Association between Hospital-acquired Disability and Clinical Outcomes in Older Patients Who Underwent Cardiac Surgical.

OBJECTIVE: This study aimed to clarify the association between hospital-acquired disability (HAD) and prognosis in older patients who underwent cardiac surgery. METHODS: This single-center, retrospective, observational study included 141 patients aged ≥65 years who underwent cardiac surgery at our hospital from November 2016 to August 2021. The primary endpoint of this study was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs) within 2 years of hospital discharge. HAD was defined as a score of ≤5 on any one of the functional independence measure (FIM) subitems at discharge compared to preoperatively. RESULTS: MACCE was observed in 16.3%, and the incidence of MACCE was significantly higher in the HAD group than that in the non-HAD group (12.1 vs. 34.5%, log-rank, p = 0.003). HAD was also significantly associated with the MACCE (hazard ratio [HD]: 2.575, 95% confidence interval [CI]: 1.001-9.655, p = 0.046). The incidence rate of HAD was 20.6%, with age (odds ratio [OR]: 1.260, 95% CI: 1.080-1.470, p = 0.004), preoperative short physical performance battery (SPPB) score (OR: 0.462, 95% CI: 0.301-0.708, p <0.001), and postoperative delirium (OR: 6.660, 95% CI: 1.480-30.000, p = 0.014) identified as significant factors. CONCLUSION: HAD is an independent predictor of MACCE in older patients who underwent cardiac surgery.

Stent assisted coil embolization for a dissecting cerebral aneurysm of middle cerebral artery: A case report and the literature review.

Background: Dissecting aneurysms of the middle cerebral artery (MCA) are very rare. We herein report a case of an unruptured dissecting aneurysm of the MCA treated by stent-assisted coil embolization. Case Description: A 65-year-old man with no history of trauma presented with a headache. Time-of-flight imaging revealed a dissecting cerebral aneurysm in the right M1 segment of the MCA, and the aneurysm had increased in size within a short time. We treated the aneurysm by endovascular stenting with coils, and the patient developed no neurological deficits. Conclusion: Because of the potential involvement of the lenticulostriate artery (LSA) in the area of dissection, choosing the best treatment (such as direct surgery or endovascular treatment) may be challenging. Treatment efficacy depends on whether the LSA is affected and on the length of the dissection. In our case, the dissection did not involve the LSA and could therefore be treated by stent-assisted coil embolization.

Durability of Bioprosthetic Valves in Patients on Dialysis.

PURPOSE: This study focused on clarifying the durability of bioprosthetic valves in current practice. METHODS: A total of 238 consecutive patients who underwent aortic valve replacement at a single institution from 2011 to 2020 were reviewed. We evaluated valve-related outcomes such as structural valve deterioration (SVD), especially in dialysis patients who received bioprosthetic valve. RESULTS: Among the tissue valves implanted in 212 patients, 5 SVDs were recorded and 3 valves were replaced. All early valve failures occurred in relatively young dialysis patients and were recorded 3 to 5 years after the initial operation. Freedom from SVD at 6 years was 49.9% in patients on dialysis, compared with 100% in non-dialysis patients. Predictors of better survival in dialysis patients were better preoperative functional class and larger prosthetic valve size. CONCLUSIONS: The durability of bioprosthetic valves in the aortic position was suboptimal in dialysis patients. Mechanical valves can be an option for young, healthy dialysis patients with a large aortic valve annulus.

Endovascular Internal Trapping by Low-Concentration N-butyl-2-Cyanoacrylate for a Ruptured Giant Common Carotid Artery Pseudoaneurysm.

Treating carotid blowout syndrome following rupture of giant pseudoaneurysms is difficult because the destroyed parent artery precludes conventional treatment. We present a patient with a ruptured giant pseudoaneurysm that we occluded using a modified internal trapping technique with low-concentration N-butyl-2-cyanoacrylate (NBCA) and a minimum number of coils. An 80-year-old man with a history of chemoradiation therapy for oropharyngeal cancer presented with several episodes of active bleeding from the subsequent tracheostomy site. Radiological examination revealed a giant right common carotid artery (CCA) pseudoaneurysm. Endovascular internal trapping was performed using both NBCA and coils under proximal flow control. We slowly injected 9 ml of low-concentration NBCA, which subsequently filled the entire pseudoaneurysm. We then injected an additional 2 ml of NBCA into the proximal CCA to achieve complete obliteration. No re-bleeding was observed during the 6-month follow-up. Endovascular internal trapping using low-concentration NBCA was feasible to treat a giant CCA pseudoaneurysm. The injected low-concentration NBCA filled the entire pseudoaneurysm without the risk of catheter entrapment.

Mural vegetation in left ventricular apex caused by Staphylococcus aureus.

A 77-year-old male on chronic haemodialysis was admitted for repeated episodes of stroke and a high fever. The patient's blood culture was positive for Staphylococcus aureus and echocardiogram results revealed moderate mitral valve regurgitation, small masses in the left atrial appendage and a 20-mm mobile, spherical structure attached to the apical cavity of the left ventricle. Surgery was conducted to successfully excise these masses and pathological investigation confirmed the diagnosis of infective endocarditis. The attachment of mobile, spherical vegetation to the apex of the left ventricle is a rare manifestation of infective endocarditis.

Delayed Rebleeding from Pseudoaneurysm After Mechanical Thrombectomy Using Stent Retriever Due to Small Artery Avulsion Confirmed by Open Surgery.

BACKGROUND: Pseudoaneurysm after mechanical thrombectomy (MT) is rare but is one of the potential complications associated with endovascular procedures. There is limited information regarding its mechanism of formation and the potential risk of delayed bleeding. CASE DESCRIPTION: An 84-year-old woman was admitted to our institution with right hemiplegia and global aphasia. Magnetic resonance imaging and angiography revealed occlusion of the M2 segment of the left middle cerebral artery with subtle acute ischemic change in this territory. After initiating intravenous thrombolysis, MT was performed for persistent occlusion of the M2. Successful revascularization was finally achieved with a single pass of a Trevo XP 3 mm × 20 mm stent retriever; significant deviation of the vessel occurred during withdrawal of the stent retriever. Anticoagulation was initiated after confirming resolution of a small amount of postprocedural subarachnoid hemorrhage 1 day after the procedure. However, 4 days after the procedure, computed tomography and angiography revealed a massive sylvian hematoma with de novo formation of a small pseudoaneurysm at the site where the stent retriever was deployed. Open surgery revealed a small artery avulsion at this site. The lesion was closed by microsurgical suturing. CONCLUSIONS: Angiographic and intraoperative findings showed that the mechanism of formation of the pseudoaneurysm was small artery avulsion resulting from deviation of the vessel during withdrawal of the stent retriever. When performing MT in a tortuous distal vessel, the possibility of small artery avulsion should be kept in mind to both prevent and manage critical hemorrhagic complications.

MicroRNA regulating stanniocalcin-1 is a metastasis and dissemination promoting factor in glioblastoma.

BACKGROUND: MicroRNAs (miRs) regulate many biological processes, such as invasion, angiogenesis, and metastasis. Glioblastoma (GBM) patients with metastasis/metastatic dissemination have a very poor prognosis; therefore, inhibiting metastasis/metastatic dissemination has become an important therapeutic strategy for GBM treatment. METHODS: Using 76 GBM tissues, we examined the expression levels of 23 GBM-related miRs and compared the miRs' expression levels between GBMs with metastasis/metastatic dissemination and GBMs without metastasis/metastatic dissemination. Using the bioinformatics web site, we searched the target genes of miRs. To analyze the function of target gene, several biological assays and survival analysis by the Kaplan-Meier method were performed. RESULTS: We found that eight miRs were significantly decreased in GBM with metastasis/metastatic dissemination. By the bioinformatics analysis, we identified stanniocalcin-1 (STC1) as the most probable target gene against the combination of these miRs. Four miRs (miR-29B, miR-34a, miR-101, and miR-137) have predictive binding sites in STC1 mRNA, and mRNA expression of STC1 was downregulated by mimics of these miRs. Also, mimics of these miRs and knockdown of STC1 by siRNA suppressed invasion in GBM cells. GBM with metastasis/metastatic dissemination had significantly higher levels of STC1 than GBM without metastasis/metastatic dissemination. Finally, Kaplan-Meier analysis demonstrated that GBMs with high STC1 level had significantly shorter survival than GBMs with low STC1 level. CONCLUSIONS: STC1 may be a novel metastasis/metastatic dissemination promoting factor regulated by several miRs in GBM. Because STC1 is a secreted glycoprotein and functions via the autocrine/paracrine signals, inhibiting STC1 signal may become a novel therapeutic strategy for GBM.

Dependence of volume dose indices on dose calculation algorithms for VMAT-SBRT plans for peripheral lung tumor.

The purpose of this study was to investigate the dependence of volume dose indices on dose calculation algorithms for volumetric modulated arc therapy (VMAT) for stereotactic body radiotherapy (SBRT) plans to treat peripheral lung tumors by comparing them with those of Monte Carlo (MC) calculations. VMAT-SBRT plans for peripheral lung tumors were created using the Eclipse treatment planning system (TPS) for 24 patients with nonsmall cell lung cancer. VMAT dose distributions for gross tumor volume (GTV), internal target volume (ITV), and planning target volume (PTV) were calculated using the analytical anisotropic algorithm (AAA), the Acuros XB (AXB) algorithm, and a MC algorithm. VMAT dose distributions of the 3 algorithms were compared using their volume dose indices from dose volume histograms (DVHs), a dose difference map, and 3-dimensional gamma analysis. The DVHs for GTV and ITV from AAA, AXB, and MC were in good agreement. The difference between the ITV and PTV volume dose indices from AAA and MC increased as D98, D95, D80, D50, and D2. In particular, the difference between D98 for PTV from AAA and MC was up to 48%. A >5% difference between D95 for PTV from AAA and MC was 11 patients, but only 2 patients for ITV. The volume dose indices for AXB were near those of MC. AAA tended to overestimate the PTV volume dose indices compared to AXB and MC. Thus, we propose that the volume dose indices for the ITV be used because they are independent of dose calculation algorithms.

Early surgery with aggressive surgical approach to improve 6-month outcomes in patients with active infective endocarditis: contribution of cerebral preoperative magnetic resonance imaging.

OBJECTIVES: We investigated the hypothesis that early surgery for infective endocarditis (IE) attenuates the rate of death or embolic events and does not increase the rate of relapse or postoperative valvular dysfunction (PVD) at 6 months. METHODS: 21 consecutive patients who underwent surgical treatment of IE were prospectively included. We assessed 6-month postoperative clinical outcomes by comparing early surgery (Group E, surgery within 72 h) and conventional treatment (Group C). Nine patients (43%) were assigned to Group E based on a combination of preoperative evaluation parameters, including the findings of cerebral magnetic resonance imaging (MRI), which was performed in all patients with left-sided IE. RESULTS: Six surgical plans (5 advancements and 1 postponement) were modified by routine MRI. Although preoperative echocardiography did not confirm all annular invasions, the rate of periannular infection, which was treated by pericardial annular patch plasty (56%) in patients with native-valve IE, was higher in Group E than C (P = 0.006). Early surgery based on MRI findings resulted in no postoperative embolic events or cerebral bleeding. The 6-month mortality rate was 0% in both groups, although the calculated 6-month IE mortality rate was 49.2 ± 25% and 28.8 ± 18%, respectively. No recurrence of IE or PVD occurred in Group E. The 6-month rate of freedom from composite events was 100% in Group E. CONCLUSIONS: Aggressive treatment (periannular resection and disuse of a prosthetic annuloplasty ring) and optimal antibiotic therapy based on intraoperative microorganisms, even in patients who underwent early surgery, reduced the 6-month relapse and PVD rates.

Stent Expansion and In-Stent Thrombus Sign in the Trevo Stent Retriever Predict Recanalization and Possible Etiology During Mechanical Thrombectomy: A Case Series of 50 Patients with Acute Middle Cerebral Artery Occlusion.

BACKGROUND: Interaction between the stent retriever and clot is a key factor for recanalization during mechanical thrombectomy. The aim of this study was to evaluate the association between radiographically apparent features during thrombectomy and angiographic outcomes using the Trevo stent retriever with a fully radiopaque strut. METHODS: We retrospectively reviewed 50 patients with acute middle cerebral artery occlusion who were treated with the Trevo. Patients were divided into groups that achieved (first-pass recanalization group, n = 21) or did not achieve (non-first-pass recanalization group, n = 29) a modified Thrombolysis in Cerebral Ischemia score of 2b or 3 with the first-pass procedure. Patients were also divided into a thromboembolic (n = 39) and atherosclerotic (n = 11) group by occlusion etiology. We evaluated radiographic findings of the Trevo's strut (e.g., degree of stent expansion and filling defect of the thrombus in the strut [in-stent thrombus sign]) during the first-pass procedure. RESULTS: Median stent expansion was significantly greater in the first-pass recanalization group than in the non-first-pass recanalization group (60% vs. 34%; P < 0.01) and in the thromboembolic group than in the atherosclerotic group (45% vs. 31%; P < 0.01). The receiver operator characteristic curve showed moderate capacity for prediction of recanalization and etiology, with an area under the curve of 0.83 and 0.73, respectively. In-stent thrombus sign was significantly more common in the thromboembolic group than in the atherosclerotic group (86% vs. 10%; P < 0.01). CONCLUSIONS: Greater stent expansion was associated with recanalization after thrombectomy. The in-stent thrombus sign may be useful for etiology prediction. These radiographic findings could provide useful real-time feedback during procedures, reflecting clot-stent interaction.

Myo-inositol concentration in MR spectroscopy for differentiating high grade glioma from primary central nervous system lymphoma.

It is sometimes difficult to distinguish gliomas from other tumors on routine imaging. In this study, we assessed whether 3-T magnetic resonance spectroscopy (MRS) with LCModel software might be useful for discriminating glioma from other brain tumors, such as primary central nervous system lymphomas (PCNSLs) and metastatic tumors. A total of 104 cases of brain tumor (66 gliomas, 20 PCNSLs, 6 metastatic tumors, 12 other tumors) were preoperatively investigated with short echo time (35 ms) single-voxel 3-T MRS. LCModel software was used to evaluate differences in the absolute concentrations of choline, N-acetylaspartate, N-acetylaspartylglutamate, glutamate + glutamine, myo-inositol (mIns), and lipid. mIns levels were significantly increased in high-grade glioma (HGG) compared with PCNSL (p < 0.001). In multivariate logistic regression analysis, mIns was the best marker for differentiating HGG from PCNSL (p < 0.0001, odds ratio 1.9927, 95% confidence interval 1.3628-3.2637). Conventional MRS detection of mIns resulted in a high diagnostic accuracy (sensitivity, 64%; specificity, 90%; area under the receiver operator curve, 0.80) for HGG. The expression of inositol 3-phosphate synthase (ISYNA1) was significantly higher in gliomas than in PCNSLs (p < 0.05), suggesting that the increased level of mIns in glioma is due to high expression of ISYNA1, the rate-limiting enzyme in the mIns-producing pathway. In conclusion, noninvasive analysis of mIns using single-voxel MRS may be useful in distinguishing gliomas from other brain tumors, particularly PCNSLs.

Diagnostic value of glutamate with 2-hydroxyglutarate in magnetic resonance spectroscopy for IDH1 mutant glioma.

BACKGROUND: Mutations in the isocitrate dehydrogenase 1 (IDH1) gene that are frequently observed in low-grade glioma are strongly associated with the accumulation of 2-hydroxyglutarate (2HG), which is a valuable diagnostic and prognostic biomarker of IDH1 mutant glioma. However, conventional MR spectroscopy (MRS)-based noninvasive detection of 2HG is challenging. In this study, we aimed to determine the additional value of other metabolites in predicting IDH1 mutations with conventional MRS. METHODS: Forty-seven patients with glioma underwent conventional single voxel short echo time MRS prior to surgery. A stereotactic navigation-guided operation was performed to resect tumor tissues in the center of the MRS voxel. MRS-based measurements of metabolites were validated with gas chromatography-mass spectrometry. We also conducted integrated analyses of glioma cell lines and clinical samples to examine the other metabolite levels and molecular findings in IDH1 mutant gliomas. RESULTS: A metabolomic analysis demonstrated higher levels of 2HG in IDH1 mutant glioma cells and surgical tissues. Interestingly, glutamate levels were significantly decreased in IDH1 mutant gliomas. Through an analysis of metabolic enzyme genes in glutamine pathways, it was shown that the expressions of branched-chain amino acid transaminase 1 were reduced and glutamate dehydrogenase levels were elevated in IDH1 mutant gliomas. Conventional MRS detection of glutamate and 2HG resulted in a high diagnostic accuracy (sensitivity 72%, specificity 96%) for IDH1 mutant glioma. CONCLUSIONS: IDH1 mutations alter glutamate metabolism. Combining glutamate levels optimizes the 2HG-based monitoring of IDH1 mutations via MRS and represents a reliable clinical application for diagnosing IDH1 mutant gliomas.

[Intraoperative Aortic Dissection].

A 69-year-old man underwent mitral valve replacement for suspected infective endocarditis and coronary artery bypass grafting with left internal thoracic artery and saphenous vein graft. During the period of coming off cardiopulmonary bypass, enlargement of the ascending aorta and bleeding from the suture line were observed. Intraoperative transesophageal echocardiography and direct epi-aortic echography revealed acute aortic dissection extending from the ascending aorta to the descending aorta. Replacement of the ascending aorta was performed under deep hypothermic circulatory arrest and continuous retrograde cerebral perfusion through the superior vena cava. The postoperative course was uneventful and he was discharged on postoperative day 41. Aortic dissection during cardiac operation is a rare but serious complication. Prompt recognition and appropriate surgical management are necessary to improve patient outcome.

Accuracy of positioning and irradiation targeting for multiple targets in intracranial image-guided radiation therapy: a phantom study.

This study investigated the accuracy of positioning and irradiation targeting for multiple off-isocenter targets in intracranial image-guided radiation therapy (IGRT). A phantom with nine circular targets was created to evaluate both accuracies. First, the central point of the isocenter target was positioned with a combination of an ExacTrac x-ray (ETX) and a 6D couch. The positioning accuracy was determined from the deviations of coordinates of the central point in each target obtained from the kV-cone beam computed tomography (kV-CBCT) for IGRT and the planning CT. Similarly, the irradiation targeting accuracy was evaluated from the deviations of the coordinates between the central point of each target and the central point of each multi-leaf collimator (MLC) field for multiple targets. Secondly, the 6D couch was intentionally rotated together with both roll and pitch angles of 0.5° and 1° at the isocenter and similarly the deviations were evaluated. The positioning accuracy for all targets was less than 1 mm after 6D positioning corrections. The irradiation targeting accuracy was up to 1.3 mm in the anteroposterior (AP) direction for a target 87 mm away from isocenter. For the 6D couch rotations with both roll and pitch angles of 0.5° and 1°, the positioning accuracy was up to 1.0 mm and 2.3 mm in the AP direction for the target 87 mm away from the isocenter, respectively. The irradiation targeting accuracy was up to 2.1 mm and 2.6 mm in the AP direction for the target 87 mm away from the isocenter, respectively. The off-isocenter irradiation targeting accuracy became worse than the positioning accuracy. Both off-isocenter accuracies worsened in proportion to rotation angles and the distance from the isocenter to the targets. It is necessary to examine the set-up margin for off-isocenter multiple targets at each institution because irradiation targeting accuracy is peculiar to the linac machine.

[Mitral valve replacement after previous coronary artery bypass grafting with functioning left internal thoracic artery graft: effectiveness of the method using a direct vision retrosternal approach; report of a case].

Performing a redo-sternotomy when a mammary artery graft is patent can be rather difficult. We previously reported a redo-sternotomy technique involving direct visualization with a retrosternal dissection (DR) method using a Kent's retractor. The DR method in detail is as follows: 1) A midline skin incision is extended to the abdomen about 5 cm. 2) The bilateral costal arches are divided from the rectal muscle. 3). A pair of retractors is placed under the costal arch. 4) A stainless steel wire is applied to the previous sternal wire at the center of the sternum. 5) The retractor and sternal wire are lifted up using the Kent's retractor to widen the retrosternal space. 6) The sternum and sub-sternal tissue are carefully divided using an electronic scalpel or metal retractor with an entirely sternal length. 7) Routine sternotomy is performed using a Stryker. Herein, we report a patient who had undergone cardiac surgery, coronary artery bypass grafting (CABG), using a left internal mammary artery and mitral annuloplasty 2 years previously, and then developed mitral regurgitation caused by infectious endocarditis. He successfully underwent redo-sternotomy and mitral valve replacement using the DR method. In a patient with a patent internal mammary artery, the DR method greatly reduces the risk of graft injury.

[Usefulness of the axillary artery perfusion in open heart surgery in a patient with severe ascending aortic calcification].

Because of high-aging Japanese society, high-risk patients with multiple co-morbidities have been increasing in regular open-heart surgery. Especially, extensive aortic atherosclerosis with severe calcification that involves the ascending aorta can complicate the choice of sites of cannulations and aortic cross-clamping for cardiopulmonary bypass. To date, the standard peripheral arterial cannulation site in such cases has been the common femoral artery;however, this approach carries the risk of atheroembolism due to retrograde aortic perfusion, or it is undesirable in case of severe iliofemoral disease. Recently, it has been reported that arterial perfusion through the axillary artery provides sufficient antegrade aortic flow associated with fewer atheroembolic complications. In this paper, we report 3 successful cases of valvular surgeries in which axillary artery cannulation was used to avoid complications of brain. In cases of extensive aortic atherosclerosis with severe calcification, arterial perfusion through the axillary artery is a safe and effective method to provide sufficient arterial inflow during cardiopulmonary bypass, and is an excellent alternative to femoral artery cannulation.

[Dose impact of a carbon fiber couch for stereotactic body radiation therapy of lung tumors].

The aim of this study was to measure the dose attenuation caused by a carbon fiber radiation therapy table (Imaging Couch Top; ICT, BrainLab) and to evaluate the dosimetric impact of ICT during stereotactic body radiation therapy (SBRT) in lung tumors. The dose attenuation of ICT was measured using an ionization chamber and modeled by means of a treatment planning system (TPS). SBRT was planned with and without ICT in a lung tumor phantom and ten cases of clinical lung tumors. The results were analyzed from isocenter doses and a dose-volume histogram (DVH): D95, Dmean, V20, V5, homogeneity index (HI), and conformity index (CI). The dose attenuation of the ICT modeled with TPS agreed to within ±1% of the actually measured values. The isocenter doses, D95 and Dmean with and without ICT showed differences of 4.1-5% for posterior single field and three fields in the phantom study, and differences of 0.6-2.4% for five fields and rotation in the phantom study and six fields in ten clinical cases. The dose impact of ICT was not significant for five or more fields in SBRT. It is thus possible to reduce the dose effect of ICT by modifying the beam angle and beam weight in the treatment plan.

Angular dependence correction of MatriXX and its application to composite dose verification.

We measured the angular dependence of central and off-axis detectors in a 2D ionization chamber array, MatriXX, and applied correction factors (CFs) to improve the accuracy of composite dose verification of IMRT and VMAT. The MatriXX doses were measured with a 10° step for gantry angles (θ) of 0°-180°, and a 1° step for lateral angles of 90°-110° in a phantom, with a 30 × 10 cm2 field for 6 MV and 10 MV photons. The MatriXX doses were also calculated under the same conditions by the Monte Carlo (MC) algorithm. The CFs for the angular dependence of MatriXX were obtained as a function of θ from the ratios of MatriXX-measured doses to MC-calculated doses, and normalized at θ = 0°. The corrected MatriXX were validated with different fields, various simple plans, and clinical treatment plans. The dose distributions were compared with those of MC calculations and film. The absolute doses were also compared with ionization chamber and MC-calculated doses. The angular dependence of MatriXX showed over-responses of up to 6% and 4% at θ = 90° and under-responses of up to 15% and 11% at 92°, and 8% and 5% at 180° for 6 MV and 10 MV photons, respectively. At 92°, the CFs for the off-axis detectors were larger by up to 7% and 6% than those for the central detectors for 6 MV and 10 MV photons, respectively, and were within 2.5% at other gantry angles. For simple plans, MatriXX doses with angular correction were within 2% of those measured with the ionization chamber at the central axis and off-axis. For clinical treatment plans, MatriXX with angular correction agreed well with dose distributions calculated by the treatment planning system (TPS) for gamma evaluation at 3% and 3 mm. The angular dependence corrections of MatriXX were useful in improving the measurement accuracy of composite dose verification of IMRT and VMAT.

A retrospective, longitudinal study to evaluate healing lower extremity wounds in patients with diabetes mellitus and ischemia using standard protocols of care and platelet-rich plasma gel in a Japanese wound care program.

Chronic wounds, especially in patients with diabetes mellitus (DM), are a major health challenge in Japan. The goal of wound care centers (WCCs) in Japan is to facilitate healing and prevent lower extremity amputations (LEAs) using standardized protocols of patient and wound care. The standard treatment algorithm includes a complete patient and wound assessment, history, physical exam, and a variety of diagnostic tests that determine the need for infection control intervention, revascularization, excision and debridement, growth factor/platelet rich plasma (PRP) gel therapy, skin graft/ flap, wound protection, and education. All patient and wound data are entered in a secure central database for all WCCs. To evaluate the outcomes of standard care regimens compared to the use of a topical PRP gel treatment in patients with a variety of complex wounds, a retrospective, longitudinal study was conducted. Wound outcomes from 39 patients with 40 chronic, nonhealing, lower extremity wounds were evaluated between two time periods: between first presentation at the WCC (T1) and after using standard topical treatments (T2) and between T2 and after using the PRP gel treatment (T3). Patient average age was 66.8 years (SD: 10.60) and mean wound duration was 99.7 days before treatment (SD: 107.73); and the majority of patients (85%) had DM. Wounds were classified as ischemic diabetic (n = 24), diabetic (n = 10), ischemic (n = 5), and pressure ulcer (n = 1). DFUs were Wagner III (77%) and lV (23%). Of those, 60% were in patients with arteriosclerotic obliterans (ASO). Infection (abscess, cellulitis, osteomyelitis, and/or gangrene) was present in all wounds and treated using debridement, antibiotic therapy, and surgery as deemed appropriate. During the first treatment period (T1 to T2) of 75.3 days, which included revascularization and/or debridement along with standard of care, none of the wounds healed and the average wound area, depth, and volume increased. Following topical PRP gel treatment, 83% of wounds healed within 145.2 days (T2 to T3) (P = 0.00002). Only one patient required an LEA. The results of this study suggest that good healing outcomes and a low amputation rate can be obtained with a protocol of supportive care (including revascularization procedures) and the PRP gel treatment. Prospective controlled studies comparing the use of this PRP gel to other advanced treatments are warranted.

Effects of combined treatment with porous bovine inorganic bone grafts and bilayer porcine collagen membrane on refractory one-wall intrabony defects.

The aim of this study was to investigate the effects of a combination of porous bovine inorganic bone graft (Bio-Oss) and bilayer porcine collagen membrane (Bio-Gide) on refractory one-wall intrabony defects in dogs. Bio-Oss and Bio-Gide were applied into the refractory one-wall intrabony defect. The contralateral sites were used as controls (without the application of Bio-Oss and Bio-Gide). At 24 weeks after surgery, similar pocket depths were found in both groups. However, histologic observation revealed an infiltration of inflammatory cells in the control group caused by poor gingival architecture, whereas only a few of the experimental sites showed inflammatory infiltration. In addition to the healthy gingival tissue, periodontal tissue regeneration was observed in the experimental group. The combination of Bio-Oss and Bio-Gide was an effective treatment for refractory one-wall intrabony defects in dogs.