Mucosal adjuvanticity and mucosal booster effect of colibactin-depleted probiotic Escherichia coli membrane vesicles.

There is a growing interest in development of novel vaccines against respiratory tract infections, due to COVID-19 pandemic. Here, we examined mucosal adjuvanticity and the mucosal booster effect of membrane vesicles (MVs) of a novel probiotic E. coli derivative lacking both flagella and potentially carcinogenic colibactin (ΔflhDΔclbP). ΔflhDΔclbP-derived MVs showed rather strong mucosal adjuvanticity as compared to those of a single flagellar mutant strain (ΔflhD-MVs). In addition, glycoengineered ΔflhDΔclbP-MVs displaying serotype-14 pneumococcal capsular polysaccharide (CPS14+MVs) were well-characterized based on biological and physicochemical parameters. Subcutaneous (SC) and intranasal (IN) booster effects of CPS14+MVs on systemic and mucosal immunity were evaluated in mice that have already been subcutaneously prime-immunized with the same MVs. With a two-dose regimen, an IN boost (SC-IN) elicited stronger IgA responses than homologous prime-boost immunization (SC-SC). With a three-dose regimen, serum IgG levels were comparable among all tested regimens. Homologous immunization (SC-SC-SC) elicited the highest IgM responses among all regimens tested, whereas SC-SC-SC failed to elicit IgA responses in blood and saliva. Furthermore, serum IgA and salivary SIgA levels were increased with an increased number of IN doses administrated. Notably, SC-IN-IN induced not only robust IgG response, but also the highest IgA response in both serum and saliva among the groups. The present findings suggest the potential of a heterologous three-dose administration for building both systemic and mucosal immunity, e.g. an SC-IN-IN vaccine regimen could be beneficial. Another important observation was abundant packaging of colibactin in MVs, suggesting increased applicability of ΔflhDΔclbP-MVs in the context of vaccine safety.

Practicality and Hemodynamic Advantage of Microvascularly Augmented Pectoralis Major Musculocutaneous Flap: Technical Approach and Evidence Based on Indocyanine Green Angiography.

ABSTRACT: We have recently shown that including the blood flow from the lateral thoracic artery (LTA) in addition to the thoracoacromial artery in the pectoralis major muscle musculocutaneous (PMMC) flap (bipedicle PMMC flap) can increase the perfusion of the flap. We also developed the concept of the supercharged PMMC flap, in which the LTA included in the flap was once cut and anastomosed to a cervical artery under a microscope. It is an effective solution to maintain the additional blood flow from the LTA, when the length of the LTA is compromised for reconstruction. The mandibular reconstruction of an oral cancer patient was performed with a supercharged PMMC flap. Intraoperative indocyanine green angiography was performed in a single pedicle, bipedicle, and supercharged conditions, and the videos were analyzed with a quantitative assessment system of perfusion using some parameters. As a result, blood supply from the LTA was essential for flap survival in this patient, and supercharging from the cervical artery improved flap perfusion compared with the perfusion in the bipedicle condition. The supercharged PMMC flap can resolve the compromise of pedicle length and be also hemodynamically advantageous, thus making the reconstruction more reliable than the conventional technique.

Incidence of Pure Orbital Fractures with Concomitant Lacrimal Drainage System Injury in the Japanese Population: A Retrospective Study.

PURPOSE: This study aims to determine the incidence of pure orbital fractures with concomitant lacrimal drainage system injuries. METHODS: A retrospective observational study involving 956 sides from 940 pure orbital blowout fracture patients was conducted in our institution. Patients with concomitant orbital rim fracture and those with old orbital fractures were excluded. RESULTS: A total of 13 sides (1.4%) from 13 patients were included in the study. Canalicular laceration, bony nasolacrimal canal fracture, and lacrimal sac wall laceration were found in 9, 4, and 1 patients, respectively (one overlapping). Majority of the injuries resulted from either sports or falls. Inferomedial orbital strut fracture (23.1% vs. 7.6%; p = .075) and orbital floor fracture occurring lateral to the infraorbital groove (30.8% vs. 9.9%; p = .035) tended to be higher in patients with lacrimal drainage system injuries. CONCLUSION: There is a 1.4% incidence rate of pure orbital fractures with concomitant lacrimal drainage system injuries among the Japanese population included in this study. Inferomedial orbital strut fractures and orbital floor fracture lateral to the infraorbital groove were found to have higher association with lacrimal drainage system injuries.

Orbital Trapdoor Fracture With Extraocular Muscle Entrapment in Adults: A Case Series.

PURPOSE: To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment. METHODS: We retrospectively reviewed 566 adult patients (>18 years) with a pure orbital fracture who were referred to us from January 2016 to May 2023. The following data were collected: age, sex, affected side, causes of injury, concomitant ocular injury and nasal bone fracture, presence or absence of oculocardiac reflex and infraorbital nerve hypesthesia, period from injury to surgery, follow-up period, and pre- and postoperative limitation of extraocular muscle motility and fields of a binocular single vision. RESULTS: We found 5 patients (0.9%) with an orbital trapdoor fracture with extraocular muscle entrapment (age range, 19-47 years; all males; 2 right and 3 left). Causes of injury included performing a bench press, fall, assault, boxing, and bicycle accident. Entrapment of the inferior and medial recti muscles was seen in 2 and 3 patients, respectively. None of the patients had any sign of oculocardiac reflex. After surgical reduction, the field of binocular single vision became normal in 3 patients and was incompletely recovered in 2 patients, in whom consultation with us was delayed. CONCLUSION: Adults with extraocular muscle entrapment may not present with an oculocardiac reflex. Urgent release of an entrapped muscle is, however, still recommended to avoid permanent limitation of extraocular muscle motility.

Treatment strategies for orbital gas-producing necrotizing fasciitis secondary to odontogenic maxillary sinusitis: Technical notes.

This paper presents treatment strategies for orbital necrotizing fasciitis (NF) in a case of a 33-year-old male diagnosed with orbital NF, which developed after dental root canal treatment. Although orbital NF is rare, it is rapidly progressive and can easily lead to the loss of tissue and visual function, sometimes to a life-threatening extent. Prompt and adequate treatment has been a challenge yet remains quite essential. In addition to the conventional approach to NF, such as immediate antibiotic administration and drainage, orbital NF patients like this case were often treated by incorporating additional steps, which include: 1) performing minimally invasive but adequate removal of necrotic tissue through intraoperative use of ultrasound equipment and postoperative use of proteolytic enzyme-containing ointment for chemical debridement; 2) managing intraorbital pressure by lateral cantholysis and orbital floor removal (decompression); and 3) maintaining the aerobic conditions of the wound after surgical drainage via orbital wall removal. Thus far, satisfactory results in patients with extensive NF of the orbit, including the presented case, were achieved with regards to preserving periorbital tissues, vision, and ocular motility through a multidisciplinary approach. These should be considered as optional means of preserving the orbital tissue and visual function.

Multiple CD34-Negative Orbital Solitary Fibrous Tumors in a Pediatric Patient.

A 12-year-old Japanese male presented with a 2-month history of headache that was later on associated with diplopia, painless proptosis of the OS, and left ophthalmoplegia. Initial examination revealed a 7-mm OS protrusion, which worsened to 9 mm in less than a month. Preoperative visual acuity worsened from 1.0 to 0.2 with the development of left afferent pupillary defect. Left ocular motility was severely restricted in all directions. Magnetic resonance imaging showed two well-defined lesions adjacent to one another in the left orbit. The patient underwent surgical excision of the left orbital masses. Histopathology findings were consistent with solitary fibrous tumor of the orbit. Immunohistochemistry findings revealed CD34-negative but signal transducer and activator of transcription 6-positive for both specimens. The patient was monitored postoperatively and there was no recurrence of the tumor even after 6 months.

Reliable and safe salivary duct repositioning technique with partial transection and intraductal stenting: Technical notes.

Salivary duct repositioning is often performed after excision of malignant tumors or removal of sialoliths to maintain salivary function and minimize the risk of swelling or pain due to the obstruction of the gland. However, there is risk of intraoperative tissue damage due to traumatic manipulation, leading to stenosis; in addition, the small diameter of the duct also renders this procedure difficult. Recently, we improved our method of salivary duct repositioning as follows. In the first technique, partial transection is made on the lateral wall of the duct ligated with thread at the end. Pulling the thread provides a view of the lumen, and appropriate tension enables a reliable and non-invasive procedure without requiring the operator to grasp the edge of the duct directly. When the diameter of the duct is small, intraductal stenting, the second technique, can be combined with the former technique by probe insertion to expand the lumen. Our approach is technically easy and simple which can be accepted by any clinicians and it could also be a promising technique that can serve as a less invasive and effective treatment.

The relationship between orbital floor fracture patterns around the infraorbital groove and development of infraorbital nerve hypoesthesia: a computed tomographic study.

PURPOSE: To examine the relationship between patterns of orbital floor fracture around the infraorbital groove and development of infraorbital nerve hypoesthesia. METHODS: This retrospective, observational study included 200 patients (200 sides) of pure orbital floor fracture with or without medial orbital wall fracture. Data on the presence or absence of infraorbital nerve hypoesthesia were collected from medical records. Based on coronal computed tomographic images, patients were classified into 3 groups: a fracture extending medially to (medial group), into (in-groove group), and laterally to the infraorbital groove (lateral group). RESULTS: Infraorbital nerve hypoesthesia was found in 72 patients (36.0%). A fracture extended into or laterally to the infraorbital groove in 86.2% of patients with infraorbital nerve hypoesthesia, while a fracture was limited to the portion medial to the infraorbital groove in 77.3% of patients without infraorbital nerve hypoesthesia (P < 0.001). A logistic regression analysis demonstrated that patients in the lateral and in-groove groups were highly associated with development of infraorbital nerve hypoesthesia, with an odds ratio of 134.788 in the lateral group (95% confidence interval, 30.496-595.735; P < 0.001) and that of 20.323 in the in-groove group (95% confidence interval, 6.942-59.499; P < 0.001) with the medial group as the reference. CONCLUSIONS: This study indicates that patients with orbital floor fracture extending into or laterally to the infraorbital groove have a high risk of infraorbital nerve hypoesthesia, compared to those with orbital floor fracture limited to the portion medial to the infraorbital groove.

Lateral Thoracic Artery Can Stabilize Circulation in the Pectoralis Major Myocutaneous Pedicle Flap: Single-center, Prospective, Uncontrolled Case Series.

BACKGROUND: Head and neck reconstructions using the pectoralis major myocutaneous pedicle flap (PMMF) with thoracoacromial artery alone are prone to hemodynamic instability, possibly leading to infection, prolapse, hematoma, seroma, and partial or total flap failure (6%-71%). Aside from unstable blood circulation, reported risk factors for these complications include feminine gender, smoking, and having diabetes mellitus. Preservation of the lateral thoracic artery in addition to the thoracoacromial artery has been suggested as a way to improve unstable blood circulation in the PMMF. METHODS: This is a single-center, prospective, uncontrolled case series. Circulation to the PMMF was studied intraoperatively with and without lateral thoracic artery clamping after harvest. Indocyanine green (ICG) angiopathy, a quantitative hemodynamic assessment method, was used to analyze three parameters: maximum intensity (Imax), time from start of ICG to maximum intensity (Tmax), and slope of intensity (Smax = Imax/Tmax). Hemodynamic parameters, such as pulse rate and blood pressure, were all within normal ranges. Allergy to contrast media was criterion for exclusion. RESULTS: Six patients all had oral cancer as their primary disease. Their background was characterized by established risk factors: four patients had a history of smoking, two had diabetes mellitus, and two were women. Postoperatively, no patients had complications at the recipient or donor sites. Mean results of the analysis were Imax: 60 ± 47, Tmax: 91 ± 55, Smax: 0.8 ± 0.5 in the clamped group and Imax: 85 ± 40, Tmax: 73 ± 42, Smax: 1.8 ± 1.5 in the un-clamped group. Significant difference was observed in Imax (P = 0.03) and Smax (P = 0.03). CONCLUSION: Lateral thoracic artery preservation appears to be useful for stabilizing blood circulation to the PMMF, including in patients considered to be at high-risk for complications, such as women, smokers, and patients with diabetes mellitus.

Anatomical implication of less occurrence of inferior oblique muscle entrapment in orbital floor trapdoor fracture.

PURPOSE: To examine the anatomy of the inferior oblique (IO) muscle and its surrounding structures to clarify why IO muscle entrapment develops less in orbital floor trapdoor fractures. METHODS: Computed tomographic (CT) images on the unaffected sides were obtained from 64 patients with unilateral orbital fractures. On coronal planes, presence or absence of an infraorbital groove below the IO muscle was confirmed. At the level of the medial margin of the infraorbital groove/canal, the distance from the orbital floor to the IO muscle (IO-floor distance), the thickness of the orbital floor, and the shortest distance from the inferior rectus (IR) muscle to the orbital floor (shortest IR-floor distance) were measured. On quasi-sagittal planes, the distances from the inferior orbital rim to the inferior margin of the IO muscle (IO-rim distance) and the most anterior point of the infraorbital groove (groove-rim distance) were measured. RESULTS: The infraorbital groove was found below the IO muscle in eight patients (12.5%), and the IO-rim and IO-floor distances were significantly longer than the groove-rim and shortest IR-floor distances, respectively (p < 0.001). The orbital floor below the IO muscle was significantly thicker than that below the IR muscle (p < 0.001). CONCLUSION: Although the medial margin of the infraorbital groove is the most common fracture site, the IO muscle was not located above the groove in most cases. A longer IO-floor distance and thicker orbital floor below the IO muscle may also contribute to less occurrence of IO muscle entrapment in orbital floor trapdoor fractures.

Anatomic Approximation Approach to Bilateral Macrostomia Repair.

ABSTRACT: In principle, reconstruction in macrostomia requires symmetry and accurate positioning of the newly reconstructed commissure. The proper position of the new commissure can be determined by several methods. In the determination of the new commissure of bilateral cases, generally the average length of the lips or the distance from anatomical landmarks other than the lips, such as the pupils or tragi, has been used. A new approach was reported by Tse et al in 2018: the anatomic approximation approach. Macrostomia repair refers to anatomical landmarks in the lips to determine the new commissure. The authors performed surgery using this anatomic approximation approach for bilateral macrostomia and achieved the good results.

Radiological findings of orbital blowout fractures: a review.

Purpose: To summarize the radiological findings in patients with orbital blowout fractures. Methods: We reviewed the published literature on radiological findings of orbital blowout fractures that were searched on PubMed and included our own radiologic findings on patients with orbital blowout fractures that were seen at our hospital. Results: Radiologic examination reveals a variety of findings in each case. However, common radiological findings of orbital blowout fractures include comminuted/unhinged, hinged, and linear fractures. These fractures are usually located in the orbital floor medial to the infraorbital nerve and in the medial orbital wall. Orbital fat is frequently herniated in the paranasal sinus or incarcerated at the fracture site. Orbital emphysema and haematoma sometimes occur as complications. Conclusions: This review will provide surgeons with a better understanding of various radiological findings, which could be helpful in the management of patients with orbital blowout fracture.

[A Resected Case of Adeno-Squamous Carcinoma of Gallbladder with Liver Invasions].

A patient was 70-year-old female. Because unknown fever following operation of left knee in December 20XX-1, abdominal simple CT was performed, diagnosed as cholecystitis and liver abscesses. However, her unknown fever did not improve with antibiotics therapy. Abdominal enhanced CT and MRI revealed to gallbladder cancer with liver invasion and metastases. These lesions were relatively localized in liver S4a/S5 and gallbladder, hepatoduodenal mesentery. Because unknown fever was exhausting, cholecystectomy, S4a+S5 hepatectomy with extrahepatic bile duct resection and lymph node dissemination were performed in January 20XX+1. In these pathological findings, there were moderate to poorly differentiated adenocarcinoma with squamous cell differentiation in almost area of gallbladder, diagnosed as adeno-squamous carcinoma with liver invasion and metastasis(pT3a[SI][H-inf], int, INF-ß, ly1, v3, pn1, pN1, pM1, pStage ⅣB). One months after operation, abdominal CT revealed multiple liver metastatic recurrences. She died 7 months after operation. Although gallbladder adeno-squamous carcinoma has a poor prognosis, these many cases had a tendency to local infiltration accompanied with tumor fever. If curative resection might be obtained and the symptoms might be improved, aggressive resection should be performed.

[A Case of Mesh Infection Due to Transverse Colon Cancer].

A 69-year-old female underwent a mesh repair for an abdominal incisional hernia 4 years previously in our hospital. She visited local hospital for abdominal pain and fever. Abdominal CT showed a localizes abscess formation above the mesh, then she was taken to our hospital. We suspected mesh infection and performed emergent mesh removal. After the operation, we examined for her anemia. Her colonoscopy and CT findings pointed to transverse colon cancer. We performed right hemicolectomy, and final diagnosis was transverse colon cancer pT4aN0M0, pStage Ⅱb. She underwent adjuvant chemotherapy, and 9 months after surgery, no recurrence was found.

Combination Laser Treatment With Real-Time Ultrasound Navigation for Oral Venous Malformations.

Vascular lesions, including hemangiomas and vascular malformations, are common benign diseases. More than 50% originate from blood vessels or vascular structures and are locate in the head and neck region. This study aimed to evaluate the efficiency and safety of a combination of laser treatments for oral venous malformations using ultrasound navigation. This study reports 3 cases of massive vascular malformation in the oral cavity, which were treated by a combination of a multiple spotted transmucosal irradiation technique (the so-called leopard technique) for the superficial layer, and intralesional photocoagulation for the deep layer using a neodymium-doped yttrium aluminum garnet laser, under real-time ultrasound navigation. All cases presented with a venous malformation with multiple blue swellings on the dorsum of the tongue, which had a maximum dimension of over 30 mm. The percent reduction in the size of the lesions was determined by magnetic resonance imaging. All cases showed a decrease in lesion volume of over 80%, without extensive tissue necrosis, 6 to 12 months after the laser treatment. None of the patients experienced any complications, and all were satisfied with the treatment outcome after one irradiation session.The results of this study suggest that laser treatment using ultrasound navigation is a promising approach for the safe and minimally invasive resolution of oral vascular lesions without scarring and loss of normal tissue architecture, sensation, oral function.

[A Case of Intestinal Obstruction Caused by Peritoneal Metastatic Recurrence One Year after Radical Operation for Pancreatic Cancer].

In December 20XX-1, abdominal enhanced CT of a 73-year-old female patient showed a 28mm-in-diameter pancreatic tail cancer with splenic venous invasion. She underwent neoadjuvant GEM/TS-1 combination chemotherapy but abandoned this chemotherapy due to melena and exanthema. She underwent a distal pancreatectomy with lymph node dissemination. In these pathological findings, the tumor was diagnosed as a pancreatic tail cancer with splenic venous invasion(T3, N0, M0, Stage ⅡA). She underwent adjuvant GEM chemotherapy, but she abandoned this chemotherapy due to exanthema and was managed with observation. In September 20XX, she had a postoperative bowel obstruction and was treated with natural light. However, she had a postoperative bowel obstruction again in July, 20XX+1. Fluoroscopic images revealed stenosis in the intestine located 170 cm from the nasal cavity. She underwent open surgery to manage the bowel obstruction. There was a peritoneal tumor with adhesion to each intestine serosa in 3 areas located 80 cm, 100 cm, and 150 cm from the Treitz ligament. Therefore, she underwent a small intestine resection and anastomosis 70 cm to 110 cm from the Treitz ligament. Pathological findings showed that there was a 3mm-in-diameter adenocarcinoma in this peritoneal tumor. In these findings, this final diagnosis was an adhesive intestinal obstruction caused by peritoneal metastasis. Curative resection for single peritoneal recurrent metastasis might be useful for prognosis prolongation.

Thickness of Retro- and Sub-Orbicularis Oculi Fat in Thyroid Eye Disease: Comparison With Controls and Its Influential Factors.

PURPOSE: To compare the thickness of the retro- and sub-orbicularis oculi fat (ROOF and SOOF) between patients with thyroid eye disease (TED) and controls via MRI and to determine factors influencing fat thickness. METHODS: This retrospective, comparative, case-control study included 136 patients (272 sides) with TED and 50 control patients (50 sides). The thickness of the ROOF and SOOF was measured on the quasi-sagittal plane through the optic nerve (the central plane) and 6 mm lateral and medial to the central plane at the level through the superior orbital rim and at the level just below the orbital septum in the lower eyelid, respectively. RESULTS: The ROOF and SOOF were thickest on the lateral plane (p < 0.050; Tukey Kramer post hoc test) and were significantly thicker in patients with TED than controls on all planes (p < 0.050; Student t test). Multivariate stepwise analysis showed that age, sex, clinical activity score, Hertel exophthalmometric values, and number of enlarged extraocular muscles are significant predictors of the ROOF and SOOF thickness in patients with TED (p < 0.050). CONCLUSIONS: Patients with TED had thicker ROOF and SOOF on all planes than controls with various factors influencing the thickness. These results may be helpful in planning rehabilitative blepharoplasty with removal of the ROOF and SOOF for correction of eyelid fullness in TED.

Successful Intralesional Laser Therapy for Sclerotherapy-resistant Huge Venous Malformation.

Venous malformations (VMs) are compressible, blue-purple tumors that are present at birth, and are treated with either surgery or sclerotherapy, or a combination of both. Patients often experience recurrent hemorrhage, swelling, pain, or difficulty in daily life. Treatment of massive VMs can, therefore, be challenging. We applied intralesional laser photocoagulation (ILP) to a 19-year-old female patient with a huge VM who had shown resistance to sclerotherapy. It spanned from the dorsal area to the lateral chest. ILP is delivered directly into thick, deep lesions through a bare fiber delivery system. The effect on deep components is optimized without directly contacting the cutaneous or mucosal surfaces to minimize epithelial damage. We applied ILP to the lesion at 30 W in continuous mode (10 seconds) under ultrasound monitoring using an Nd:YAG laser of 1064-nm wavelength. In total, there have been 4 sessions of the same treatment; the lesion was treated with a combined 120 kJ of energy. Satisfactory regression of the huge VM was achieved by this ILP treatment. No significant complications (major bleeding, severe pain, post-perforation skin ulcer, and scar contraction) occurred during the treatment. ILP has been indicated for only sclerotherapy-resistant cases until now, but we suggest that it is a potentially safe and minimally-invasive resolution of VM without scarring or loss of normal shape, sensory feel, or function. ILP appears to be a safe and minimally-invasive resolution of VM. We propose that this technique could become a first-choice treatment modality for VM.

[Bilateral Multiple Liver Metastases after Pancreatoduodenectomy for a Duodenal Neuroendocrine Tumor-A Case Report].

The patient was a 79-year-old woman. In January 20XX, upper gastrointestinal endoscopy revealed a duodenal tumor with bleeding and ulceration. This tumor was diagnosed as a duodenal neuroendocrine tumor(NET)based on biopsy findings. In March 20XX, the patient underwent pancreatoduodenectomy with lymph node dissemination. Based on these pathological findings, the tumor was diagnosed as a duodenal NET(G2)with a lymph node metastasis(T2, N1, M0, Stage Ⅲ). Twenty months after the operation, abdominal CT revealed multiple liver metastases(S4, S7, and S8). After this recurrence, she underwent the subcutaneous somatostatin analogue injection therapy every 28 days, and transarterial chemoembolization( TACE)when these recurrent tumors showed remarkable regrowth, once a year, accounting for her age. She has maintained good disease control for 5 years.