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.

Comparing advance care planning between older adults with and without HIV.

We compared completion of advance directives (AD), designation of a healthcare proxy, and stage in the advance care planning process (pre-contemplation/contemplation, preparation/action) between older adults with (N = 110) and without (N = 50) HIV. Participants' mean age was 61.3, most identified as male (82%) and sexual minorities (74%), were racially/ethnically diverse (44% white, 28% Latinx, 16% Black); 37% had an AD and 44% had a healthcare proxy. In adjusted logistic regressions, HIV- individuals had higher odds of being in preparation/action for having an AD (aOR: 2.6) and healthcare proxy (aOR: 3.6) compared to people living with HIV. Older age (aOR: 1.1) and having a sense of greater purpose in life (aOR: 2.1) were also positively associated with being in the preparation/action stage for having a healthcare proxy.

Incidence and Economic Burden of Adverse Drug Reactions in Hospitalization: A Prospective Study in Korea.

BACKGROUND: Adverse drug reactions (ADRs) are escalating, and their socioeconomic burden is increasing. However, large-scale prospective studies investigating ADRs during hospitalization are rare in Korea. We prospectively investigated the incidence, characteristics, and economic burden of ADRs in hospitalized patients based on electronic medical records (EMRs). METHODS: Among patients admitted to three hospitals from October 2016 to October 2017, 5,000 patients were randomly selected and prospectively observed during hospitalization. Research nurses monitored and detected patients who had symptoms, signs, or laboratory findings suspicious for ADRs using an EMR-based detection protocol. Next, allergy and ADR specialists reviewed the medical records to determine the relationship between adverse reactions and drugs. Cases in which a causal relationship was certain, probable/likely, or possible were included in the ADR cases. Clinically meaningful ADR cases or those leading to prolonged hospitalization were defined as significant ADRs. RESULTS: ADRs occurred in 510 (10.2%) patients. The mean length of hospital stay was approximately 5 days longer in patients with ADRs. Opioids accounted for the highest percentage of total ADRs. Significant ADRs were observed in 148 (3.0%) patients. Antibiotics accounted for the highest percentage of significant ADRs. Drug hypersensitivity reactions (DHRs) occurred in 88 (1.8%) patients. Antibiotics accounted for the highest percentage of DHRs. The average medical expenses for one day of hospitalization per patient were highest in significant ADRs, followed by non-significant ADRs, and non-ADRs. CONCLUSION: ADRs in hospitalized patients are an important clinical issue, resulting in a substantial socioeconomic burden. EMR-based strategy could be a useful tool for ADR monitoring and early detection.

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.

Disparity in access for people with disabilities to outpatient dental care services: a retrospective cohort study.

BACKGROUND: People with disabilities face difficulties in oral health management and gaining access to dental care. The availability of a regular source of dental care (RSDC) is an important factor that influences the access to health services and care management. The purpose of this study was to determine the effect of the availability of RSDC on the number of annual dental visits and dental expenses per visit among people with disabilities. METHODS: Data of 7,896,251 patients with dental problems in South Korea were analyzed using the 2002-2018 National Health Insurance claims data. A generalized estimating equation was applied to analyze the repeated-measurement data, and the interaction effect between RSDC and the disability severity was evaluated. RESULTS: The number of annual dental visits was higher among people with (2.62) than among those without (2.23) disabilities. Despite their increased dental needs, both annual dental visits and dental expenses per visit were low among older individuals (p < 0.001). The proportion and frequency of annual dental visits was lower among women than among men with disabilities. RSDC had differential effects on the severity of disability. Compared to people without disabilities, RSDC increased the number of annual dental visits (p = 0.067) and the dental expenses per visit (p < 0.05) among those with severe disabilities, but the effect on the number of annual dental visits was not significant among those with mild disabilities (p = 0.698). CONCLUSIONS: Our results suggest a need for a special dental care system for people with disabilities, to ensure an RSDC, particularly for women and for older people with disabilities.

Occupational hazards among dental hygienists: Risk level assessment of scaling work.

OBJECTIVES: This study aimed to classify occupational hazards of ultrasonic scaling by factor and to identify the distribution of occupational risk levels of the study participants according to occupational hazards. In addition, the relationship between the general characteristics of dental hygienists and the occupational risk level of scaling was investigated. METHODS: This study was conducted on 237 dental hygienists. Exposure frequency and the degree of work loss were investigated on a five-point scale for each of the 15 occupational hazards of scaling. RESULTS: Among occupational hazards, the proportion of high-risk individuals for biological hazards (32.9%) was the highest. Dental clinics (33.6%) were found to have a higher proportion of high-risk individuals than dental hospitals (16.5%) (p < 0.05). The proportion of high-risk individuals was higher in the absence of an infection control coordinator (33.9%) (p < 0.05) and infection control education in the preceding 2 years (28.6%) (p < 0.05). CONCLUSION: To create a safe dental work environment, appropriate measures according to the risk level and measurement of occupational risk should be discussed.

Effect of Morphologically Transformed Acellular Dermal Matrix on Chronic Diabetic Wounds: An Experimental Study in a Calvarial Bone Exposure Diabetic Rat Model.

BACKGROUND: The use of acellular dermal matrix on chronic diabetic wounds in clinical practice is hindered by its high cost and difficulty in application. We aimed to acquire experimental evidence on the effect of morphologically transformed acellular dermal matrix on chronic diabetic wounds and investigate how this transformation affects the wound healing mechanism. MATERIALS AND METHODS: We developed a new chronic wound model that resembles a diabetic chronic wound as it involves an open wound with partial calvarial bone exposure in diabetic rats. According to treatment materials, rats were assigned into the CONTROL, ADM, and PASTE groups. The wound healing period was subdivided into T1 and T2 (postoperative days 14 and 30, respectively). Three-staged analyses were performed using 3D camera, histological analysis, and real-time quantitative polymerase chain reaction. RESULTS: The morphologically transformed acellular dermal matrix showed a compatible treatment rate in the total wound and more rapidly reduced the initial bone exposure area. In the PASTE group, collagen scaffold appeared at a later period and expression levels of epidermal growth factor and epidermal growth factor receptor increased. CONCLUSIONS: The transformation of acellular dermal matrix into the pulverized form is thought to contribute to its non-inferior therapeutic effect compared with normal acellular dermal matrix. With respect to the mechanism, the pulverized form reduced the bone exposure area in the early stage and provided a collagen scaffold at a later period. An increase in epithelial growth factors through mechanochemical transformations along with increased contact area contribute to the enhanced healing capacity of the morphologically transformed acellular dermal matrix.

The association between wildfire exposure in pregnancy and foetal gastroschisis: A population-based cohort study.

BACKGROUND: Global climate change has led to an increase in the prevalence and severity of wildfires. Pollutants released into air, soil and groundwater from wildfires may impact embryo development leading to gastroschisis. OBJECTIVE: The objective of this study was to determine the association between wildfire exposure before and during pregnancy and the risk of foetal gastroschisis development. METHODS: This was a retrospective cohort study using The California Office of Statewide Health Planning and Development Linked Birth File linked to The California Department of Forestry and Fire Protection data between 2007 and 2010. Pregnancies complicated by foetal gastroschisis were identified by neonatal hospital discharge ICD-9 code. Pregnancies were considered exposed to wildfire if the mother's primary residence zip code was within 15 miles to the closest edge of a wildfire. The exposure was further stratified by trimester or if exposed within 30 days prior to pregnancy. Multivariable log-binomial regression analyses were performed to estimate the association between wildfire exposure in each pregnancy epoch and foetal gastroschisis. RESULTS: Between 2007 and 2010, 844,348 (40%) births were exposed to wildfire in California. Compared with births without wildfire exposure, those with first-trimester exposure were associated with higher rates of gastroschisis, 7.8 vs. 5.7 per 10,000 births (adjusted relative risk [aRR] 1.28, 95% confidence interval [CI] 1.07, 1.54). Furthermore, those with prepregnancy wildfire exposure were also found to have higher rates of gastroschisis, 12.5 vs. 5.7 per 10,000 births, (aRR 2.17, 95% CI 1.42, 3.52). In contrast, second- and third-trimester wildfire exposures were not associated with foetal gastroschisis. CONCLUSIONS: Wildfire exposure within 30 days before pregnancy was associated with more than two times higher risk of foetal gastroschisis, whereas a 28% higher risk was demonstrated if exposure was in the first trimester.

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.

Changes in dental hygiene students' working posture following digital sound feedback.

INTRODUCTION: This study aimed to observe changes in working posture by measuring the REBA (Rapid Entire Body Assessment) score of dental hygiene students according to digital sound feedback linked with a smartphone application. METHODS: This study was conducted on 28 fourth-year dental hygiene students who received theoretical and practical training on dental posture in the second year and then practised on mannequins and patients for about four semesters. Periodontal instrumentation was performed freely by applying digital sound notification feedback for four weeks after baseline, 30 minutes per week. REBA was measured after performing periodic structure construction without providing digital sound notification feedback for the last 1-2 minutes. Follow-up was conducted the same way 2-3 weeks after the intervention period. RESULTS: The REBA score for total, neck and trunk of all subjects showed statistically significant decreases post-intervention compared with the baseline scores (total p < .001, neck p < .001 and trunk p = .042). CONCLUSIONS: A digital sound feedback system was shown to be effective in encouraging correct working posture in dental hygiene students by helping them improve their REBA scores.

Research on dental plaque removal methods for efficient oral prophylaxis: With a focus on air polishing and rubber cup polishing.

OBJECTIVES: This study was conducted to compare the plaque control effectiveness of rubber cup polishing with that of air polishing during oral prophylaxis procedures and to investigate the effect of the order of air-polishing application on the efficiency of oral prophylaxis. METHODS: The study included adult patients (≥20 years of age) who had visited the dental clinic for oral prophylaxis. A total of 173 subjects were divided into three groups (scaling followed by rubber cup polishing, SR; scaling followed by air polishing, SA; and air polishing followed by scaling, AS) based on sex, age, oral health status, oral hygiene status, and indications and contraindications according to the oral prophylaxis method. The analysis of variance (ANOVA) was used to determine the difference in oral prophylaxis time, residual deposits rate, subjects and dental hygienist satisfaction. RESULTS: The total scaling time was shorter in the AS group (15.4 ± 6.9 minutes) than in the SA (18.7 ± 5.5 minutes) and SR groups (19.9 ± 6.2 minutes) (p < 0.05). The rate of residual deposits was significantly higher in the SR group than in the AS or SA groups (p < 0.05). The satisfaction level of dental hygienists was higher in the AS group (8.8 ± 1.0 points) and the SA group (8.4 ± 1.0 points) than in the SR group (6.2 ± 1.3 points). CONCLUSION: During oral prophylaxis, dental plaque removal using air polishing requires a relatively longer time when compared to rubber cup polishing, but it can better eliminate dental plaque. In addition, we found that dental plaque removal using air polishing prior to scaling reduced the total scaling time.

Efficacy of mobile health care in patients undergoing fixed orthodontic treatment: A systematic review.

OBJECTIVES: We performed a systematic review of studies that assessed the efficacy of mobile health care in patients undergoing fixed orthodontic treatment, in an attempt to obtain contemporary evidence on the clinical impact of mobile health care on the patients' oral health and orthodontic treatment outcomes. METHODS: A systematic literature search was conducted using the PRISMA guidelines. We performed a comprehensive search using multiple databases (Cochrane Library, MEDLINE, EMBASE, Scopus, Google Scholar and Web of Science) with no restrictions on the language of publication or publication status up until 23 April 2019 to identify eligible studies. RESULTS: We included 11 unique studies. In this review, 9 of the 11 selected studies showed positive effects of mobile healthcare intervention, which resulted in reduced scores of oral hygiene and periodontal indices and white-spot lesions, as well as decreased duration of treatment, sagittal distance and intensity of self-reported pain. CONCLUSIONS: Mobile health care can be utilized as an adjuvant intervention to improve treatment outcomes in patients undergoing fixed orthodontic treatment. Oral healthcare experts should consider novel interventions using mobile devices in addition to the conventional mode of intervention.

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.

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.

Silver-Impregnated Negative-Pressure Wound Therapy for the Treatment of Lower-Extremity Open Wounds: A Prospective Randomized Clinical Study.

OBJECTIVE: To investigate the antibacterial efficacy of silver-impregnated negative-pressure wound therapy (NPWT) in lower-extremity acute traumatic wounds. METHODS: Open contaminated wounds caused by high-velocity trauma in the lower extremities were randomly allocated into two groups. The wounds in the control and experimental groups were treated with conventional NPWT (n = 31) and silver-impregnated NPWT (n = 35), respectively. MAIN OUTCOME MEASURES: Serial bacterial cultures were obtained from the participants' wounds, polyurethane foam, and suction tubes weekly during the 4-week follow-up to identify bacteria and follow their conversions. MAIN RESULTS: Bacterial colonization rates in the silver NPWT group were generally lower than those in the conventional NPWT group, and the difference increased with time. For methicillin-resistant Staphylococcus aureus colonization, wounds treated with silver-impregnated NPWT showed a significant reduction in bacterial load compared with those treated with conventional NPWT. CONCLUSIONS: Silver-impregnated NPWT effectively decreases bacterial load in open contaminated wounds of the lower extremities. It can be used as a temporizing measure to manage bacterial colonization while patients and wounds are being prepared for final wound reconstruction.

Differences in plantar pressure by REBA scores in dental hygienists.

OBJECTIVES: The purpose of the present study was to analyse the effects of working posture, physical balance and work accumulation on shifts in plantar pressure in dental hygienists, by measuring REBA, which evaluates working posture, and plantar pressure, which evaluates physical balance. METHODS: This study was conducted on 24 dental hygienists currently working in dental clinics. The ergonomic assessment method of the Rapid Entire Body Assessment was used to evaluate working posture in the dental hygienists, and a Gait Analyzer was used to measure plantar pressure. RESULTS: The subjects' mean REBA score was 4.96 ± 1.04 points, and 87.5% of the subjects showed poor working posture, with a REBA score of at least four points. Among subjects with a REBA score of four points or more, seven of the eight parts of the sole of the foot showed significant differences in plantar pressure between the right and left feet (P < 0.05). When we examined changes in plantar pressure over a week, pressure increased on the left side, and in particular, for subjects with a REBA score of four points or higher, pressure increased in the left foot and in the anterior right foot. CONCLUSIONS: Most of the dental hygienists in this study showed poor posture during working. Subjects with poor posture at a level requiring intervention showed differences in plantar pressure between the right and left feet. Inappropriate posture can cause musculoskeletal disorders. Therefore, it will be necessary to prepare internal and external measures to maintain proper working posture in dental hygienists, including education, exercise, improvement of the working environment and improvement of ergonomic equipment and devices.

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.

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.

Restoration of Complicated Epicanthus: Modified Reverse Skin Redraping With Mini-epicanthoplasty for Rescue in Unsatisfied Epicanthoplasty Patients.

PURPOSE: We had reported the surgical outcome of reverse skin redraping technique for restoration of previously performed epicanthoplasty. In this study, we introduce a modified reverse skin redraping technique that added mini-epicanthoplasty in patients with unsatisfactory results after epicanthoplasty. METHODS: Three hundred twenty-four patients (288 female and 36 male patients) who had unsatisfied results with previous epicanthoplasty and that were treated with our modified restoration surgery were included in this study. RESULTS: The mean preoperative interepicanthal distance was 33.6 mm, and the mean postoperative interepicanthal distance was 36.9 mm; the mean difference in the interepicanthal distance before and after restoration surgery was 3.3 mm. Satisfactory aesthetic results were obtained with improvements in areas of asymmetry, overexposure of the caruncle, and the appearance of the previous scar. Only minor complications developed in 15 patients (4.6%) that were resolved with minor revisions. No severe complications requiring reoperations were noted. CONCLUSIONS: Our modified method involving reverse skin redraping and mini-epicanthoplasty is simple and reproducible and is useful for resolution of unsatisfactory results to obtain a naturally shaped epicanthus.

Alanine aminotransferase and gamma-glutamyl transferase have different dose-response relationships with risk of mortality by age.

BACKGROUND & AIMS: It remains unclear whether the respective dose-response relationships between serum alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) levels and risk of mortality are consistent by age. METHODS: We used sampled cohort data from the National Health Insurance Corporation to conduct a retrospective cohort study. A total of 313 252 participants who received medical health check-ups from 2002 to 2008 were assessed for risk of death according to serum ALT and GGT levels over an average of 6 years. The hazard ratios (HRs) for mortality were analysed with Cox proportional hazard model. RESULTS: The crude mortality rate increased linearly with increasing serum ALT and GGT levels in adults aged <60 years. However, the all-cause mortality rate showed a J-shaped relationship with increasing serum ALT levels whereas all-cause mortality rate showed a linear relationship with increasing serum GGT levels in adults aged ≥60 years. The HR of death showed U-shaped relationships with increasing serum ALT levels in adults aged ≥60 years. On the contrary, the HR of death from any cause had a linear association with increasing serum GGT levels among all age groups. CONCLUSIONS: In this study, U-shaped relationship patterns were demonstrated between serum ALT levels and risk for all-cause mortality in adults aged ≥60 years while serum GGT levels showed a linear relationship with risk for all-cause death. Very low levels of serum ALT in elderly patients suggest that they are at high risk of mortality.