentiating media induced the gene expression of cytochrome P450 19A1 (CYP19A1), which plays a key role in estrogen biosynthesis, and increased 17ß-estradiol secretion upon testosterone addition. Furthermore, CYP11A1, CYP17A1, and 3ß-hydroxysteroid dehydrogenase type-1 gene expression levels were significantly increased in TMSCs. In bone marrow-derived and adipose tissue-derived MSCs, this differentiation method also induced the gene expression of CYP19A1, but not CYP17A1, suggesting TMSCs are a superior source for estrogen secretion. CONCLUSION: These results imply that TMSCs can differentiate into functional estrogen-secreting cells, thus providing a novel, alternative cell therapy for estrogen deficiency.

Percutaneous Transluminal Ballooning Angioplasty for Flap Salvage in a Complex Lower Extremity Reconstruction.

The treatment of lower extremity trauma with extensive soft tissue defects requires a multidisciplinary approach. Following precise bone fixation, appropriate soft tissue reconstruction is a major requisite. We present a case of a severe lower extremity injury caused by an excavator bucket that fell on the patient's foot, which was reconstructed with multiple perforator flaps after concise bone fixation. During the treatment, we repeatedly experienced threatened flaps, which could not be recovered with emergent re-explorations. Although vascular occlusion after a free flap surgery may be rare, it poses a major challenge. It necessitates urgent re-exploration, but there are logistical challenges with providing sufficient resources for endovascular revascularization. We attempted an immediate postoperative angioplasty after the failure of surgical re-exploration as a salvage option and achieved successful flap survival. As the flap completely survived without complications, the patient could walk, with bearing his full weight without the use of any orthosis. Despite the development of new techniques for flap revision, which have increased the possibility of limb salvage, immediate postoperative endovascular revascularization can be considered as a salvage option in cases of a compromised flap.

3D-printed titanium implant with pre-mounted dental implants for mandible reconstruction: a case report.

BACKGROUND: This clinical case presented a novel method of segmental mandible reconstruction using 3D-printed titanium implant with pre-mounted dental implants that was planned to rehabilitate occlusion. CASE PRESENTATION: A 53-year-old male who suffered osteoradionecrosis due to the radiation after squamous cell carcinoma resection. The 3D-printed titanium implant with pre-mounted dental implant fixtures was simulated and fabricated with selective laser melting method. The implant was successfully inserted, and the discontinuous mandible defect was rehabilitated without postoperative infection or foreign body reaction during follow-ups, until a year. CONCLUSIONS: The 3D-printed titanium implant would be the one of the suitable treatment modalities for mandible reconstruction considering all the aspect of mandibular functions.

The influence of contralateral breast augmentation on the development of complications in direct-to-implant breast reconstruction.

BACKGROUND: Simultaneous contralateral augmentation in direct-to-implant (DTI) breast reconstruction may increase the risk of skin flap necrosis on the reconstruction side due to increased tension on the skin flap when implants are larger than the original breast size. The purpose of this study was to evaluate whether the contralateral augmentation procedure affects complications in unilateral DTI breast reconstruction. METHODS: Patients who underwent immediate unilateral DTI breast reconstruction from January 2013 to July 2017 were included in this study. Data were collected through retrospective review of individual medical records. The primary outcome variable was the development of perioperative complications including skin flap necrosis. Univariable and multivariable logistic regression analyses were performed to identify risk factors for complications. RESULTS: A total of 121 patients who underwent unilateral immediate DTI breast reconstruction were included in this study. Twenty-one patients (17.4%) underwent simultaneous contralateral augmentation mammoplasty and 100 patients (82.6%) underwent DTI without contralateral augmentation. Overall complications were not different between the contralateral augmentation and no-augmentation groups (23.8% vs. 31%, respectively, p = 0.512). The frequency of skin flap necrosis in the augmentation group (14.3%) was not significantly different from that in the no-augmentation group (18.0%, p > 0.999). In multivariable analysis, mastectomy weight was the only predictor for complications (p = 0.053) and contralateral augmentation was not associated with development of complications. CONCLUSION: Contralateral breast augmentation in DTI breast reconstruction is not a risk factor for complications and can be safely performed in selected patients.

Significance of Increased Rapid Treatment from HIV Diagnosis to the First Antiretroviral Therapy in the Recent 20 Years and Its Implications: the Korea HIV/AIDS Cohort Study.

From December 2006 to December 2016, 1,429 patients enrolled in the Korea human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) Cohort Study were investigated. Based on the year of diagnosis, the time interval between HIV diagnosis and initiation of antiretroviral therapy (ART) was analyzed by dividing it into 2 years. The more recent the diagnosis, the more likely rapid treatment was initiated (P < 0.001) and the proportion of patients starting ART on the same day of HIV diagnosis was increased in 2016 (6.5%) compared to that in 2006 (1.7%). No significant difference in the median values of CD4+ cell counts according to the diagnosis year was observed. In the past 20 years, the time from the HIV diagnosis to the initiation of ART was significantly reduced. Rapid treatment was being implemented at the HIV diagnosis, regardless of CD4+ cell count. Considering the perspective "treatment is prevention," access to more rapid treatment is necessary at the time of HIV diagnosis.

A pilot study of occupational exposure to pathogenic microorganisms through lip cosmetics among dental hygienists.

OBJECTIVES: In dental clinics, dental hygienists are exposed to aerosolized pathologic bacteria, which can be transmitted to the oral cavity via lip cosmetics. Accordingly, such contamination poses a consistent health risk among staffs. Our study examined the bacterial contamination of lip cosmetics used by dental hygienists while in a clinic setting. METHODS: Sixteen dental hygienists were surveyed regarding their job assignments and habits associated with lip cosmetic. Subsequently, microorganisms were analyzed in collected samples of the hygienists' lip cosmetics using colony-forming unit (CFU) assays, 16s-rDNA polymerase chain reaction, and DNA sequencing. RESULTS: Notably, 81.3% of the submitted lip cosmetic samples were contaminated, with bacterial CFUs ranging from undetectable to innumerable. Many samples (43.8%) exceeded the microbial limits of cosmetic contamination. Of the lip cosmetic used for more than 6 months, 60% exceeded the microbial limit. When wearing a mask every time, only one of the six samples exceeded the microbial limit. More frequent dental mask changing was associated with a lower likelihood that the cosmetic sample would exceed the microbial limit. No samples from hygienists who changed their masks four times a day exceeded the microbial limit, compared to 33.3% from hygienists who only changed the mask when it became wet. Most isolated bacteria were gram-positive, facultative anaerobic, asporogenic, and opportunistically pathogenic, and the most prevalent species were Staphylococcus aureus, Streptococcus salivarius, and Staphylococcus epidermidis. CONCLUSION: Our findings indicate that dental staff, including dental hygienists, should exercise more careful workplace habits, particularly with regard to infection control and cosmetic use.

Cancer Survivors and Returning to Work Perspectives from Occupational Health Physicians in Korea.

BACKGROUND: This study was conducted from an occupational health perspective to document cancer survivors' ability to return to work, the role of clinical care, and the current status of effective return-to-work. METHODS: This cross-sectional study was conducted to evaluate the experiences and opinions of occupational health physicians (OHPs) regarding cancer survivors' return-to-work. A self-reported survey was conducted from December 30, 2015, to January 30, 2016, targeting 337 OHPs. Questions included: 1) treatment experiences of survivors in the words of OHPs, 2) current status of the assessments of fitness for work of cancer survivors, 3) experiences associated with workplace and treatment, and 4) problems of returning to work and overcoming system. RESULTS: Only 25% of the respondents said that they had experience treating cancer survivors, and the average number of patients was 12.6 per annum, which indicated that few cancer survivors were treated. Eleven cases included conducting assessment of fitness for work. There were 17 respondents who did not treat cancer survivors. Both those who had and did not have experience in treating survivors showed higher musculoskeletal system disorders (53.8 vs. 63.5) than cancer (15.5 vs. 11.2) in terms of frequency of the diseases in the assessment of fitness for work. Most respondents said that OHPs evaluate the current role appropriately and preferred OHPs in the future. They responded that OHPs found it difficult to treat cancer survivors, and it was psychologically tough to communicate with them (61.4%). Regarding the association of patient rehabilitation with workplaces, 48.9% said that workplaces provide inadequate support. CONCLUSION: As a preliminary study, we found that OHPs were found to have little experience in treating cancer survivors and undergo difficulties owing to poor collaboration with workplaces and communication with patients. This study will provide basic data for future studies to promote cancer survivors' return to workplaces.

Effect of Human Placental Extract Treatment on Random-Pattern Skin Flap Survival in Rats.

Background: Human placental extract (HPE), prepared from the placentas of healthy, postpartum females, displays various physiological activities, including antioxidative properties. In this study, a dorsal skin flap model was used to investigate the effect of HPE on flap viability in rats. Materials and methods: Forty male Sprague-Dawley rats underwent random-pattern skin flap surgeries. The animals were randomly divided among a control group and three treatment groups (localized injection (LI), 10 mg/kg/d localized HPE injections; low-dose treatment (LT), 10 mg/kg/d systemic HPE injections; high-dose treatment (HT), 40 mg/kg/d systemic HPE injections). Surviving skin flap areas were measured 7 days after surgery and tissue samples were stained with hematoxylin and eosin; vascular endothelial growth factor expression was determined immunohistochemically. To evaluate the antioxidant and antiapoptotic effects of HPE, malondialdehyde, glutathione peroxidase, and caspase-3 levels were examined. Results: Seven days after surgery, HPE-treated animals had significantly reduced necrotic areas, rats receiving the highest HPE dose demonstrated the greatest flap survival. In the HPE groups, the histopathological scores were lower than for the control group. Immunohistochemistry showed markedly more numerous vascular endothelial growth factor-positive cells in the HT group than in the C group. Malondialdehyde levels were significantly lower and glutathione peroxidase levels were higher in the HT group than in the C group. HPE treatment significantly inhibited apoptosis by lowering caspase-3 activity. Conclusions: HPE treatment yielded positive effects on flap survival, due to its antioxidant and antiapoptotic properties. These results suggest a new therapeutic approach for enhancing flap viability and accelerating wound repair.

Flap thinning: Defatting after conventional elevation.

Perforator flaps become a reliable option for coverage of various defects and the interest is change from survival of perforator flaps to make thin flaps for better aesthetic and functional outcomes. Multiple flap thinning methods have been demonstrated but it has not been widely attempted because of concerns about compromising circulation of flap thinning. This article will demonstrate the feasibility and benefits of flap thinning technique: defatting after conventional flap elevation.

Is the "ghost surgery" the subject of legal punishment in Korea?

PURPOSE: Recently a controversy has arisen about so-called "ghost surgery" practices, and people have voiced their opinions for legal sanction against such practices, which clearly undermine the foundation of medical ethics. However, there has been a lack of legal basis for punishing those actions. The present study aims to examine which pre-existing legal provisions could be applied to regulate ghost surgery. METHODS: The Korean Medical Service Act has a provision relating to informed consent to inhibit ghost surgery but does not include penalty provisions prohibiting ghost surgery itself. Also, the Korean Supreme Court precedents on this issue have not been settled as of yet. Therefore, this study referred to U.S precedents, law books, and related papers. RESULTS: With respect to ghost surgery, we expect the charges of bodily harm, assault and battery, and fraud could be applied under Korean law, in addition to charges regarding the violation of medical law, such as the omission of entries or false entries in medical records. A patient provides consent to bodily harm prior to surgery, and only the person who is entrusted with such permission can become the operating surgeon in the operating room. CONCLUSION: In other words, even if other medical professionals are present in the operating room, the operating surgeon who received consent must take overall responsibility for the whole process of the surgery. A surgeon should bear in mind that a violation of such duty can constitute a criminal offense.

Asymptomatic Deep Vein Thrombosis during Free Flap: Concerns in Free Flap Surgery.

BACKGROUND: Venous insufficiency is the most frequent cause of failure in free flap reconstruction of the lower extremity. When deep vein thrombosis is detected during preoperative assessment of the lower extremity, decisions regarding treatment plans become difficult, and no relevant guidelines regarding surgery and preoperative treatment of patients with deep vein thrombosis who need a free flap transfer are currently available. METHODS: To find a relevant guideline in decision-making regarding surgery and preoperative treatment of patients with deep vein thrombosis who require free flap reconstruction, a systematic literature review was conducted searching MEDLINE, PubMed Central, Cochrane, and Embase databases for articles published between 1996 and 2015. In addition, the authors introduced six of their cases of deep vein thrombosis diagnosed before free flap surgery in which the flap survived. RESULTS: The literature review identified two articles that discussed intraoperative deep vein thrombosis diagnosed in three patients, including the reported cases. Analyses included epidemiology, cause, and management strategy. A consensus for the management of asymptomatic deep vein thrombosis before free flap surgery is still lacking. In the authors' cases, successful flap transfer was possible by proceeding with an appropriate preoperative evaluation, intensive anticoagulation treatment, intraoperative reperfusion procedure, and postoperative care. CONCLUSION: Preoperatively detected asymptomatic deep vein thrombosis is not a contraindication for free flap reconstruction, and a flap transfer can be successfully performed with suitable planning and management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Effects of Transfusion on Free Flap Survival: Searching for an Optimal Hemoglobin Threshold for Transfusion.

BACKGROUND: Microsurgical free tissue transfer is a popular technique nowadays. Because of its considerably exquisite procedure, various risk factors can affect surgical outcome. However, current key practices, especially those in blood transfusion, are in contention due to the lack of enough evidence. Therefore, the objective of this study was to investigate the impact of perioperative blood transfusion on microsurgical complication. METHODS: Data of a total of 168 patients who underwent microvascular free tissue transfer from 2013 through 2016 were retrospectively reviewed. Age, comorbidity, anatomical surgical site, preoperative and postoperative lowest hemoglobin (Hb) level, estimated blood volume loss, and final clinical flap outcome were compared between patients with and without transfusion treatment. Factors with a significance of p < 0.05 in univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. RESULTS: Of 168 patients, 72 (43%) were in the transfusion group. Cross analysis statistics showed that flap failure in the transfusion group was 3.6 times higher (p = 0.018) than that in the control group. Multivariable analysis revealed that age (p = 0.083) and perioperative lowest Hb level (p = 0.021) remained as significant predictors of flap failure. Receiver-operating characteristic curve analysis showed that the appropriate lower limit of transfusion commencement of Hb was 8.75 g/dL (area under the curve: 0.721). CONCLUSION: A transfusion during perioperative period of free flap did not increase its failure rate. Rather than appropriate transfusion strategy, perioperative lowest Hb level, and age were significant predictors of flap failure. Therefore, transfusion can be confidently used in patients who undergo free flap without any hesitation. Results of this study provide practical evidence of performing perioperative transfusion for free tissue transfer patients.

Risk Factors of Vasopressor-Induced Symmetrical Peripheral Gangrene.

BACKGROUND: Symmetrical peripheral gangrene (SPG) is an uncommon syndrome showing symmetrical gangrene in acral regions without evidence of large-vessel occlusion or vasculitis. Intravenous vasopressors are frequently used to manage hemodynamically unstable patients. There have been few reports about SPG after using inotropics. However, risk factors for SPG have not been extensively studied. Therefore, the objective of this study was to analyze several cases of SPG and identify risk factors for SPG. METHODS: From October 2013 to October 2016, 36 patients with SPG after using vasopressors were included in this study. SPG is an extremely rare disease entity. Therefore, this work was designed as a matched case-control study. For the control group, 42 patients (25 men and 17 women) with similar age, admission department, sex, and vasopressor usage in intensive care unit patients during the same period were selected. Retrospective chart review was performed to identify risk factors within the following categories: medical conditions, vasopressor-related factors, and Sequential Organ Failure Assessment scores. RESULTS: Differences between the 2 groups concerning medical condition-related variables did not exist. Statistically significant differences were found in intensive care unit duration (P = 0.0011) and survival. All vasopressor-related factors were adjusted according to weights of patients. Weight-compensated mean dose of dopamin significantly (P = 0.028) affected the occurrence of SPG. Weight-compensated peak dose of norpin, dopamin, and epinephrine also significantly contributed to SPG. CONCLUSIONS: Symmetrical peripheral gangrene is a rare clinical syndrome related with a high mortality and up to 70% of patients who survive require amputation. Several studies have mentioned that there are several factors affecting the result of SPG. Few studies on SPG have been reported and most of them are case reports. In this study, we revealed the influence of vasopressors to the occurrence of SPG, and this was the first matched case-control study based on the analysis of multiple risk factors.

The Effect of Reproductive Factors on Breast Cancer Presentation in Women Who Are BRCA Mutation Carrier.

PURPOSE: Germline mutations in the BRCA1 and BRCA2 genes confer increased risks for breast cancers. However, the clinical presentation of breast cancer among women who are carriers of the BRCA1 or BRCA2 (BRCA1/2 carriers) mutations is heterogenous. We aimed to identify the effects of the reproductive histories of women with the BRCA1/2 mutations on the clinical presentation of breast cancer. METHODS: We retrospectively analyzed clinical data on women with proven BRCA1 and BRCA2 mutations who were recruited to the Korean Hereditary Breast Cancer study, from 2007 to 2014. RESULTS: Among the 736 women who were BRCA1/2 mutation carriers, a total of 483 women had breast cancers. Breast cancer diagnosis occurred at significantly younger ages in women who experienced menarche at ≤14 years of age, compared to those who experienced menarche at >14 years of age (37.38±7.60 and 43.30±10.11, respectively, p<0.001). Additionally, the number of full-term pregnancies was significantly associated with the age of diagnosis, especially in women with the BRCA2 mutation. The prevalence of advanced stages (stage II or III vs. stage I) of disease in parous women was higher than in nulliparous women (68.5% vs. 55.2%, p=0.043). This association was more pronounced in women with the BRCA2 mutation (hazard ratio, 2.67; p=0.014). CONCLUSION: Our results suggest that reproductive factors, such as the age of onset of menarche and the presence of parity, are associated with the clinical presentation patterns of breast cancer in BRCA1/2 mutation carriers.