Complication analysis of complete versus partial coverage of tissue expanders using serratus anterior musculofascial flaps in immediate breast reconstruction.

PURPOSE: To prevent tissue expander (TE) exposure following mastectomy flap necrosis in immediate breast reconstruction, the TE is usually covered completely or partially with a musculofascial (MF) flap. This study compares the complications of the two coverage methods. METHODS: We reviewed, retrospectively, 106 cases of immediate TE-based breast reconstruction. The patients were divided into two groups according to whether complete or partial TE coverage was done. In the complete coverage group, the serratus anterior MF flap was dissected and sutured to the pectoralis major muscle to cover the TE completely. In the partial coverage group, the serratus anterior MF flap was not dissected, and the lateral border of the pectoralis major muscle was sutured to the mastectomy skin flaps. RESULTS: The TEs were covered completely in 60 breasts and partially in 46 breasts. The mastectomy flap necrosis rate was significantly higher in the complete coverage group (p < 0.01), but there was no incidence of TE exposure in either groups. The lateral migration rate was significantly higher in the partial coverage group (p = 0.033). There were no significant differences in the cranial migration rate (p = 0.133). CONCLUSIONS: The complete coverage method is a better option if there is a high risk of mastectomy flap necrosis; however, surgeons should monitor carefully for cranial migration.

A Comparison of Large Soft Palate Defect Reconstruction Using the New "Tunnel Structure" and Traditional "Port Structure" Methods.

Background For soft palate defects of more than two-thirds, we previously described the bent anterolateral thigh (ALT) method in which the pharyngeal isthmus was reconstructed as a tunnel structure. In this study, we compared the new "tunnel structure" reconstruction in our bent ALT flap method and the traditional "port structure" reconstruction. Methods From April 2010 to March 2015, 25 patients in Saitama Cancer Center (Saitama, Japan) underwent oropharyngeal tumor resection including soft palate resection. In patients who had soft palate resection of less than two-thirds, the Gehanno method was performed in 10 patients (the data were shown as a comparison). In patients who had soft palate resection of more than two-thirds, the pharyngeal isthmus was reconstructed as a tunnel structure using the bent ALT flap method in eight patients and as a port structure in seven patients. The functional outcomes were assessed by interviewing patients about their symptoms and measuring the standard articulation test. Results Postoperative function was favorably maintained at equal levels in the tunnel structure reconstruction group and the Gehanno method group at approximately 12 months postoperation. However, in most patients in the port structure reconstruction group, the pharyngeal isthmus became larger after 12 months postoperation and the articulation test was significantly worse than the Gehanno group and the tunnel group. Conclusion The bent ALT flap method had superior results to the conventional method. Thus the pharyngeal isthmus should be reconstructed as a tunnel structure for patients with soft palate defects of more than two-thirds.

No correlation between initial arterial carboxyhemoglobin level and degree of lung injury following ovine burn and smoke inhalation.

Fire victims often suffer from burn injury and concomitant inhalation trauma, the latter significantly contributing to the morbidity and mortality in these patients. Measurement of blood carboxyhemoglobin levels has been proposed as a diagnostic marker to verify and, perhaps, quantify the degree of lung injury following inhalation trauma. However, this correlation has not yet been sufficiently validated. A total of 77 chronically instrumented sheep received sham injury, smoke inhalation injury, or combined burn and inhalation trauma following an established protocol. Arterial carboxyhemoglobin concentrations were determined directly after injury and correlated to several clinical and histopathological determinants of lung injury that were detected 48 hours post-injury. The injury induced severe impairment of pulmonary gas exchange and increases in transvascular fluid flux, lung water content, and airway obstruction scores. No significant correlations were detected between initial carboxyhemoglobin levels and all measured clinical and histopathological determinants of lung injury. In conclusion, the amount of arterial carboxyhemoglobin concentration cannot predict the degree of lung injury at 48 hours after ovine burn and smoke inhalation trauma.

Time course of early histopathological lung changes in an ovine model of acute lung injury and pulmonary infection.

Large animal models are valuable tools in biological and medical lung research. Despite the existence of established large animal models, the scientific progress requires more detailed description and expansion of established methods. Previously, we established an ovine model of acute lung injury and subsequent bacterial instillation into the lungs. The current study was designed to assess the time course of early lung histopathological alterations in a large animal model. Injury was induced by smoke inhalation and instillation of live Pseudomonas aeruginosa into the lungs. After 4, 8, 12, 18, and 24 hours, respectively, lung tissue was harvested and histopathological changes were evaluated (n = 4 each). Additional four sheep received no injury and only lung tissue was taken. In injured animals, bronchial obstruction score increased over time and was significantly elevated from 12 to 24 hours (P < .05 versus no injury). Inflammation score was significantly increased at 12 and 18 hours (P < .05 versus no injury). Hemorrhage score was increased at 8 and 12 hours (P < .05 versus no injury). Alveolar edema score was significantly higher in injured sheep at 8, 18, and 24 hours (P < .05 each versus no injury). In conclusion, bronchial obstruction and alveolar edema scores significantly increased over time and reached a plateau, while both inflammation and hemorrhage scores were transiently increased peaking around the 12-hour time point. This information improves the understanding of lung histopathological alterations following acute lung injury and pulmonary infection and may help optimizing the timing of study interventions and evaluation time points in future experiments with this model.

Multiple pilomatricomas in Kabuki syndrome.

Pilomatricoma is a benign tumor of the hair matrix cell that presents predominantly in childhood. Although pilomatricoma occurs spontaneously, multiple pilomatricomas have been described in association with several inherited syndromes. We report on a 28-year-old man with Kabuki syndrome with three pilomatricomas in his head and thigh. Although several reports describe multiple pilomatricomas associated with Turner syndrome, there are no reports of multiple pilomatricomas combined with Kabuki syndrome. Ectodermal abnormalities such as hair abnormality and hirsutism are symptoms of Kabuki syndrome, and pilomatricomas are frequently associated with the mutations of beta-catenin in hair follicle development. The predisposition of pilomatricomas may be not merely a coincidental finding, but an added association with Kabuki syndrome.

Lower lip reconstruction using a combined technique of the webster and johanson methods.

Oral reconstruction, especially with lower lip defects greater than 80% of the lip, is still challenging for plastic surgeons. Webster technique is mostly used for lower lip defects greater than 80% of the lip; however, resulting scars in the chin area (Schuchardt flap, a half-circle scar) are relatively conspicuous in Asian populations because of the trapdoor deformity. On the other hand, Johanson staircase flap technique, which is used to reconstruct lower lip defects of up to two thirds of the lip, results in relatively inconspicuous scarring and prevents trapdoor deformity. Thus, instead of Schuchardt flaps, we designed staircase flaps with a Webster technique. Two patients with lower lip carcinoma were operated on using this new technique. Large triangles of the skin and subcutaneous fat were removed from the nasolabial folds, and small staircases were removed from the lower lip to allow medial movement of the cheek tissues. The cosmetic and functional results were improved from the original Webster technique.

Continuous local intravenous heparin infusion after re-exploration for venous congestion in free-flap breast reconstruction: A case series.

We demonstrated local intravenous heparin infusion to salvage flaps after re-exploration for postoperative venous congestion after free-flap breast reconstruction. All flaps were salvaged using local intravenous heparin infusion without major complications. Local intravenous heparin infusion is an effective and safe procedure.

Gemini Anastomosis for Dual Venous Anastomosis in Head and Neck Reconstruction.

Free tissue transfer has been frequently used in head and neck reconstruction. However, vascular problems still cause serious damage to patients when thromboses occur in microvascular anastomoses. In the Gemini anastomosis procedure, two flap pedicle veins are anastomosed adjacently to the internal jugular vein using the end-to-side anastomosis method. From April 2019 to March 2021, 12 patients whose free flaps had two pedicle veins underwent head and neck surgery in Saitama Cancer Center (Saitama, Japan). In six patients, the veins were anastomosed adjacently to the internal jugular vein using the Gemini procedure (Gemini group). In the other six patients, the veins were anastomosed to the internal jugular vein using the end-to-side anastomosis method at a distance from each other (control group). The anastomosis time was measured retrospectively by reviewing video from the operations and comparing them across groups. There were no reoperations in any patients, and all flaps survived without exhibiting any circulatory problems. The mean total anastomosis time in the Gemini group was 21 minutes 38 seconds ± 75 seconds. The mean total anastomosis time in the control group was 34 minutes 14 seconds ± 121 seconds. The mean flap ischemic time in the Gemini group was 124 minutes ± 3 minutes. The mean flap ischemic time in the control group was 135 minutes ± 6 minutes. The Gemini anastomosis procedure is effective and convenient when the pedicle has two veins and the recipient vein choice is only the internal jugular vein in head and neck reconstruction.

A Novel Risk Model for Predicting Dysphagia after Tongue Reconstruction: A Retrospective Multicenter Study in Japan.

BACKGROUND: There is no consensus on the postoperative outcomes of tongue reconstruction. Therefore, the authors developed a novel risk model for predicting dysphagia after tongue reconstruction. METHODS: This retrospective study was conducted by the Oral Pharyngeal Esophageal Operation and Reconstruction Analytical, or OPERA, group across 31 cancer centers and university hospitals in Japan. A total of 532 patients [390 (73.3%) men and 142 (26.7%) women; median age at surgery, 60 years (range, 15 to 88 years)] who were diagnosed with oral tongue squamous cell carcinoma and underwent tongue reconstruction following glossectomy between 2009 and 2013 were included. Independent risk factors were identified using univariate regression analysis and converted to a binary format for multivariate analysis. An integer value was assigned to each risk factor to calculate a total score capable of quantifying the risk of feeding tube dependence. RESULTS: Overall, 54 patients (10.2%) required a feeding tube at the time of evaluation. Predictive factors for feeding tube dependence were advanced age, lower American Society of Anesthesiologists physical status, low body mass index, lower serum albumin, comorbid hypertension and diabetes, extended tongue defect, resection beyond the tongue, laryngeal suspension, postoperative radiation therapy, and no functional teeth. In multivariate logistic regression analysis, age greater than or equal to 58.5 years, postoperative radiation therapy, wider tongue defect, and body mass index less than 21.27 kg/m 2 earned 6, 4, 3, and 2 points, respectively, for a maximum total score of 15. CONCLUSION: The authors' risk model provides a mathematical tool for estimating the individual risk of postoperative feeding tube dependence before tongue reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Changes in calf muscle deoxygenation after foam sclerotherapy in patients with superficial venous insufficiency.

OBJECTIVE: This study assessed changes in the calf muscle deoxygenated hemoglobin (HHb) level during light-intensity exercise after ultrasound-guided foam sclerotherapy (UGFS) for superficial venous insufficiency. METHODS: UGFS with 1% or 3% polidocanol foam (POL-F) was used to treat unilateral great saphenous vein reflux in 84 patients. Near-infrared spectroscopy (NIRS) was used to measure calf muscle HHb levels before and 3 months after UGFS. The calf venous HHb blood-filling index was calculated on standing, the calf venous HHb ejection index was obtained after one tiptoe movement, and the venous HHb retention index was obtained after 10 tiptoe movements. The primary end point was an evident improvement in calf muscle deoxygenation after UGFS. The secondary end point was obliteration of the great saphenous vein. RESULTS: Treatment consisted of 1% POL-F in 48 limbs and 3% POL-F in the remaining 36. Ultrasound imaging at the 3-month follow-up demonstrated complete occlusion in 56.3% of the patients who received injections of 1% POL-F and in 66.7% of those who received injections of 3% POL-F. The difference in treatment outcome between the groups was not significant (P=.333). Reflux was absent in 39 limbs (81.3%) treated with 1% POL-F and in 34 limbs (94.4%) treated with 3% POL-F, and no significant difference was observed between the two groups (P=.076). Postsclerotherapy NIRS demonstrated significant reductions in the levels of the HHb filling index in both treatment groups (P=.039, P=.0001, respectively) and significant reductions in the levels of the HHb retention index (P<.0001, P=.008, respectively). However, the differences in the levels of the HHb ejection index before and after UGFS were not significant (P=.250, P=.084, respectively). CONCLUSIONS: Our present findings suggest that changes in the values of these parameters may be of potential use for assessing the effects of foam sclerotherapy in patients with superficial venous insufficiency.

Time course of the inflammatory and oxidative stress response to pulmonary infection in mice.

The pathophysiological response to pulmonary infection includes a surge of proinflammatory cytokines and excessive production of nitric oxide (NO), but the time changes are not sufficiently defined. The current study was designed to assess the time course of proinflammatory cytokines and NO production in a murine model of pulmonary infection. The injury was induced by intranasal administration of live Pseudomonas aeruginosa (3.2 × 10(7) colony-forming units) in C57BL/6 wild-type mice. The animals were euthanized at 3, 6, 9, 12, and 15 hours postinjury. Additional mice received sham injury (0 hours; control). Lung tissue and plasma samples were harvested at the respective time points. The injury induced an early increase in interleukin (IL)-1 ß protein in lung tissue that persisted during the entire study period with a peak at the 9-hour time point. The increases in TNF-α and IL-6 proteins in lung tissue were less intense, but showed a peak about 9 hours postinjury. The plasma levels of IL-1 ß and tumor necrosis factor (TNF)-α protein were not elevated during the experimental period, but only an increase in plasma levels of IL-6 plasma protein was detected. These findings compensate for the limitations of previous experiments with similar infection models and improve the understanding of pathophysiologic alterations in response to pulmonary infection. In addition, the identification of the time changes of the described pathogenetic factors may enhance the timing of innovate therapeutic approaches in future experiments.

Usefulness of radial recurrent artery in transplant of radial forearm flap: an anatomical and clinical study.

Because of its long and stable pedicle, the radial forearm flap is very useful for salvage operations in which there are few choices of recipient vessels. However, pedicle length deficiency and size discrepancy of anastomotic vessels still exist. In such cases, the radial recurrent artery that bifurcates from the radial artery can be used as an anastomotic vessel. Anatomical variations of the recurrent radial artery were studied in 18 cadavers. The branch types were classified as branch from radial artery (Type A), branch from radial artery root (Type B), branch from brachial artery (Type C), and branch from ulnar artery (Type D). Radial artery and radial recurrent artery diameters were measured. The radial recurrent artery was used as an anastomotic vessel in four salvage operations. Branching type variations were Type A: 61.1%, Type B: 33.3%, Type C: 0%, and Type D: 5.6%. Radial recurrent artery diameter was 1.84 ± 0.59 mm at the 20 mm point from bifurcation. In clinical cases, all flaps survived without any anastomotic difficulties. Thus, anastomosis using radial recurrent artery vessels is recommended as a strategy in free radial forearm transplantation for salvage operations.

Usefulness of Harmonic Focus during anterolateral thigh flap elevation.

Meticulous hemostasis and careful ligation of branches are necessary for pedicle dissection during flap elevation. The aim of this study was to evaluate the effectiveness of the Harmonic Focus handpiece (Ethicon Endo-Surgery, Inc., Blue Ash, Cincinnati, OH, USA) in reducing operation time, bleeding volume, and volume of postoperative drainage during anterolateral thigh flap elevation. Ten patients requiring flap elevation were divided into two groups: (1) Harmonic Focus group (three men, two women), and (2) control group (three men, two women). Operating time was found to be lower in the Harmonic Focus group than in the control group. Bleeding volume and postoperative drainage volume were nearly identical in the Harmonic Focus group and the control group, and the number of silk ligatures was significantly lower in the Harmonic Focus group compared with the control group. Although somewhat costly, the Harmonic Scalpel with the Harmonic Focus handpiece is advantageous for flap elevation, and it is likely that Harmonic Scalpel use will increase in plastic surgery.

Analysis of various defects and reconstructive methods after invasive thyroid carcinoma resection.

OBJECTIVE: The thyroid gland adjoins the trachea, pharynx, esophagus, carotid artery and cervical skin. Most thyroid carcinomas have been treated at lower stages; however, in some cases the carcinomas have invaded the surrounding organs. After resecting invasive thyroid carcinomas, the defects vary depending on the invasion area and organs affected; subsequent reconstructive methods vary depending on the size of defect and its components. This study analysed the pattern of defects and the reconstructive methods used following invasive thyroid carcinoma resection. METHODS: From April 2011 to March 2021, 665 patients in Saitama Cancer Center (Saitama, Japan) were diagnosed with thyroid carcinoma and subsequently underwent thyroidectomies. In the 25 patients (3.8%), the thyroid carcinoma invaded surrounding organs and any reconstructive surgery-including end-to-end tracheal anastomosis and simple pharynx closure-was performed after thyroid carcinoma resection. The patients' records were retrospectively reviewed, and the defects and subsequent reconstructive methods were analysed. RESULTS: When our new classification system was applied to the defects, the number of cases for each type was totaled: Tr0: 1; Tr1a: 3; Tr2b: 5; Tr3a: 1; La-Tr3b+PE2: 7; La-Tr3b+PE2+S2: 1; PE1: 1; PE1+S1: 2; S1: 2; S2: 2. For Tr0, a tracheal fenestration was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr1a defect, a tracheal fenestration was performed with cervical skin after the tumor resection and the tracheal fenestration was closed with a deltopectoral flap or pectralis major musculocutaneous flap. In one recent patient, the tracheal fenestration was reconstructed using free forearm flap and cervical skin, and the fenestration was closed with a hinge flap. For Tr2b defect, free forearm flap and costal cartilage graft reconstruction was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr3a defect, end-to-end anastomosis was performed in one patient. For La-Tr3b+PE2 defect, total pharyngolaryngectomy with free jejunal flap reconstruction was performed. For PE1 defect, a simple closure was performed in one patient and a PMMC muscle flap was used for covering the suture line in two patients. For S1 and S2 defect, PMMC flap or DP flap was used. CONCLUSION: Our analysis of defects and reconstructive methods defines the complex defect patterns occurring after invasive thyroid carcinoma resection, describes the patterns of subsequent reconstructive methods.

Beneficial pulmonary effects of a metalloporphyrinic peroxynitrite decomposition catalyst in burn and smoke inhalation injury.

During acute lung injury, nitric oxide (NO) exerts cytotoxic effects by reacting with superoxide radicals, yielding the reactive nitrogen species peroxynitrite (ONOO(-)). ONOO(-) exerts cytotoxic effects, among others, by nitrating/nitrosating proteins and lipids, by activating the nuclear repair enzyme poly(ADP-ribose) polymerase and inducing VEGF. Here we tested the effect of the ONOO(-) decomposition catalyst INO-4885 on the development of lung injury in chronically instrumented sheep with combined burn and smoke inhalation injury. The animals were randomized to a sham-injured group (n = 7), an injured control group [48 breaths of cotton smoke, 3rd-degree burn of 40% total body surface area (n = 7)], or an injured group treated with INO-4885 (n = 6). All sheep were mechanically ventilated and fluid-resuscitated according to the Parkland formula. The injury-related increases in the abundance of 3-nitrotyrosine, a marker of protein nitration by ONOO(-), were prevented by INO-4885, providing evidence for the neutralization of ONOO(-) action by the compound. Burn and smoke injury induced a significant drop in arterial Po(2)-to-inspired O(2) fraction ratio and significant increases in pulmonary shunt fraction, lung lymph flow, lung wet-to-dry weight ratio, and ventilatory pressures; all these changes were significantly attenuated by INO-4885 treatment. In addition, the increases in IL-8, VEGF, and poly(ADP-ribose) in lung tissue were significantly attenuated by the ONOO(-) decomposition catalyst. In conclusion, the current study suggests that ONOO(-) plays a crucial role in the pathogenesis of pulmonary microvascular hyperpermeability and pulmonary dysfunction following burn and smoke inhalation injury in sheep. Administration of an ONOO(-) decomposition catalyst may represent a potential treatment option for this injury.

Specific inhibition of nitric oxide synthases at different time points in a murine model of pulmonary sepsis.

Excessive production of nitric oxide (NO) by NO synthase (NOS) and a subsequent oxidative stress reaction are thought to be critically involved in the pathophysiology of sepsis. Previous studies suggested that NO production by neuronal NOS (nNOS) and inducible NOS (iNOS) is implemented in the disease process at different time points after the injury. Here we tested the roles of selective pharmacological inhibition of nNOS and iNOS at different time points in a murine model of pulmonary sepsis. The injury was induced by intranasal administration of live Pseudomonas aeruginosa (3.2×10(7) colony-forming units) in C57BL/6 wild-type mice. The animals received no treatment (control) or treatment with a specific nNOS inhibitor (4 or 8h), iNOS inhibitor (4 or 8h), or non-specific NOS inhibitor (4 or 8h). In controls, the injury was associated with excessive releases of pro-inflammatory cytokines in the plasma, enhanced tissue lipid peroxidation, and decreased survival. Non-specific NOS inhibition at either time point did not influence survival and was not further investigated. While nNOS inhibition at 4h was associated with a trend toward improved survival and significantly reduced contents of lung nitrite/nitrate (NO(x)) and liver malondialdehyde, the blockade of nNOS at 8h had no effect on these parameters. In contrast, early iNOS inhibition was associated with a trend toward decreased survival and no effects on lung NO(x) and liver malondialdehyde contents, whereas later iNOS blockade was associated with decreased malondialdehyde content in liver homogenates. In conclusion, pulmonary sepsis in mice may be beneficially influenced by specific pharmacological nNOS inhibition at an earlier time point and iNOS inhibition at a later time points post-injury. Future investigations should identify the time changes of the expression and activation of NOS isoforms.

Preclinical evaluation of epinephrine nebulization to reduce airway hyperemia and improve oxygenation after smoke inhalation injury.

OBJECTIVE: Acute lung injury secondary to smoke inhalation is a major source of morbidity and mortality in burn patients. We tested the hypothesis that nebulized epinephrine would ameliorate pulmonary dysfunction secondary to acute lung injury by reducing airway hyperemia and edema formation and mediating bronchodilatation in an established, large animal model of inhalation injury. DESIGN: Prospective, controlled, randomized trial. SETTING: University research laboratory. SUBJECTS: Twenty-four chronically instrumented, adult, female sheep. INTERVENTIONS: Following baseline measurements, the animals were allocated to a sham-injured group (n = 5), an injured and saline-treated group (n = 6), or an injured group treated with 4 mg of nebulized epinephrine every 4 hrs (n = 6). Inhalation injury was induced by 48 breaths of cotton smoke. The dose of epinephrine was derived from dose finding experiments (n = 7 sheep). MEASUREMENTS AND MAIN RESULTS: The injury induced significant increases in airway blood flows, bronchial wet/dry weight ratio, airway obstruction scores, ventilatory pressures, and lung malondialdehyde content, and contributed to severe pulmonary dysfunction as evidenced by a significant decline in Pao2/Fio2 ratio and increase in pulmonary shunt fraction. Nebulization of epinephrine significantly reduced tracheal and main bronchial blood flows, ventilatory pressures, and lung malondialdehyde content. The treatment was further associated with significant improvements of Pao2/FIO2 ratio and pulmonary shunting. CONCLUSIONS: Nebulization of epinephrine reduces airway blood flow and attenuates pulmonary dysfunction in sheep subjected to severe smoke inhalation injury. Future studies will have to improve the understanding of the underlying pathomechanisms and identify the optimal dosing for the treatment of patients with this injury.

Deep vein thrombosis after total knee or hip arthroplasty is associated with increased preoperative calf muscle deoxygenation as measured by near-infrared spectroscopy.

OBJECTIVE: To assess whether the preoperative level of deoxygenated hemoglobin (HHb) in the calf muscle during light-intensity exercise is useful for identifying patients at risk of developing deep vein thrombosis (DVT) after total knee or hip arthroplasty. METHODS: Sixty-eight patients undergoing total knee or total hip arthroplasty were enrolled. The Caprini risk assessment model was used to stratify patients into Caprini 5 to 6, Caprini 7 to 8, and Caprini >8 groups. The preoperative diameter of each venous segment was measured, and the time-averaged velocity (TAV) and time-averaged flow (TAF) of the popliteal vein (POPV) were assessed. Moreover, the prevalence of venous reflux in the POPV was evaluated preoperatively. Near-infrared spectroscopy (NIRS) was used to measure the calf muscle HHb level. The calf venous blood filling index (FI-HHb) was calculated on standing, and then the calf venous ejection index (EI-HHb) was obtained after one tiptoe movement and the venous retention index (RI-HHb) after 10 tiptoe movements. All patients received low-dose unfractionated heparin preoperatively and fondaparinux for postoperative thromboprophylaxis. Patients with arterial insufficiency, those who had preoperative DVT, and those who developed bilateral DVT after surgery were excluded from the study. RESULTS: Four patients were excluded on the basis of the exclusion criteria. Among the 64 patients evaluated, 14 (21.9%) were found to have DVT postoperatively. Among the risk factors for DVT, only the previous DVT was significantly predominant in patients who developed DVT (P = .001). The diameter of the popliteal vein was significantly smaller in patients who developed postoperative DVT than in those who did not (P = .001). Similarly, the diameter of the gastrocnemius vein was significantly larger in patients with postoperative DVT than in those without (P = .010). TAV and TAF were significantly increased in the popliteal vein in patients who developed postoperative DVT (P = .043, 0.046, respectively). Both groups showed a similar prevalence of reflux in the POPV (P = .841). The preoperative NIRS-derived RI was significantly increased in patients who developed DVT relative to those who did not (P = .004). The RI increased as the Caprini score progressed; however, there were no statistically significant differences between the three categories. Using ultrasound- and NIRS-derived parameters of significance as a unit of analysis, an optimal RI cut-off point of >2.3 showed the strongest ability to predict postoperative DVT, followed by a cut-off point >0.25 cm for the diameter of the gastrocnemius vein (GV). CONCLUSIONS: NIRS-derived RI >2.3 may be a promising parameter for identifying patients at risk of developing postoperative DVT despite pharmacologic DVT prophylaxis. A GV diameter of >0.25 cm also seems to contribute to the development of postoperative DVT. These results might be helpful to physicians for deciding which patients require more intensive thromboprophylaxis.

Predictive role of arterial carboxyhemoglobin concentrations in ovine burn and smoke inhalation-induced lung injury.

Inhalation injury frequently occurs in burn patients and contributes to the morbidity and mortality of these injuries. Arterial carboxyhemoglobin has been proposed as an indicator of the severity of inhalation injury; however, the interrelation between arterial carboxyhemoglobin and histological alterations has not yet been investigated. Chronically instrumented sheep were subjected to a third degree burn of 40% of the total body surface area and inhalation of 48 breaths of cotton smoke. Carboxyhemoglobin was measured immediately after injury and correlated to clinical parameters of pulmonary function as well as histopathology scores from lung tissue harvested 24 hours after the injury. The injury was associated with a significant decline in pulmonary oxygenation and increases in pulmonary shunting, lung lymph flow, wet/dry weight ratio, congestion score, edema score, inflammation score, and airway obstruction scores. Carboxyhemoglobin was negatively correlated to pulmonary oxygenation and positively correlated to pulmonary shunting, lung lymph flow, and lung wet/dry weight ratio. No significant correlations could be detected between carboxyhemoglobin and histopathology scores and airway obstruction scores. Arterial carboxyhemoglobin in sheep with combined burn and inhalation injury are correlated with the degree of pulmonary failure and edema formation, but not with certain histological alterations including airway obstruction scores.

Outcomes of ultrasound-guided foam sclerotherapy for varicose veins of the lower extremities: a single center experience.

OBJECTIVE: Ultrasound-guided foam sclerotherapy is increasing in popularity as a method to treat varicose veins of the lower extremities. In 2001, we began using ultrasound-guided foam sclerotherapy to treat varicose veins of the lower extremities. The outcomes of our treatment are described in this study. METHODS: One hundred four patients underwent ultrasound-guided foam sclerotherapy for 138 extremities over a 5-year period, from January 2004 to December 2008, at Tokyo Women's Medical University Hospital. The outcomes were studied retrospectively using chart review. The average age, sex, and recurrence rates were calculated. At 24 months after treatment, the primary and secondary success rates were analyzed. RESULTS: The mean age of the patients was 63.2; 30 (22%) were male. Twenty-five (27%) patients had recurrences in 35 (34%) extremities. At 24 months, the primary success rate was 62.2%, and the secondary success rate was 75.8%. CONCLUSIONS: None of the patients experienced adverse events. The recurrence rates were slightly higher than those of other published data, which may be due to the lower dose of foam used in GSV. In summary, ultrasound-guided foam sclerotherapy can be easily and effectively performed in an outpatient clinical setting. The authors have indicated no significant interest with commercial supporters.