The Making of a Flight Feather: Bio-architectural Principles and Adaptation.

The evolution of flight in feathered dinosaurs and early birds over millions of years required flight feathers whose architecture features hierarchical branches. While barb-based feather forms were investigated, feather shafts and vanes are understudied. Here, we take a multi-disciplinary approach to study their molecular control and bio-architectural organizations. In rachidial ridges, epidermal progenitors generate cortex and medullary keratinocytes, guided by Bmp and transforming growth factor ß (TGF-ß) signaling that convert rachides into adaptable bilayer composite beams. In barb ridges, epidermal progenitors generate cylindrical, plate-, or hooklet-shaped barbule cells that form fluffy branches or pennaceous vanes, mediated by asymmetric cell junction and keratin expression. Transcriptome analyses and functional studies show anterior-posterior Wnt2b signaling within the dermal papilla controls barbule cell fates with spatiotemporal collinearity. Quantitative bio-physical analyses of feathers from birds with different flight characteristics and feathers in Burmese amber reveal how multi-dimensional functionality can be achieved and may inspire future composite material designs. VIDEO ABSTRACT.

Impact of COVID-19-Induced Academic Stress on Insomnia and Suicidal Ideation among Taiwanese Health Trainees and Junior Doctors.

BACKGROUND Clinical training for allied health trainees (AHTs) and postgraduate-year (PGY) doctors needed to go online during the outbreak of coronavirus disease 2019 (COVID-19), which may have caused academic stress and consequent outcomes among this cohort. MATERIAL AND METHODS To evaluate academic-related stress, clinical confidence, psychological distress, and insomnia, an online survey-based study was conducted among Taiwanese AHTs and PGY doctors between July and December, 2022, during the COVID-19 pandemic. The survey included the 21-item Depression, Anxiety, and Stress Scale (DASS-21), the Insomnia Severity Index (ISI), and self-designed questions. It was distributed using convenience sampling and snowball sampling and was completed by 522 participants. RESULTS Structural equational modelling showed that academic stress was negatively associated with clinical confidence (standardized coefficient [ß]=-0.382, p<0.001). Clinical confidence was negatively associated with psychological distress (ß=-0.397, p<0.001), which was associated with insomnia (ß=0.648, p<0.001). Additionally, clinical confidence and psychological distress were the significant mediators. Results indicated that higher academic stress was associated with higher level of insomnia via the mediation of clinical confidence and psychological distress. CONCLUSIONS Academic stress related to changes in clinical training may have led to insomnia among AHTs and PGY doctors during the pandemic. Factors to reduce academic stress should be investigated to promote good mental health while providing sufficient clinical training, especially during events that can cause increased stress (eg, epidemics, pandemics).

Surgical Treatment of Malignant Peripheral Nerve Sheath Tumor of the Scalp With Intracranial and Extracranial Extension: A Rare Case Report.

ABSTRACT: Malignant peripheral nerve sheath tumors of the scalp are rare neoplasms of the peripheral nervous system. Here, we describe an unusual malignant peripheral nerve sheath tumor of the scalp in an 84-year-old Asian man. The tumor was associated with bony destruction, intracranial, and extracranial extension. Trans-arterial embolization was done twice preoperatively. En block excision was performed and the dura and soft tissue defect were reconstructed by anterolateral thigh free fasciocutaneous flap. There is no recurrence and the wound healed well during follow-up.

Reconstruction With Flow-Through Chimeric Anterolateral Thigh Flap Combining Vascularized Fibular Bone Graft for Extensive Composite Tissue Defect of the Forearm: A Case Report.

ABSTRACT: The management of critical limb trauma is challenging because limb salvage is preferable to amputation. For upper limb reconstruction, the surgical restoration of functionality, and appearance, a multidisciplinary approach is needed. We report the case of an extensive composite tissue defect of the forearm caused by a machine-crushing injury that was repaired by a flow-through chimeric anterolateral thigh flap with a vascularized fibular graft. Reconstruction was performed as a single-stage procedure; no complications occurred, and both functional and aesthetic outcomes were satisfactory.

Plate-related complication and health-related quality of life after mandibular reconstruction by fibula flap with reconstruction plate or miniplate versus anterolateral thigh flap with reconstruction plate.

BACKGROUND: Plate-related complications are major long-term complications in mandible reconstruction. There are controversies regarding the use of a reconstruction plate versus miniplates and a bone flap versus a soft tissue flap with a bridging plate. Direct comparisons of a fibula flap and an anterolateral thigh flap, the applicability between a reconstruction plate and miniplate, and the correlation between plate-related complications and quality of life remain unclarified. Therefore, this study aimed to the explore complications of different flaps and plates and how they impact the patients' quality of life. METHODS: We retrospectively reviewed the medical records of a total of 205 patients aged >18 years who underwent segmental mandibulectomy and reconstruction using fibula flap with reconstruction plate (FR; n = 86), fibula flap with miniplate (FM; n = 61), and anterolateral thigh flap with reconstruction plate (AR; n = 58) due to cancer ablation, osteoradionecrosis, or benign tumor excision between August 2010 and December 2019. Data on characteristics, complications, and health-related quality of life were collected and analyzed. RESULTS: The plate-related complication rate was the highest in the AR group (37.9%), then in the FR group (25.6%), and was the lowest in the FM group (13.1%; p = 0.0079). The plate exposure rate was the highest in the AR group (24.1%), then in the FR group (15.7%), and was the lowest in the FM group (4.9%; p = 0.0128). The plate fracture and dislodge rates for the AR group were both higher than those for the FR and FM groups (24.1% versus 9.3% versus 9.8%, respectively; p = 0.023). The AR group had worse complication-free survival (hazard ratio [HR]: 3.61, 95% CI: 1.99-6.56, and p < 0.0001) than the FR and FM groups. Osteoradionecrosis (HR: 6.19, 95% CI: 2.11-18.21, and p = 0.0009) and postoperative radiotherapy (HR: 2.87, 95% CI: 1.34-6.12, and p = 0.0402) were both independent adverse factors for complication-free survival, whereas patient treated primarily (HR: 0.35, 95% CI: 0.17-0.73, and p = 0.0048) was an independent protective factor. Plate-related complication negatively impacted the quality of life based on pain scores (ß: -0.56, SE: 0.26, and p = 0.034). CONCLUSIONS: Using a fibular flap fixed with miniplates and avoiding the use of a reconstruction plate may yield a reduced plate exposure rate and better health-related quality of life, particularly for patients with osteoradionecrosis or those who need postoperative radiotherapy.

Increasing burden of major trauma in elderly adults during 2003-2015: Analysis of real-world data from Taiwan.

BACKGROUND: Major trauma has been one of the leading causes of morbidity, mortality, and functional disability, resulting in substantial societal burden. The aim of this study was to estimate the trends in burden of adult major trauma in Taiwan during 2003-2015. METHODS: Adult patients with initial encounter of major trauma (injury severity score ≥ 16) were abstracted from the claim data of National Health Insurance (NHI) in Taiwan from January 2003 to December 2015. We explored the trends of incidence and mortality rates over time stratified by age and sex, as well as life expectancy (LE), loss-of-LE, lifetime healthcare expenditure and total loss-of-LE compared with age, sex and calendar-year matched referents simulated from the vital statistics of Taiwan. RESULTS: A total of 71,731 cases of adult major trauma, and an estimated loss of 979,676 life-years were found with an increasing trend in cumulative incidence rate (CIR18-84) during 2003-2015. The incidence rates were significantly higher in men than women. For both sexes, the incidence rates for those aged 65 and above were about 2-3 times higher than those of all other age groups. The one-year case fatality rates among the elderly were about 31-61%, higher than all other ages. The lifetime healthcare expenditures per person were 47,616 USD in men and 43,416 USD in women. CONCLUSION: There is a consistently increasing trend in incidence and mortality of major trauma in Taiwan, especially among elderly people. For Taiwan, an aged society beginning since 2018, the challenge should be tackled more effectively in the coming decades.

Unilateral Vision Loss After Hyaluronic Acid Injection: A Case Report.

ABSTRACT: Vascular occlusion causing vision loss is a rare yet one of the most devastating complications of facial esthetic fillers. In this article, we present a case of unilateral blindness and superficial skin necrosis in a 31-year-old woman after the injection of hyaluronic acid for esthetic purposes. The delicate ocular fundal findings of ophthalmic artery occlusion were demonstrated by ophthalmoscopy, optical coherence tomography, and fluorescein angiography. Magnetic resonance imaging also showed subsequent ischemic changes in the optic nerve and posterior scleral wall after ophthalmic artery occlusion. Despite management including intraocular pressure-lowering agents, globe massage, and anticoagulation with acetylsalicylic acid and hyperbaric oxygen therapy, her final vision was not restored. Given the lack of effective treatments, this report depicts the comprehensive ocular fundal findings of an ophthalmic artery occlusion after esthetic hyaluronic acid filler injection, and highlights the importance of a preventive approach to avoid such catastrophic complications.

Dynamic Traction Splint as an Alternative Surgical Treatment for Comminuted Intraarticular Fracture of Metacarpophalangeal Joint.

BACKGROUND: Comminuted intraarticular fractures of the metacarpophalangeal joint (MPJ) are difficult to treat. We evaluated the clinical outcomes of using a dynamic traction splint to treat comminuted intraarticular fracture of MPJ. PATIENTS AND METHODS: We conducted a retrospective chart review on patients with comminuted intraarticular fracture of the MPJ treated with a dynamic traction splint at National Cheng Kung University Hospital between March 2014 and February 2018. The surgical procedures consisted of a transverse Kirschner wire insertion and treatment for concomitant injuries. The patients then received staged regular rehabilitation programs under a hand therapists' supervision for 14 weeks. Active range of motion (ROM) of injured digits, Visual Analog Scale score for pain, and return-to-work status were recorded to evaluate functional outcomes. RESULTS: A total of 10 patients were included. All were male patients and aged 8 to 66 years. The most common injury mechanism was motor vehicle accident (70%). The locations of fractures were 1 at the metacarpal head and 9 at the proximal phalangeal bases. Half of the fractures were open. Concomitant injuries were 1 digital nerve severance, 1 extensor tendon rupture, and 3 dorsal skin avulsions. There were no postoperative complications. The active ROM of the MPJ ranged from 40° to 90° with a median ROM of 80°. The Visual Analog Scale score for pain was 0 in 8 patients and 1 in the other 2 patients. All patients returned to their original workplace after rehabilitation. CONCLUSIONS: Dynamic traction splints and postoperative rehabilitation programs could be an alternative treatment for comminuted intraarticular fracture of the MPJ.

Regeneration of rete ridges in Lanyu pig (Sus scrofa): Insights for human skin wound healing.

Rete ridges are important to the mechanical function of skin in animals with minimal hair, including humans. As mice do not exhibit rete ridges, the need for a quality animal model is pertinent. Here, we develop a Lanyu pig (Sus scrofa) full-thickness wound model to explore tissue regeneration because the architecture and function are similar to humans and inbred genetic variants are available. Full- and partial-thickness wounds were generated on the dorsum. Full-thickness wounds at post-wound day 57 exhibit severe scar with no signs of wound-induced hair follicle neogenesis. Wound contraction is greater in the anterior/posterior relative to the medial/lateral axis. In wound beds, K14+ cells increased while K10+ , p63+ and PCNA+ cells decreased compared to unwounded tissue. Epithelial ß-catenin is unchanged. The wound bed expresses more ColI, less ColIII and no elastin. Rete ridges do not form after full-thickness wounding, but incompletely regenerate after partial-thickness wounding. An alkaline phosphatase (ALP)+ cell population, not associated with hair follicles, is present at the bottom of the rete ridge basal layer in pig and human unwounded skin. These K5+ /K10- /PCNA- /ALP+ epithelial cells are absent after full-thickness wounding but reappear after partial-thickness wounding, before invagination of new rete ridges. In summary, full-thickness wounding on the dorsum of Lanyu pigs results in scar formation and perturbed molecular expression while partial-thickness wounding permits limited rete ridge and papillary dermis regeneration. Future functional studies and further characterization will help contribute knowledge for the regenerative medicine field.

Locked Thumb Metacarpophalangeal Joint Caused by Entrapment of the Sesamoid Bone: A Report of 2 Cases.

Locked thumb metacarpophalangeal joint caused by entrapment of the sesamoid bone is an uncommon entity. The intact volar plate, strong ligamentous attachment between the sesamoid bone and the joint, and altered axis of inserted muscle all contribute to failure of closed reduction. The patient's history, clinical presentation, and plain radiographic findings are all important clues to diagnosing this rare disease. We describe 2 patients with a similar mechanism of injury, where the sesamoid bones were displaced into the thumb metacarpophalangeal joint causing lock thumb. The anatomy, pathophysiology, and surgical management of the patients are also described and discussed. Both patients were successfully treated with meticulous open reduction.

Esophageal reconstruction after oncological total laryngopharyngoesophagectomy: Algorithmic approach.

BACKGROUND: Reconstruction for total laryngopharyngoesophagectomy is accomplished mainly by gastrointestinal transposition but can be complicated by anastomotic tension or associated neck-skin defect. Here, we present the results of total esophageal reconstruction by gastrointestinal transposition alone or with additional free tissue transfer and propose an algorithm accordingly. METHODS: We reviewed patients who had oncologic total laryngopharyngoesophagectomy between January 2012 and January 2016. Twenty-four men and one woman were included with a mean age of 54 (range, 41-72) years. Patients were grouped by reconstruction into the gastric pull-up (GP, n = 15), colon interposition (CI, n = 2), GP combined with free jejunal flap (GPFJ, n = 6), or GP combined with anterolateral thigh flap (GPALT, n = 2) group to compare clinical outcomes. RESULTS: The mean operation time was 1037.3 minutes and was significantly longer in the GPALT group than in the GP group (1235.0 ± 50.0 minutes vs. 929.7 ± 137.7 minutes, p =.009). All flaps survived. After a mean follow-up of 18 months, the overall leakage, stricture, and successful swallowing rates were 44%, 4%, and 76%, respectively. There was no significant difference in the leakage (53.3%, 50.0%, 16.7%, and 50.0%, p =.581), stricture (6.7%, 0%, 0%, and 0%, p = 1.000), or successful swallowing (73.3%, 50.0%, 83.3%, and 100%, p =.783) rates between GP, CI, GPFJ, and GPALT groups, respectively. CONCLUSIONS: The proposed algorithm that ranks gastric pull-up as a priority and uses additional free tissue transfer to overcome the anastomotic tension or associated neck-skin defect is feasible.

A Touch-Observation and Task-Based Mirror Therapy Protocol to Improve Sensorimotor Control and Functional Capability of Hands for Patients With Peripheral Nerve Injury.

IMPORTANCE: To develop a practical program in the early phase after nerve repair for more rapid return of function. OBJECTIVE: To investigate the effects of touch-observation and task-based mirror therapy on the sensorimotor outcomes of patients with nerve repair. DESIGN: An assessor-blinded study with a randomized controlled design. SETTING: University hospital. PARTICIPANTS: We recruited 12 patients with median or ulnar nerve repair between the level of midpalm and elbow referred by the plastic surgeons. INTERVENTION: The patients were randomized into touch-observation and task-based mirror therapy or control groups, and both groups received training for 12 wk. OUTCOMES AND MEASURES: The Semmes-Weinstein monofilament (SWM) test, two-point discrimination test, Purdue Pegboard Test (PPT), Minnesota Manual Dexterity Test (MMDT), and pinch-holding-up activity test were assessed at pretreatment, immediately after treatment, and 12 wk after the last treatment. RESULTS: The experimental group showed greater improvements in the results of the pinch-holding-up activity test and the PPT Unilateral Pin Insertion, Bilateral Pin Insertion, and Assembly subtests. However, change on the SWM test revealed no significant difference between the two groups. CONCLUSIONS AND RELEVANCE: Touch-observation and task-based mirror therapy is an effective but low-cost treatment protocol to optimize sensorimotor control and functional capability of the upper limb in patients with peripheral nerve injury.

The Incidence of Necrotizing Fasciitis in Taiwan: A Nationwide Population-Based Study.

BACKGROUND: Little is known about the national population-based incidence rates of necrotizing fasciitis (NF) and related epidemiological profiles in Asian countries. We plastic surgeons always face and treat this complicated disease in the first line at the hospital. METHODS: Using Taiwan's National Health Insurance inpatient claims data from 2005 through 2010, we investigated the national annual incidence rate of NF by sex, age, year, month, beneficiary category, and region. RESULTS: The overall average annual incidence rate (cases per 100,000 population) of those 6 years of inpatients with NF was 11.6 (95% confidence interval [CI], 11.4-11.8) for both sexes, 14.9 (95% CI, 14.9-15.5) for males, and 8.3 (95% CI, 7.9-8.3) for females. The age-adjusted annual incidence rate was 10.7 (95% CI, 10.3-11.1) in 2005 and 12.3 (95% CI, 11.9-12.8) in 2010. The annual incidence rate increased with age, peaked in August, was the highest in southern Taiwan, and correlated with monthly temperature. CONCLUSIONS: The annual incidence rate of NF in Taiwan was highest between 2005 and 2009 and slightly lower in 2010 in this study. Although additional studies are needed to identify modifiable risk factors associated with NF, the aforementioned risk factors alert the first line doctors, such as plastic surgeons, to pay much more attention to this complicated disease entity and make an accurate critical decision making for the patients.

Intensive Care Unit Versus Ward Management After Anterolateral Thigh Flap Reconstruction After Oral Cancer Ablation.

BACKGROUND: Whether postoperative care in the intensive care unit (ICU) is a necessity for patients undergoing head and neck free flap reconstruction remains debatable. In August 2012, our institute initiated a policy to care for these patients in the ICU, opposed to the previous policy of care in the ward. Thus, we used this opportunity to compare outcomes between these 2 care approaches. PATIENTS AND METHODS: Patients with oral cancer who underwent cancer ablation and immediate anterolateral thigh flap reconstruction from August 2010 to July 2014 were included in this retrospective study. Patients who simultaneously received an additional flap reconstruction were excluded. Before August 2012, these patients were routinely transferred to the ward for postoperative care (ward group, n = 179). Since August 2012, these patients have routinely been transferred to the ICU for postoperative care (ICU group, n = 138). RESULTS: Both groups had comparable flap outcomes in terms of the rates of take-back, successful salvage, flap survival, and flap complication. Compared with the ward group, the ICU group showed an increased use of postoperative sedation (26.7% vs 6.8%, P = 0.000), a correspondingly longer use of mechanical ventilation (3.0 ± 2.7 days vs 0.4 ± 1.4 days, P = 0.000), and a higher incidence of sepsis (3.6% vs 0%, P = 0.015). CONCLUSIONS: Postoperative care of patients who have undergone anterolateral thigh flap reconstruction after oral cancer ablation in the ward or ICU resulted in comparable flap outcomes. Risks and benefits between ward and ICU postoperative management in terms of nursing workloads, monitoring facilities, use of sedation and mechanical ventilation, and potential for sepsis should be taken into consideration when defining postoperative care settings in these patients.

Determining the functional sensibility of the hand in patients with peripheral nerve repair: Feasibility of using a novel manual tactile test for monitoring the progression of nerve regeneration.

STUDY DESIGN: Case-controlled cohort study. INTRODUCTION: Sensory function is difficult to observe during nerve regeneration processes. Traditional sensory tests are limited to identifying the level of functioning hand sensation for sensory stimulus is given passively to the cutaneous surface of the hand. PURPOSE OF THE STUDY: To examine the outcome changes in the manual tactile test (MTT), Semmes-Weinstein monofilament (SWM) and 2-point discrimination (2PD) tests for patients with nerve repair and to investigate the concurrent validity of MTT by comparing it with the results of traditional tests. METHODS: Fifteen patients with nerve injury of the upper limbs were recruited, along with 15 matched healthy controls. The MTT, SWM, and 2PD tests were used to examine the sensory status of the subjects. RESULTS: Three subtests (barognosis, roughness differentiation, and stereognosis) in MTT showed that the patients improved with time. A moderate and mild correlation was found between the MTT and 2PD results and between the barognosis and SWM results. CONCLUSIONS: The MTT provides practical and functional perspectives on detecting nerve progression during the courses of degeneration and regeneration. LEVEL OF EVIDENCE: IV.

Manual Tactile Test Predicts Sensorimotor Control Capability of Hands for Patients With Peripheral Nerve Injury.

OBJECTIVES: To comprehend the merits of a Manual Tactile Test (MTT) in assessing hand sensorimotor functions by exploring the relations among 3 subtests along with the precision pinch performances for patients with peripheral nerve injuries (PNIs); and to understand the accuracy of the MTT by constructing the sensitivity and specificity of the test for patients with PNI. DESIGN: Case-control study. SETTING: Hospital and local community. PARTICIPANTS: Patients with PNI (n=28) were recruited along with age-, sex-, and handedness-matched healthy controls (n=28) (N=56). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Semmes-Weinstein monofilament, moving and static 2-point discrimination, roughness differentiation, stereognosis and barognosis subtests of the MTT, and precision pinch performance were used to examine the sensory and sensorimotor status of the hand. RESULTS: The worst results in all sensibility tests were found for the patients with PNI (P<.001) in comparison with the controls. Multiple linear regression analysis showed the MTT was a better indicator for predicting the sensorimotor capacity of hands in the patients with PNI (r(2)=.189, P=.003) than the traditional test (r(2)=.088, P=.051). The results of the receiver operating characteristic curve estimation show that the area under the curve was .968 and .959 for the roughness differentiation and stereognosis subtests, respectively, and .853 for the barognosis subtest, therefore revealing the accuracy of the MTT in assessing sensorimotor status for patients with PNI. CONCLUSIONS: This study indicates that the MTT is highly accurate and a significant predictor of sensorimotor performance in hands of patients with PNI. The MTT could therefore help clinicians obtain a better understanding of the sensorimotor and functional status of the hand with nerve injuries.

Revascularization Surgery: Its Efficacy for Limb Salvage in Diabetic Foot.

The estimated prevalence of diabetes is 9.78% in Taiwan. The lifetime risk for patients with diabetes to have foot ulcers might be as high as 25%. About 15% of these patients require major limb amputation because of ischemia and infection. Peripheral artery disease is still a major problem involved in diabetic foot disease and the cause for major amputation despite an increase in the prevalence of revascularization surgery and new revascularization techniques over the past 20 years. We investigated the major limb amputation rates in patients with diabetic foot and critical limb ischemia who had undergone revascularization surgery in our hospital. The records of 42 patients who had undergone revascularization surgery for diabetic foot were retrospectively reviewed. Nineteen patients (45%) required major limb amputation despite revascularization. The affected limbs of only 15 patients (36%) were salvaged. Four patients died soon after surgery because of comorbidities, and another 4 were lost to follow-up. Two patients died from procedure-related sepsis, and overall perioperative mortality was 4.8%. Ten predictive risk factors (duration of diabetes, history of smoking, coronary artery disease, congestive heart failure, cerebral vascular accident, contralateral amputation, end-stage renal disease, fever episode, wound infection severity score, and arterial obstruction level) were included for analysis. Although none was significant, long-duration diabetes (OR: 1.13), end-stage renal disease (OR: 10.02), wound infection (OR: 1.56), and infrapopliteal lesions (OR: 3.00) tended to be unfavorable predictive risk factors of limb amputation. Revascularization surgery is still potentially beneficial for these patients--eg, it decreases the contralateral limb amputation rate by 7.5%--if done early in high-risk patients.

Glomus Tumor: Twenty-Year Experience and Literature Review.

Glomus tumors are rare, usually benign, vascular hamartomas consisting cells resembling the smooth muscle cells of the normal glomus body. They can be solitary or multiple, whereas solitary tumors are majorly located on the digits. Digital glomus tumors most commonly appear in subungual region and show a strong female predominance. There are several classical symptoms, clinical tests, and imaging tools, such as X-ray, magnetic resonance imaging, and ultrasonography, which can provide good accuracy for clinical diagnosis. However, misdiagnosis and delayed diagnosis are still commonly observed because primary physicians are unfamiliar with classical symptoms and clinical tests. Complete surgical excision often can result in complete relief of symptoms. Recurrence is largely caused by incomplete excision, but repeated image study is recommended to rule out new or malignant lesions. This series is a retrospective review of 50 cases with glomus tumors managed at our institute. We aim to review the key aspects of glomus tumor and provide a simple guideline for earlier diagnosis and treatment.

Prognostic factor of mortality and its clinical implications in patients with necrotizing fasciitis caused by Vibrio vulnificus.

In Taiwan, the aquatic environment and endemic hepatitis contribute to the high susceptibility of Vibrio vulnificus infection. A multidisciplinary treatment protocol for necrotizing fasciitis caused by V. vulnificus was developed in our institute, namely, ceftriaxone or ceftazidime combined with doxycycline or minocycline followed by an emergency fasciotomy and intensive care unit admission. We retrospectively reviewed 100 cases to evaluate the effectiveness of our treatment protocol and identify independent predictors of mortality to improve clinical outcomes. Cases of culture-confirmed V. vulnificus infection between January 1996 and December 2011 were reviewed. Necrotizing fasciitis was surgically diagnosed if these criteria were met: necrotic fascia, "dishwater discharge", and loss of resistance while doing finger dissection along the fascia plane. One hundred cases met these criteria and were included for analysis. Eighteen patients died (18 % mortality). Unknown injury events, presence of multiple skin lesions, leukocytes < 10,000 cells/mm(3), platelets < 100,000/mm(3), serum creatinine ≥1.3 mg/dL, serum albumin < 2.5 mg/dL, and delayed treatment beyond 3 days post-injury or symptom onset were associated with significantly higher mortality. Multivariate analysis showed that treatment delayed beyond 3 days is an independent factor indicating a poor prognosis (OR 10.75, 95 % CI 1.02-113.39, p = 0.048). Early diagnosis and prompt treatment within 3 days post-injury or symptom onset should be the goal for treating patients with necrotizing fasciitis caused by V. vulnificus. Additional investigations to rescue patients with a prolonged disease course of necrotizing fasciitis (≥3 days) may be important.