Treatment Effectiveness and Recurrence of Extracranial Arteriovenous Malformations Following Surgical Operations: A 15-Year Retrospective Cohort Study.

BACKGROUND: At present, there is no golden standard for treatment of extracranial arteriovenous malformations (AVMs) and recurrence remains a major challenge with limited available evidence on the associated factors. This study aimed to evaluate the effectiveness of surgical treatment options, in terms of size reduction, symptoms, and early recurrence in patients treated surgically for AVMs. METHODS: A retrospective cohort study was conducted to evaluate patients with AVMs following surgical treatment in 2 centers from 2005 to 2020. Posttreatment lesion size and symptoms, as well as recurrence, were assessed. Multiple regression analysis was performed to identify factors associated with recurrence. RESULTS: Forty-four surgical treatment cases in 31 patients were assessed with a mean follow-up duration period of 67.9 ± 39.5 months. Treatment included total resection in 26 cases (59.1%) and partial resection 18 (40.9%), with free flap coverage used in 19 cases (43.2%). No acute exacerbation following treatment was observed in our cohort. Total resection significantly reduced posttreatment lesion size ( P < 0.001), symptoms ( P < 0.001), and recurrence (20.0%, P = 0.03). The recurrence rate was significantly higher after partial resection (73.7%, P = 0.03). Total resection was identified as an associated factor for significantly reduced AVM recurrence (odds ratio: 0.12; 95% confidence interval: 0.03, 0.52). However, the use of free flaps did not significantly reduce recurrence, post treatment size or improve AVM symptoms. CONCLUSIONS: Total resection is the optimal treatment for AVMs. Free flaps are useful in covering large defects but the regulative effect of free flap remains controversial.

Optimizing Excitation Light for Accurate Rapid Bacterial Species Identification with Autofluorescence.

Rapid identification of bacterial species in patient samples is essential for the treatment of infectious diseases and the economics of health care. In this study, we investigated an algorithm to improve the accuracy of bacterial species identification with fluorescence spectroscopy based on autofluorescence from bacteria, and excitation wavelengths suitable for identification. The diagnostic accuracy of each algorithm for ten bacterial species was verified in a machine learning classifier algorithm. The three machine learning algorithms with the highest diagnostic accuracy, extra tree (ET), logistic regression (LR), and multilayer perceptron (MLP), were used to determine the number and wavelength of excitation wavelengths suitable for the diagnosis of bacterial species. The key excitation wavelengths for the diagnosis of bacterial species were 280 nm, 300 nm, 380 nm, and 480 nm, with 280 nm being the most important. The median diagnostic accuracy was equivalent to that of 200 excitation wavelengths when two excitation wavelengths were used for ET and LR, and three excitation wavelengths for MLP. These results demonstrate that there is an optimum wavelength range of excitation wavelengths required for spectroscopic measurement of bacterial autofluorescence for bacterial species identification, and that measurement of only a few wavelengths in this range is sufficient to achieve sufficient accuracy for diagnosis of bacterial species.

Stair-Step Incision for Composite Grafts in Nasal Reconstruction.

Composite grafts are excellent options for treating external nasal deformities because they provide support and include the skin, which improves the delicate anatomy of the nose. However, they are constrained by size limits since the grafts rely on blood flow to the nasal bed. This is a critical issue when the recipient sites have scarring or degenerative diseases. A novel stair-step incision was made to produce a graft bed with a blood supply and to maximize the use of nonvascularized composite grafts. Instead of making a full-thickness defect through the skin envelope and lining, we placed individual incisions and connected them via a subcutaneous dissection. By dividing the defect into 2 layers, the graft bed was produced and the risk of fistula was reduced. From 2009 to 2020, we satisfactorily conducted 3 cases of nasal reconstruction with a stair-step incision followed by a composite tissue graft. One patient was a girl, and 2 were men. Their ages ranged from 11 to 44 years. The largest graft was 24 × 24 mm in size. No complications were observed. The stair-step incision method for nasal reconstruction can eliminate the limitations of composite grafts and maximize improvements through a simple procedure. This makes composite grafts safer in cases with poor vascularity, enables larger composite grafts to survive, and lowers the risk of fistula formation by avoiding full-thickness defects.

Safety of SARS-CoV-2 Vaccination in Patients with Vascular Malformations: Patient-Reported Adverse Vaccine Reactions.

Objectives: Concerns among susceptible individuals, especially those with vascular malformations, have been raised by reports of thromboembolism following the administration of the SARS-CoV-2 vaccination against coronavirus disease 2019 (COVID-19). This study's goal was to assess any negative side effects that patients with vascular malformations who received the SARS-CoV-2 vaccine reported after receiving it. Materials and Methods: Through the three patient groups for vascular malformations in Japan in November 2021, a questionnaire was distributed to patients with vascular malformations who were 12 years of age or older. Multiple regression analysis was used to find relevant variables. Results: A total of 128 patients responded, representing a response rate of 58.8%. Ninety-six participants (75.0%) had received at least one dose of SARS-CoV-2 vaccine. In total, 84 (87.5%) and 84 (89.4%) subjects experienced at least 1 general adverse response following dose 1 and dose 2, respectively. Adverse reactions related to vascular malformations were reported by 15 participants (16.0%) after the 1st dose and 17 (17.7%) after the 2nd dose. Notably, no case of thromboembolism following vaccination was reported. Conclusion: The rate of vaccine-related adverse reactions in patients with vascular malformations is not different from that reported in the general population. There is no report of life-threatening responses in the research population.

In situ-formable, dynamic crosslinked poly(ethylene glycol) carrier for localized adeno-associated virus infection and reduced off-target effects.

The adeno-associated virus (AAV) is a potent vector for in vivo gene transduction and local therapeutic applications of AAVs, such as for skin ulcers, are expected. Localization of gene expression is important for the safety and efficiency of genetic therapies. We hypothesized that gene expression could be localized by designing biomaterials using poly(ethylene glycol) (PEG) as a carrier. Here we show one of the designed PEG carriers effectively localized gene expression on the ulcer surface and reduced off-target effects in the deep skin layer and the liver, as a representative organ to assess distant off-target effects, using a mouse skin ulcer model. The dissolution dynamics resulted in localization of the AAV gene transduction. The designed PEG carrier may be useful for in vivo gene therapies using AAVs, especially for localized expression.

Molecular Weight-Dependent Diffusion, Biodistribution, and Clearance Behavior of Tetra-Armed Poly(ethylene glycol) Subcutaneously Injected into the Back of Mice.

Four-armed poly(ethylene glycol) (PEG)s are essential hydrophilic polymers extensively utilized to prepare PEG hydrogels, which are valuable tissue scaffolds. When hydrogels are used in vivo, they eventually dissociate due to cleavage of the backbone structure. When the cleavage occurs at the cross-linking point, the hydrogel elutes as an original polymer unit, i.e., four-armed PEG. Although four-armed PEGs have been utilized as subcutaneously implanted biomaterials, the diffusion, biodistribution, and clearance behavior of four-armed PEG from the skin are not fully understood. This paper investigates time-wise diffusion from the skin, biodistribution to distant organs, and clearance of fluorescence-labeled four-armed PEGs with molecular weight (Mw) ranging from 5-40 kg/mol subcutaneously injected into the back of mice. Changes over time indicated that the fate of subcutaneously injected PEGs is Mw-dependent. Four-armed PEGs with Mw ≤ 10 kg/mol gradually diffused to deep adipose tissue beneath the injection site and distributed dominantly to distant organs, such as the kidney. PEGs with Mw ≥ 20 kg/mol stagnated in the skin and deep adipose tissue and were mainly delivered to the heart, lung, and liver. The fundamental understanding of the Mw-dependent behavior of four-armed PEGs is beneficial for preparing biomaterials using PEGs, providing a reference in the field of tissue engineering.

Transgenerational inheritance of acquired epigenetic signatures at CpG islands in mice.

Transgenerational epigenetic inheritance in mammals remains a debated subject. Here, we demonstrate that DNA methylation of promoter-associated CpG islands (CGIs) can be transmitted from parents to their offspring in mice. We generated DNA methylation-edited mouse embryonic stem cells (ESCs), in which CGIs of two metabolism-related genes, the Ankyrin repeat domain 26 and the low-density lipoprotein receptor, were specifically methylated and silenced. DNA methylation-edited mice generated by microinjection of the methylated ESCs exhibited abnormal metabolic phenotypes. Acquired methylation of the targeted CGI and the phenotypic traits were maintained and transmitted across multiple generations. The heritable CGI methylation was subjected to reprogramming in parental PGCs and subsequently reestablished in the next generation at post-implantation stages. These observations provide a concrete step toward demonstrating transgenerational epigenetic inheritance in mammals, which may have implications in our understanding of evolutionary biology as well as the etiology, diagnosis, and prevention of non-genetically inherited human diseases.

Somatic GJA4 gain-of-function mutation in orbital cavernous venous malformations.

Orbital cavernous venous malformation (OCVM) is a sporadic vascular anomaly of uncertain etiology characterized by abnormally dilated vascular channels. Here, we identify a somatic missense mutation, c.121G > T (p.Gly41Cys) in GJA4, which encodes a transmembrane protein that is a component of gap junctions and hemichannels in the vascular system, in OCVM tissues from 25/26 (96.2%) individuals with OCVM. GJA4 expression was detected in OCVM tissue including endothelial cells and the stroma, through immunohistochemistry. Within OCVM tissue, the mutation allele frequency was higher in endothelial cell-enriched fractions obtained using magnetic-activated cell sorting. Whole-cell voltage clamp analysis in Xenopus oocytes revealed that GJA4 c.121G > T (p.Gly41Cys) is a gain-of-function mutation that leads to the formation of a hyperactive hemichannel. Overexpression of the mutant protein in human umbilical vein endothelial cells led to a loss of cellular integrity, which was rescued by carbenoxolone, a non-specific gap junction/hemichannel inhibitor. Our data suggest that GJA4 c.121G > T (p.Gly41Cys) is a potential driver gene mutation for OCVM. We propose that hyperactive hemichannel plays a role in the development of this vascular phenotype.

Wearable, wireless, multi-sensor device for monitoring tissue circulation after free-tissue transplantation: a multicentre clinical trial.

Wearable sensors have seen remarkable recent technological developments, and their role in healthcare is expected to expand. Specifically, monitoring tissue circulation in patients who have undergone reconstructive surgery is critical because blood flow deficiencies must be rescued within hours or the transplant will fail due to thrombosis/haematoma within the artery or vein. We design a wearable, wireless, continuous, multipoint sensor to monitor tissue circulation. The system measures pulse waves, skin colour, and tissue temperature to reproduce physician assessment. Data are analysed in real time for patient risk using an algorithm. This multicentre clinical trial involved 73 patients who underwent transplant surgery and had their tissue circulation monitored until postoperative day 7. Herein, we show that the overall agreement rate between physician and sensor findings is 99.2%. In addition, the patient questionnaire results indicate that the device is easy to wear. The sensor demonstrates non-invasive, real-time, continuous, multi-point, wireless, and reliable monitoring for postoperative care. This wearable system can improve the success rate of reconstructive surgeries.

Microsurgical Lymphovenous Anastomosis for Pelvic Lymphoceles after Gynecological Cancer Surgery.

BACKGROUND: Pelvic lymphoceles are the most common complications after pelvic lymphadenectomy. Microsurgical procedures have attracted attention as an alternative treatment for lymphoceles. Here, we report six cases of refractory lymphoceles that were successfully treated using lymphovenous anastomosis (LVA). METHODS: Six patients underwent surgery for gynecological cancers and developed pelvic lymphoceles, which did not respond to conventional treatment. We mainly performed LVA on the ipsilateral lower limbs, although some procedures were also performed on the contralateral limbs. The change in the lymphocele volume after LVA was examined using computed tomography and compared using the Wilcoxon test. RESULTS: Five of the six refractory lymphocele cases were successfully treated using LVA, and the remaining case exhibited an 87% reduction in lymphocele volume. The average numbers of anastomoses were 6.7 on the ipsilateral side and 2.8 on the contralateral side (the median numbers: 6 [range: 5-9] vs. 3 [range: 1-4], P = 0.034). The average lymphocele volume decreased significantly from 414.0 mL preoperatively to 8.0 mL postoperatively (the median lymphocele volume: 255.8 [range: 61.5-1,329.2] vs. 0 [range: 0-47.7], P = 0.0313). CONCLUSION: We found that microsurgical treatment was potentially effective for lymphoceles that did not respond to conventional treatment.

Establishing a Lymphatic Venous Anastomotic Training Model in Pig Trotters.

BACKGROUND: Lymphatic venous anastomosis (LVA) is a widely accepted surgical procedure for lymphedema. To obtain the best outcomes, surgeons should be well trained. A recent study introduced an LVA training model using pig trotters for their utility and structural similarity to human tissues. However, details regarding the utilization of anastomosis models, such as feasible points for training based on vessel anatomy, have not been clarified. Therefore, we assessed the anatomical details of lymphatic vessels and veins of trotters to establish a practical training model of LVA. METHODS: Ten frozen trotters were used. After thawing at room temperature, indocyanine green fluorescent lymphography was used to visualize the lymphatic course. To dissect the lymphatic vessels and veins from the distal to the proximal end, whole skins were detached thoroughly from the plantar side. Data from the lymphatic vessels and veins were collected based on their courses, diameters, and layouts to clarify adjacent points feasible for LVA training. RESULTS: Both lymphatic vessels and veins were classified into four major courses: dorsal, medial, lateral, and plantar. The majority were dorsal vessels, both lymphatic vessels and veins. The adjacent points were always found in the distal dorsum center and were especially concentrated between the metacarpophalangeal (MP) joint and central interphalangeal crease, followed by the medial and lateral sides. CONCLUSION: The most relevant point for LVA surgical training in the trotter was the dorsal center distal to the MP joint, where parallel vessels of similar sizes were found in all cases. This practical LVA surgical model would improve surgeon skills in not only anastomosis but also preoperative fluorescent lymphography.

Ultrasound assessment of deep tissue on the wound bed and periwound skin: A classification system using ultrasound images.

AIMS: Given the utility of ultrasonography in assessing pressure injury, some ultrasonographic findings have already been used as indicators of deep tissue pressure injury. Despite reports showing that a cloud-like ultrasonographic pattern reflected the presence of deep tissue necrosis, identifying cloud-like patterns was difficult given the presence of similar findings, such as a cobblestone-like pattern. This case series reports patients with pressure injuries who presented with a cloud-like (five cases) and cobblestone-like (four cases) pattern during ultrasonography. METHODS: This study was conducted at a Japanese university hospital. Participants included patients who underwent routine examination by an interdisciplinary pressure injury team. Pressure injury severity was assessed using the DESIGN-R® scoring system and the wound size were measured using ImageJ software based on the wound photograph. RESULTS: Among the five cases showing a cloud-like pattern upon ultrasonography, all exhibited an increase in the total DESIGN-R® score, while three exhibited an increase in wound size. On the other hand, all four cases showing a cobblestone-like pattern displayed no increase in the total DESIGN-R® score and a decrease in wound size. CONCLUSION: This study suggested that distinguishing between cloud-like and cobblestone-like ultrasonography patterns is necessary for determining the presence or absence of deep tissue pressure injury. In order to comprehensively assess pressure injuries with ultrasonography, future studies should be conducted in a large number of participants.

Reconstruction for Severe Extracorporeal Membrane Oxygenation-induced Ischemic Lower Limb Injury Complicated by Osteomyelitis.

Extracorporeal membrane oxygenation (ECMO) is a well-established mechanical circulatory support system used in patients with life-threatening cardiopulmonary conditions. However, severe complications associated with vascular access require consideration. We report a patient with fatal ventricular arrhythmia who was successfully resuscitated with ECMO but who developed severe lower limb ischemia, which resulted in compartment syndrome. Even with emergent fasciotomy, tissue necrosis developed in wide areas of the limb, with subsequent tibial osteomyelitis. After extensive debridement and tibial sequestrectomy, the soft tissue and bone defect were simultaneously reconstructed with free tissue transfer of the latissimus dorsi muscle and scapular tip composite flap. The limb was successfully salvaged with satisfactory functional outcomes without major complications. This report discusses limb reconstruction for ECMO-induced compartment syndrome and illustrates the importance of appropriate selection of reconstruction methods among various composite flaps.