Intracoronary electrocardiogram detects coronary microvascular dysfunction and ischemia in patients with no obstructive coronary arteries disease.

BACKGROUND: Coronary microvascular dysfunction (CMD) is the leading cause of ischemia with no obstructive coronary arteries disease (INOCA) disease. Diagnosis of CMD relies on surrogate physiological indices without objective proof of ischemia. OBJECTIVES: Intracoronary electrocardiogram (icECG) derived hyperemic indices may accurately and objectively detect CMD and reversible ischemia in related territory. METHODS: INOCA patients with proven ischemia by myocardial perfusion scan (MPS) and completely normal coronary arteries underwent simultaneous intracoronary electrophysiological (icECG) and physiological (intracoronary Doppler) assessment in all 3 coronary arteries during rest and under adenosine induced hyperemia. RESULTS: Sixty vessels in 21 patients were included in the final analysis. All patients had at least one vessel with abnormal CFR. 41 vessels had CMD (CFR < 2.5), of which 26 had increased microvascular resistance (structural CMD, HMR > 1.9 mmHg.cm-1.s) and 15 vessels had CMD (CFR < 2.5) with normal microvascular resistance (functional CMD, HMR <= 1.9 mmHg.cm-1.s). Only one-third of the patients (n = 7) had impaired CFR < 2.5 in all 3 epicardial arteries. Absolute ST shift between hyperemia and rest (∆ST) has shown the best diagnostic performance for ischemia (cut-off 0.10 mV, sensitivity: 95%, specificity: 72%, accuracy: 80%, AUC: 0.860) outperforming physiological indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002). CONCLUSIONS: In INOCA patients, CMD involves coronary artery territories heterogeneously. icECG can accurately detect CMD causing perfusion abnormalities in patients with INOCA outperforming physiological CMD markers, by demonstrating actual ischemia instead of predicting the likelihood of inducible ischemia based on violated surrogate thresholds of blunted flow reserve or increased minimum microvascular resistance. CONDENSED ABSTRACT: In 21 INOCA patients with coronary microvascular dysfunction (CMD) and myocardial perfusion scan proved ischemia, hyperemic indices of intracoronary electrocardiogram (icECG) have accurately detected vessel-specific CMD and resulting perfusion abnormalities & ischemia, outperforming invasive hemodynamic indices. Absolute ST shift between hyperemia and rest (∆ST) has shown the best classification performance for ischemia in no Obstructive Coronary Arteries (AUC: 0.860) outperforming Doppler derived CMD indices (CFR: 0.623 and HMR: 0.653 DeLong's test P = .0002).icECG can be used to diagnose CMD causing perfusion defects by demonstrating actual reversible ischemia at vessel-level during the initial CAG session, obviating the need for further costly ischemia tests. CLINICALTRIALS: GOV: NCT05471739.

Clinical features of 26 cases of COVID-19-associated conjunctivitis.

PURPOSE: To explore the clinical features of COVID-19-associated conjunctivitis with the objective of preventing the spread of infection. STUDY DESIGN: Retrospective cohort study. METHODS: From March 2020 to March 2021, we retrospectively reviewed 26 (9.8%) consecutive COVID-19 patients with conjunctivitis among 282 COVID-19 cases admitted to our hospital. Clinical symptoms, onset date of conjunctivitis, time to patient recovery, and eye drop intervention were investigated. In addition, risk factors for developing conjunctivitis were statistically examined among 206 inpatients available for within 5 days of the onset. A multivariate analysis of conjunctivitis risk factors was performed. RESULTS: Among the 282 COVID-19 patients, 4 (1.4%) had conjunctival hyperemia as the primary symptom. The median time of onset was 4 days after the COVID-19 onset. Hyperemia was observed in all cases, but other ocular symptoms were rare. The median duration of hyperemia was 3 days. A multiple logistic regression analysis revealed that a young age (p=0.005) and current smoking habit (p=0.027) were independent risk factors for conjunctivitis after COVID-19. CONCLUSIONS: COVID-19-associated conjunctivitis is rare in the elderly and strongly associated with a history of smoking. It often occurs in the early stages of infection, and while hyperemia is recognized as a clinical symptom, other ocular symptoms are rare or non-existent. Many cases recover within a short time.

Using blood glucose and lactate levels for early detection of venous congestion following a free flap procedure for lower extremity open fractures.

PURPOSE: Gustilo-Anderson type IIIB and IIIC open fractures of the lower extremities require reconstruction of extensively injured soft tissues using a free flap; however, impaired blood flow through the flap is an early postoperative complication. To detect flap congestion due to venous thrombosis, blood glucose and lactate level measurements within the flap are taken to determine variations in these levels. We aimed to detect early-stage venous congestion and to perform salvage operations. METHODS: We included 22 limbs with lower leg and foot open fractures, with fracture sites covered using a free flap. A pinprick test was used to measure blood glucose and lactate levels. RESULTS: Of 7 and 15 congested and non-congested limbs, respectively, the 7 congested limbs had a mean flap blood glucose level immediately before salvage surgery of 3.8 ± 2.0 (7.4-1.8) mmol/L. The ratio to blood glucose levels in healthy fingertips was 0.6 ± 0.2 (0.8-0.3). Lactate levels increased to 13.3 ± 5.1 (9.4-22.8) mmol/L. The ratio of blood glucose levels in congested flaps and in healthy fingertips was significantly lower than that in non-congested flaps and in healthy fingertips (p = 0.0016). Lactate levels were significantly higher in patients with congestion (p = 0.0013). Salvage surgery was performed, thrombi were removed, and six limb flaps were viable. CONCLUSION: Flap blood glucose and lactate levels provide a quantitative method of evaluating blood flow and detecting flow abnormalities postoperatively, and are useful in detecting early congestion due to venous thrombosis.

Energetic Basis for Exercise-Induced Pulmonary Congestion in Heart Failure With Preserved Ejection Fraction.

BACKGROUND: Transient pulmonary congestion during exercise is emerging as an important determinant of reduced exercise capacity in heart failure with preserved ejection fraction (HFpEF). We sought to determine whether an abnormal cardiac energetic state underpins this process. METHODS: We recruited patients across the spectrum of diastolic dysfunction and HFpEF (controls, n=11; type 2 diabetes, n=9; HFpEF, n=14; and severe diastolic dysfunction attributable to cardiac amyloidosis, n=9). Cardiac energetics were measured using phosphorus spectroscopy to define the myocardial phosphocreatine to ATP ratio. Cardiac function was assessed by cardiovascular magnetic resonance cine imaging and echocardiography and lung water using magnetic resonance proton density mapping. Studies were performed at rest and during submaximal exercise using a magnetic resonance imaging ergometer. RESULTS: Paralleling the stepwise decline in diastolic function across the groups (E/e' ratio; P<0.001) was an increase in NT-proBNP (N-terminal pro-brain natriuretic peptide; P<0.001) and a reduction in phosphocreatine/ATP ratio (control, 2.15 [2.09, 2.29]; type 2 diabetes, 1.71 [1.61, 1.91]; HFpEF, 1.66 [1.44, 1.89]; cardiac amyloidosis, 1.30 [1.16, 1.53]; P<0.001). During 20-W exercise, lower left ventricular diastolic filling rates (r=0.58; P<0.001), lower left ventricular diastolic reserve (r=0.55; P<0.001), left atrial dilatation (r=-0.52; P<0.001), lower right ventricular contractile reserve (right ventricular ejection fraction change, r=0.57; P<0.001), and right atrial dilation (r=-0.71; P<0.001) were all linked to lower phosphocreatine/ATP ratio. Along with these changes, pulmonary proton density mapping revealed transient pulmonary congestion in patients with HFpEF (+4.4% [0.5, 6.4]; P=0.002) and cardiac amyloidosis (+6.4% [3.3, 10.0]; P=0.004), which was not seen in healthy controls (-0.1% [-1.9, 2.1]; P=0.89) or type 2 diabetes without HFpEF (+0.8% [-1.7, 1.9]; P=0.82). The development of exercise-induced pulmonary congestion was associated with lower phosphocreatine/ATP ratio (r=-0.43; P=0.004). CONCLUSIONS: A gradient of myocardial energetic deficit exists across the spectrum of HFpEF. Even at low workload, this energetic deficit is related to markedly abnormal exercise responses in all 4 cardiac chambers, which is associated with detectable pulmonary congestion. The findings support an energetic basis for transient pulmonary congestion in HFpEF.

Impact of aging on the effects of intracoronary adenosine, peak hyperemia and its duration during fractional flow reserve assessment.

INTRODUCTION: Functional assessment of coronary stenoses is crucial for determining the correct therapeutic strategy. Age-related modifications in cardiovascular function could alter the functional significance of an intermediate coronary lesion. Therefore, the aim of the present study was to investigate the impact of age on fractional flow reserve (FFR) measurements in patients with intermediate coronary artery disease. METHODS: We included patients undergoing coronary angiography at our Division of Cardiology from June 2008 to February 2019 for elective indication or recent acute coronary syndrome and receiving FFR assessment for an intermediate coronary stenosis (angiographic 40-70% stenoses). FFR measurement was performed by pressure-recording guidewire (Prime Wire; Volcano Imaging System Philips Healthcare, San Diego, California, USA), after induction of hyperemia with intracoronary boluses of adenosine (from 60 to 720 µg, with dose doubling at each step). RESULTS: We included in our study 276 patients, undergoing FFR evaluation on 314 lesions, that were divided according to age (< or ≥70 years). Elderly patients displayed a higher cardiovascular risk profile and received more often specific therapy. We found significantly higher FFR values and lower Delta FFR and time to recovery in patients with age ≥70 years old even with high-dose adenosine. Elderly patients showed a trend in lower percentage of positive FFRs, especially with high-dose (P = 0.09). Overall, any FFR ≤ 0.80 was observed in 33.5% of younger patients and 21.1% of patients ≥70 years (P = 0.02). Results were confirmed after correction for baseline differences [adjusted odds ratio (95% confidence interval) = 0.60 (0.33-1.09), P = 0.08]. CONCLUSION: This is one of the first studies investigating the impact of age on the measurement of FFR with high-dose adenosine. Patients with age >70 years old with intermediate CAD are more likely to have higher FFR values and lower duration of hyperemia after adenosine boluses, as compared with younger patients.

Cortisol level after dexamethasone suppression test in patients with non-functioning adrenal incidentaloma is positively associated with the duration of reactive hyperemia response on microvascular bed.

PURPOSE: Data on endothelial derangements in patients with non-functioning adrenal incidentaloma (NFAI) are scarce. METHODS: We investigated if NFAI patients present clinical, biochemical and endothelial alterations compared to individuals without an adrenal lesion and also the associations among these variables. Forty-two NFAI and 40 controls were evaluated. NFAI diagnosis and controls were defined according to the current guidelines and based on a normal adrenal imaging exam, respectively. Body composition was evaluated by dual emission X-ray absorptiometry. Endothelial reactivity was assessed by two methods: tonometry (Endo-PAT®) and laser speckle contrast imaging (LSCI). RESULTS: There were no differences between groups regarding age, gender, ethnicity, smoking status, and statin use. The frequency of metabolic syndrome according to the International Diabetes Federation criteria was 69% and 57.9%, respectively in NFAI and controls (p = 0.36), whereas the atherosclerotic cardiovascular disease (ASCVD) risk was 63.4% and 66.7% (p = 0.81). The clinical, laboratory, and anthropometric characteristics, as well as body composition, were similar between the groups. Additionally, any differences between groups were observed on endothelial reactivity tests. Nevertheless, we noted an association between cortisol levels after 1 mg-dexamethosone suppression test (1 mg-DST) and the duration of post-occlusive reactive hyperemia tested on microcirculation (r = 0.30; p = 0.03). NFAI patients require more antihypertensive drugs to achieve blood pressure control (p = 0.04). The number of antihypertensive drugs used to control blood pressure correlated with cortisol levels after 1 mg-DST (r = 0.29; p = 0.03). CONCLUSIONS: Since both groups herein investigated had a high frequency of metabolic syndrome and ASCVD risk, it might explain similarities observed on endothelial reactivity. Nevertheless, prolonged reactive hyperemia response on microcirculation was correlated with cortisol levels under suppression.

Suitability of the muscle O2 resaturation parameters most used for assessing reactive hyperemia: a near-infrared spectroscopy study / Adequação de parâmetros de ressaturação muscular de O2 mais utilizados na avaliação da hiperemia reativa: um estudo por espectroscopia no infravermelho próximo

Abstract Background There is a spectrum of possibilities for analyzing muscle O2 resaturation parameters for measurement of reactive hyperemia in microvasculature. However, there is no consensus with respect to the responsiveness of these O2 resaturation parameters for assessing reactive hyperemia. Objectives This study investigates the responsiveness of the most utilized muscle O2 resaturation parameters to assess reactive hyperemia in the microvasculature of a clinical group known to exhibit impairments of tissue O2 saturation (StO2). Methods Twenty-three healthy young adults, twenty-nine healthy older adults, and thirty-five older adults at risk of cardiovascular disease (CVD) were recruited. Near-infrared spectroscopy (NIRS) was used to assess StO2 after a 5-min arterial occlusion challenge and the following parameters were analyzed: StO2slope_10s, StO2slope_30s, and StO2slope_until_baseline (upslope of StO2 over 10s and 30s and until StO2 reaches the baseline value); time to StO2baseline and time to StO2max (time taken for StO2 to reach baseline and peak values, respectively); ∆StO2reperfusion (the difference between minimum and maximum StO2 values); total area under the curve (StO2AUCt); and AUC above the baseline value (StO2AUC_above_base). Results Only StO2slope_10s was significantly slower in older adults at risk for CVD compared to healthy young individuals (p < 0.001) and to healthy older adults (p < 0.001). Conversely, time to StO2max was significantly longer in healthy young individuals than in older adult at CVD risk. Conclusions Our findings suggest that StO2slope_10s may be a measure of reactive hyperemia, which provides clinical insight into microvascular function assessment.

Resumo Contexto Existe um espectro de possibilidades na análise dos parâmetros de ressaturação de O2 muscular como uma medida de hiperemia reativa na microvasculatura. No entanto, não há consenso com relação à responsividade desses parâmetros de ressaturação de O2 para avaliação de hiperemia reativa. Objetivos Este estudo investigou a capacidade de resposta dos parâmetros de ressaturação muscular de O2 mais utilizados para avaliar a hiperemia reativa na microvasculatura de um grupo clínico conhecido por apresentar comprometimento da saturação de O2 (StO2). Métodos Foram recrutados 23 jovens saudáveis, 29 idosos saudáveis e 35 idosos com risco para doença cardiovascular. A espectroscopia no infravermelho próximo foi usada para avaliar a StO2 após um teste de oclusão arterial de 5 minutos, no qual os seguintes parâmetros foram analisados: StO2slope_10s, StO2slope_30s e StO2slope_until_baseline (inclinação da StO2 em 10 s, 30 s e até StO2 atingir valores basais); tempo para StO2baseline e tempo para StO2máx (o tempo necessário para StO2 atingir os valores da linha de base e o máximo, respectivamente); ∆StO2reperfusão (a diferença entre o valor de StO2mínimo e StO2máximo); área total sob a curva (StO2AUCt); e área sob a curva acima do valor da linha de base (StO2AUC_above_base). Resultados Apenas StO2slope_10s foi significativamente mais lento em idosos em risco de doença cardiovascular comparados com indivíduos jovens saudáveis (p < 0,001) e idosos saudáveis (p < 0,001). Por outro lado, o tempo para StO2max foi significativamente maior em indivíduos jovens saudáveis do que em idosos em risco de doença cardiovascular. Conclusões Nossos achados sugerem que StO2slope_10s pode ser uma medida de hiperemia reativa, que fornece informações clínicas sobre a avaliação da função microvascular.

Intra-abdominal pressure and its relationship with markers of congestion in patients admitted for acute decompensated heart failure.

Systemic congestion is one of the mechanisms involved in acute decompensated heart failure (ADHF). Increased intra-abdominal pressure (IAP), elicited by abdominal congestion, has been related to acute kidney injury and prognosis. Nonetheless, the link between diuretic response, surrogate markers of congestion and renal function remains poorly understood. We measured IAP in 43 patients from a non-interventional, exploratory, prospective, single center study carried out in patients admitted for ADHF. IAP was measured with a calibrated electronic manometer through a catheter inserted in the bladder. Normal IAP was defined as < 12 mmHg. At baseline, median IAP was 15 mmHg, with a reduction over the next 72 h to a median of 12 mmHg. A higher IAP at admission was associated with higher baseline blood urea (83 mg/dL [62-138] vs. 50 mg/dL [35-65]; p = 0.007) and creatinine (1.30 mg/dL vs. 0.95 mg/dL; p = 0.027), and with poorer diuretic response 72 h after admission, either measured by diuresis (14.4 mL/mg vs. 21.6 mL/mg; [p = 0.005]) or natriuresis (1.2 mEqNa/mg vs. 2.0 mEqNa/mg; [p = 0.008]). A higher incidence for 1-year all-cause mortality (45.0% vs. 16.7%; log-rank test = 0.041) was observed among those patients with IAP > 12 mmHg at 72 h. In patients with ADHF, higher IAP at admission is associated with poorer baseline renal function and impaired diuretic response. The persistence of IAP at 72 h above 12 mmHg associates to longer length of hospital stay and higher 1-year all-cause mortality.

Application of non-invasive detection of peripheral vascular dysfunction in ovarian hyperstimulation syndrome (OHSS): A pilot study of clinical relevance.

OBJECTIVE: The current study tested the hypothesis that vascular endothelial function, as reflected by the reactive hyperemia index (RHI), and biochemical factors, including VEGF, TNFα, CRP, inhibin A, and inhibin B, were involved in the pathogenesis of ovarian hyperstimulation syndrome (OHSS). MATERIALS AND METHODS: This study was conducted between June 2010 and June 2012, enrolling 15 patients with OHSS and 6 healthy control subjects <45 years of age. Detailed clinical parameters were reviewed, including serum VEGF, TNFα, CRP, inhibin A, inhibin B, and hematocrit. RHI assessed by novel automatic peripheral arterial tonography was used to evaluate the vascular endothelial function. RESULTS: Twenty-one subjects were evaluated. There was no significant difference between patients with OHSS and control subjects with respect to VEGF, TNFα, CRP, inhibin A and inhibin B. The RHI was not significantly different between patients with OHSS and control subjects (mean, 1.8 ± 0.4 vs. 1.7 ± 0.2). The hematocrit was significantly different between patients with OHSS and control subjects. CONCLUSIONS: Our preliminary data did not reveal direct evidence of vascular endothelial dysfunction in patients with OHSS. To identify whether RHI could reflect vascular endothelial dysfunction in patients with OHSS, more cases with different severities of OHSS should be recruited in the future study.

Comparison of different smartphone cameras to evaluate conjunctival hyperaemia in normal subjects.

Despite the significant advantages that smartphones' cameras can provide in teleophthalmology and artificial intelligence applications, their use as black-box systems for clinical data acquisition, without adequate information of the quality of photographs can compromise data accuracy. The aim of this study is to compare the objective and subjective quantification of conjunctival redness in images obtained with calibrated and non-calibrated cameras, in different lighting conditions and optical magnifications. One hundred ninety-two pictures of the eye were taken in 4 subjects using 3 smartphone cameras{Bq, Iphone, Nexus}, 2 lighting levels{high 815 lx, low 122 lx} and 2 magnification levels{high 10x, low 6x}. Images were duplicated: one set was white balanced and color corrected (calibrated) and the other was left as it was. Each image was subjective and objectively evaluated. There were no significant differences in subjective evaluation in any of the conditions whereas many statistically significant main effects and interaction effects were shown for all the objective metrics. The clinician's evaluation was not affected by different cameras, lighting conditions or optical magnifications, demonstrating the effectiveness of the human eye's color constancy properties. However, calibration of a smartphone's camera is essential when extracting objective data from images.

Measurement of Microvascular Function in Pediatric Inflammatory Bowel Disease.

BACKGROUND AND AIMS: Altered vascular flow is known to both play a role in the pathogenesis and influence the severity of inflammatory bowel disease (IBD). This phenomenon has been described in other systemic conditions and contributes to disease progression by facilitating inflammation and thrombosis. Microvascular dysfunction may represent an early sign of generalized vascular disease (VD). It manifests by failure to achieve a normal response of vasodilation and increased blood flow following a period of vaso-occlusion. Although thromboembolic complications are well described in IBD, their pathogenesis is not fully understood. This study sought to assess microvascular responsiveness in pediatric subjects with IBD, by recording postocclusion peripheral arterial pulsatile volume changes. PATIENTS AND METHODS: A total of 32 pediatric subjects were studied, including 16 with IBD and 16 age-matched controls. All patients with IBD were in clinical remission, and none had known VD. Vascular reactivity was evaluated using the Itamar Medical EndoPAT2000, a noninvasive device utilizing plethysmography to measure microvascular flow. Results were reported as the reactive hyperemia index (RHI), indicating post- to preocclusion pulsatile volume changes. RESULTS: Baseline characteristics, including body mass index, plasma lipid levels, hemoglobin, and serum albumin, were similar in both study groups. All patients with IBD were in clinical remission, assessed by standard disease activity scoring methods. Measurements of microvascular function indicated patients with IBD exhibited a mean RHI both within the range associated with VD risk in adults (≤1.67) and significantly lower than that in controls (IBD vs control = 1.66 vs 2.02, P = 0.036). CONCLUSIONS: Microvascular plethysmography is a safe and noninvasive method for assessing microvascular function in children with IBD. Patients with IBD in clinical remission demonstrate an attenuated, postocclusion microvascular hyperemic response, compared with the normal response in controls. These findings suggest pediatric IBD subjects with a mean RHI within the VD "at risk" range should be monitored for thromboembolic phenomena. Further studies in a larger patient population and over longer periods should be conducted to validate our findings and to determine the importance of these measurements in guiding IBD management.

Lens induced glaucoma in a tertiary eye care centre in Western Nepal.

INTRODUCTION: Lens induced glaucoma due to hypermature cataracts is an important cause of secondary glaucoma in the developing world. The most common etiology of lens induced glaucoma is phacomorphic glaucoma from untreated senile cataract. OBJECTIVES: To study the demographics, clinical presentations and surgical outcome of lens induced glaucoma (LIG). MATERIALS AND METHODS: It is the prospective case series of fifty three patients eyes with LIG over a 6 months period from June 2015 to November 2015. All cases of lens induced glaucoma underwent cataract surgery. Data including demographics, clinical presentations, surgical outcome were analysed using Statistical Package for Social Studies 20.0. RESULTS: The mean age was 61.5 years (Standard deviation 8.9) with predominantly women (30, 56.6%) were affected. Phacomorphic glaucoma (38, 71.7%) was the main cause of lens induced glaucoma, followed by phacolytic glaucoma (15, 28.3%). The main clinical symptoms were reduced vision (100%), eye pain (96.2%) and redness of eyes (62.3%). All patients (100%) presented with visual acuity of <3/60 or worse and intraocular pressure (IOP) more than 40 mm Hg (34, 64.2%). All 53(100%) patients underwent cataract surgery and all of them had tremendously reduced intraocular pressure with a mean 13.9 mmHg and vision had improved from >6/18 as noted in 16(30.2%) cases. CONCLUSIONS: The main clinical presentations of LIG are triad of acute reduced vision, eye pain and redness. The better final BCVA is found when there is an early presentation and less IOP at the time of presentation Public awareness, early detection and early intervention aids in good visual recovery and control of intraocular pressure in LIG.

Contrast Fractional Flow Reserve (cFFR): A pragmatic response to the call for simplification of invasive functional assessment.

AIM: To review the current approaches to simplify functional assessment of coronary stenosis with particular regard for contrast Fractional Flow Reserve (cFFR). METHODS AND RESULTS: Maximal hyperaemia to assess FFR is perceived as time-consuming, costly, unpleasant for the patient and associated with side effects. Resting indexes, like Pd/Pa and iFR, have been proposed to circumvent the use of vasodilators as well as an approach based on the administration of contrast medium to induce coronary vasodilation, the cFFR. Contrast FFR can be obtained quickly, at very low cost in the absence of substantial side effects. Among these alternative indexes, cFFR shows the best correlation with FFR, reduces the use of adenosine even more than a hybrid resting approach but has not yet been tested in a randomized, controlled trial with clinical end-points. CONCLUSION: cFFR represents a cheap, safe and effective alternative to FFR, able to facilitate the dissemination of a functional approach to myocardial revascularization.

Multimodal analysis using flowmeter analysis, laser-Doppler spectrophotometry, and indocyanine green videoangiography for the detection of venous compromise in flaps in rats.

Venous congestion results in tissue damage and remains the most common failure of free microvascular transfer if it is not recognized early. The purpose of this experimental study was to evaluate venous congestion and describe the findings with two different monitoring tools. A standardized epigastric flap was raised, and total occlusion of the draining vein was temporarily applied for 4, 5, 6, or 7 h. Blood flow measurements, including laser-Doppler flowmetry, and tissue spectrophotometry (O2C) and indocyanine green (ICG) videoangiography using the FLOW® 800 tool, were performed systematically after each surgical step, an interval of venous occlusion, and 1 week of clinical observation. Both monitoring tools were capable of detecting acute venous occlusion. ICG videoangiography data showed a significant decrease in the first and second maximum, and the area under the curve, during venous occlusion, whereas hemoglobin levels in the O2C analysis remained stable. Changes in fluorescence values in border areas of the flap correlated significantly with the incidence of necrosis. O2C data later showed significant correlation with the area of necrosis, and more individual changes during flap monitoring. ICG videoangiography might therefore be useful in the prediction of flap necrosis in critical areas of perfusion.

Ocular Onset of Paraneoplastic Pemphigus Presenting as Hyperemic Conjunctivitis and Massive Bilateral Eyelid Ulceration: A Case Report and Literature Review.

INTRODUCTION: Paraneoplastic clinical signs are characterized by a large and heterogeneous variety of manifestations due to several possible underlying neoplasms. Paraneoplastic pemphigus (PNP) is a particular paraneoplastic variety that usually primarily affects the dermic and/or oral mucosa and is characterized by a high rate of mortality (90%). Therefore, it is important to recognize its possible signs early. This report describes a case of ocular paraneoplastic pemphigus (PNP) presenting with recalcitrant eyelid ulceration and hyperemic conjunctivitis caused by an undiagnosed prostate cancer. METHODS: A 77-year-old man was admitted to our department because of recalcitrant hyperemic conjunctivitis in both eyes, complicated with large ulceration of both upper eyelids in spite of topical therapy. After 3 weeks, oral mucositis and bullous dermatitis on the chest and arms developed. RESULTS: Complete slit lamp ocular study, conjunctival swabs, routine hematologic tests, serum neoplasm markers, indirect immunofluorescence study, immunoblotting, and oral mucose biopsy with direct immunofluorescence were performed under the hypothesis of a paraneoplastic sign. Total body computed tomography scan and ultrasound-guided needle prostate biopsy completed the diagnostic process and confirmed the diagnosis of prostate PNP. Complete remission of ocular clinical signs was achieved by treatment of the prostate malignancy with systemic immunosuppressive therapy and chemotherapy.

Intraoperative objective evaluation of venous congestion in deep epigastric artery perforator flap breast reconstruction: A pilot study.

BACKGROUND: In a deep epigastric artery perforator (DIEP) flap breast reconstruction, the necessity of additional anastomosis of the superficial inferior epigastric vein (SIEV) should be determined intraoperatively. The purpose of this pilot study is to propose a method to detect venous congestion intraoperatively using the blood glucose measurement index (BGMI). METHODS: In 70 DIEP flaps of 67 patients for breast reconstruction, the ratio of blood glucose content in the flap to systemic blood glucose (BGMI) was measured immediately after wound closure. Eight flaps in which BGMI was less than 0.8 were categorized into the low BGMI group, and additional venous anastomosis using SIEV was conducted. The other 62 flaps were categorized into the normal BGMI group. Perioperative objective color difference of the flap calculated using the L*a*b* color coordinate scale was recorded simultaneously. Correlation between BGMI and color difference was analyzed. RESULTS: In all flaps in the low BGMI group, SIEV diameter was increased; after additional anastomosis, the BGMI significantly improved (from 0.71 ± 0.05 to 0.94 ± 0.05, P < .01). There was a significant correlation between BGMI and color difference (P = .04). The determination coefficient was 0.265. When a BGMI of less than 0.8 was assumed to be a true positive, the area under the curve of color difference in the receiver operating characteristic curve was 0.82. CONCLUSION: BGMI immediately after wound closure may be useful to detect initial signs of venous congestion. Intraoperative objective color difference also reflects venous congestion; however, it is not highly accurate.