Preoperative photoacoustic versus indocyanine green lymphography in lymphaticovenular anastomosis outcomes for lower extremity lymphedema: A pilot study.

BACKGROUND: Identification of the proper lymphatics is important for successful lymphaticovenular anastomosis (LVA) for lymphedema; however, visualization of lymphatic vessels is challenging. Photoacoustic lymphangiography (PAL) can help visualize lymphatics more clearly than other modalities. Therefore, we investigated the usefulness of PAL and determined whether the clear and three-dimensional image of PAL affects LVA outcomes. METHODS: We recruited 22 female patients with lower extremity lymphedema. The operative time, number of incisions, number of anastomoses, lymphatic vessel detection rate (number of functional lymphatics identified during the operation/number of incisions), and limb volume changes preoperatively and 3 months postoperatively were compared retrospectively. The patients were divided according to whether PAL was performed or not, and results were compared between those undergoing PAL (PAL group; n = 10) and those who did not (near-infrared fluorescence [NIRF] group, n = 12). RESULTS: The mean age of the patients was 55.9 ± 15.1 years in the PAL group and 50.7 ± 14.9 years in the NIRF group. One patient in the PAL group and three in the NIRF group had primary lymphedema. Eighteen patients (PAL group, nine; and NIRF group, nine) had secondary lymphedema. Based on preoperative evaluation using the International Society of Lymphology (ISL) classification, eight patients were determined to be in stage 2 and two patients in late stage 2 in the PAL group. In contrast, in the NIRF group, one patient was determined to be in stage 0, three patients each in stage 1 and stage 2, and five patients in late stage 2. Lymphatic vessel detection rates were 93% (42 LVAs and 45 incisions) and 83% (50 LVAs and 60 incisions) in the groups with and without PAL, respectively (p = 0.42). Limb volume change was evaluated in five limbs of four patients and in seven limbs of five patients in the PAL and NIRF groups as 336.6 ± 203.6 mL (5.90% ± 3.27%) and 52.9 ± 260.7 mL (0.71% ± 4.27%), respectively. The PAL group showed a significant volume reduction. (p = .038). CONCLUSIONS: Detection of functional lymphatic vessels on PAL is useful for treating LVA.

The acute effect of roller massager on knee joint range of motion and muscle pain in older adults with total knee arthroplasty.

OBJECTIVES: Older adults with total knee arthroplasty (TKA) have a limited range of knee joint motion due to pain and stiffness. A roller massager (RM) has recently been suggested to decrease pain and increase joint range of motion (ROM). Therefore, this study aimed to investigate the acute effect of RM intervention on pain and knee joint ROM in older adults with TKA in the second postoperative week. METHODS: The participants were 23 patients (76.3±5.4 years) who had undergone TKA for knee OA. The degree of pain during the ROM measurements was measured using the visual analog scale before and immediately after the RM intervention. The RM intervention was performed on the thigh's lateral, central, and medial parts for three sets of 60 s using an RM. RESULTS: RM intervention could significantly increase knee flexion ROM (p<0.01, d=0.41, Δchange: 4.1±3.2°) and decrease pain during the knee ROM measurements (p<0.01, d=-0.53, Δchange: -11.9±21.0). CONCLUSIONS: The three sets of 60-s RM intervention significantly increased knee flexion ROM and reduced pain in older adults with TKA in the second postoperative week. These results show that RM intervention is an effective tool for treating stiffness and pain after TKA.

Establishment of a BRAF V595E-mutant canine prostate cancer cell line and the antitumor effects of MEK inhibitors against canine prostate cancer.

Canine prostate cancer (cPCa) is a malignant neoplasm with no effective therapy. The BRAF V595E mutation, corresponding to the human BRAF V600E mutation, is found frequently in cPCa. Activating BRAF mutations are recognized as oncogenic drivers, and blockade of MAPK/ERK phosphorylation may be an effective therapeutic target against BRAF-mutated tumours. The aim of this study was to establish a novel cPCa cell line and to clarify the antitumor effects of MEK inhibitors on cPCa in vitro and in vivo. We established the novel CHP-2 cPCa cell line that was derived from the prostatic tissue of a cPCa patient. Sequencing of the canine BRAF gene in two cPCa cell lines revealed the presence of the BRAF V595E mutation. MEK inhibitors (trametinib, cobimetinib and mirdametinib) strongly suppressed cell proliferation in vitro, and trametinib showed the highest efficacy against cPCa cells with minimal cytotoxicity to non-cancer COPK cells. Furthermore, we orally administered 0.3 or 1.0 mg/kg trametinib to CHP-2 xenografted mice and examined its antitumor effects in vivo. Trametinib reduced tumour volume, decreased phosphorylated ERK levels, and lowered Ki-67 expression in xenografts in a dose-dependent manner. Although no clear adverse events were observed with administration, trametinib-treated xenografts showed osteogenesis that was independent of dosage. Our results indicate that trametinib induces cell cycle arrest by inhibiting ERK activation, resulting in cPCa tumour regression in a dose-dependent manner. MEK inhibitors, in addition to BRAF inhibitors, may be a targeted agent option for cPCa with the BRAF V595E mutation.

A 1-Week Comprehensive Foam Rolling Intervention Program Can Improve Knee Pain but Not Muscle Function and Range of Motion in Patients with Total Knee Arthroplasty.

We investigate the effect of a 1-week comprehensive foam rolling (FR) intervention program on knee pain, range of motion (ROM), and muscle function in patients with TKA.Thirty patients with TKA were randomly allocated to FR (n = 15) or control (n = 15) groups. The control group received only regular physical therapy. Patients in the FR group performed the FR intervention in addition to their regular physical therapy twice daily from postoperative weeks two to three (60 s × 3 repetitions × 2 times/day × 6 days: total = 2160 s). Pain score, knee flexion and extension ROM, muscle strength, walking function, and balance function were measured before and after the FR intervention. From the second to third postoperative weeks, there were significant improvements in all variables, and the reduction in pain score at stretching was significantly greater in the FR group (-26.0 ± 1.4; p < 0.05) than in the control group (-12.5 ± 1.9). However, there was no significant difference in changes in the other variables except for the pain score at stretching between FR and control groups. A 1-week comprehensive FR intervention program in patients with TKA could reduce pain scores at stretching without a synergistic effect on physical function, i.e., walking speed, balance function, and muscle strength of the knee extensors muscles.

Measurement of lymphatic vessel depth using photoacoustic imaging.

OBJECTIVES: Information regarding the depth of lymphatic vessel is important for lymphatic surgeons because rapid identification of functional lymphatic vessels and veins is necessary to perform good lymphaticovenular anastomosis, which is a surgical procedure for lymphedema cases. Photoacoustic lymphangiography (PAL) may be useful for such identification because it allows the assessment of the depth of lymphatic vessels. Thus, we aimed to measure the lymphatic vessel depth using images obtained by PAL. METHODS: This study included healthy individuals and patients with lymphedema. In all participants, indocyanine green dissolved in dextrose was injected subcutaneously into the first and fourth webs of the foot and the lateral malleolus, and PAL was performed on the medial side of the lower leg. The lymphatic vessel depth was measured from the ankle joint, 10 cm above the medial malleolus, and 20 cm above the medial malleolus on PAL in the cross-sectional view and was compared between the participant groups. RESULTS: The healthy group (mean age, 43.3 ± 12.9 years) included 21 limbs of 4 male and 16 female healthy individuals (bilateral limbs of 1 patient were considered). The lymphedema group (mean age, 62.0 ± 11.7 years) included 17 limbs of 3 male and 14 female patients with lymphedema. The average lymphatic vessel depths from the ankle joint, 10 cm above the medial malleolus, and 20 cm above the medial malleolus were 2.6, 4.7, and 5.6 mm in the healthy group and 3.6, 7.3, and 7.4 mm in the lymphedema group, respectively. Lymphatic vessels were significantly deeper in the lymphedema group than in the healthy group at all measurement locations. CONCLUSIONS: Using PAL, we determined the lymphatic vessel depth in living bodies. By searching for the lymphatic vessels based on our findings, even surgeons who are relatively inexperienced with lymphatic surgery may be able to identify functional lymphatic vessels more efficiently.

Genital Feminizing Surgery without Vaginoplasty as a Safe, Aesthetic, and Cost-Effective Option for Gender-Affirming Surgery for Transwomen.

Gender affirming surgery (GAS) has important impacts for people with gender incongruence (GI), both physically and socially. As the societal acceptance of gender diversity spreads, the number of individuals with GI who wish to be identified as the gender of their choice is increasing. Indeed, many elderly people who have lived a long time with GI now wish to undergo GAS, but face greater surgical risks due to greater burdens of underlying medical conditions. Generally, vaginoplasty is performed for transwomen; however, this surgery is time-consuming and involves heavy bleeding, and thus, should be avoided in elderly people. A less invasive technique is needed. In this article, we describe a new, less invasive genital feminizing surgical technique for transwomen with reports from two clinical cases. We present this novel technique as a safe, aesthetic, and cost-effective option for gender-affirming surgery for transwomen.

Photoacoustic lymphangiography is a possible alternative for lymphedema staging.

OBJECTIVE: Photoacoustic imaging is a new technique that uses the photoacoustic effect. In photoacoustic lymphangiography (PAL), images of the lymphatic vessels can be visualized using light-absorbing contrast agents. In the present study, we investigated the efficacy of PAL for lymphedema staging. METHODS: We performed PAL of the lower extremities and examined the clinical implications of using PAL for staging lymphedema by comparing the PAL images with those obtained using lymphoscintigraphy. Of 47 patients with lymphedema who had been outpatients or hospitalized at our institution between May 2018 and September 2020 and had undergone PAL, 15 with 18 limbs who had also undergone lymphoscintigraphy were included in the present study. The lymphoscintigraphy findings were classified using the Maegawa classification. We also investigated whether PAL could clearly visualize the lymphatic vessels and concisely reflect the disease state by counting the number of lymphatic vessels observed using PAL. RESULTS: The PAL findings were categorized into three groups: collecting lymphatic vessels, dermal backflow (DBF), and no lymphatic vessels. The collecting lymphatic vessels group corresponded to types 2 and 3 in the Maegawa classification; DBF corresponded to types 3 and 4, and the no lymphatic vessels group corresponded to type 4. The number of lymphatic vessels visualized using PAL was similar to that with lymphoscintigraphy. As the disease progressed, the number of lymphatic vessels observed decreased, increased DBF was detected, and, eventually, the lymphatic vessels were not visible, corresponding to the general changes observed via lymphoscintigraphy with stage progression. CONCLUSIONS: The findings from PAL and lymphoscintigraphy tended to correspond, suggesting that PAL could be useful for lymphedema staging.

Muscle Fiber Composition Changes after Selective Nerve Innervation.

Facial nerve paralysis interferes with mimetic muscle function. To reconstruct natural facial movement, free muscle flaps are transplanted as new muscles. However, it is difficult to maintain resting tonus. A dual innervation technique in which other nerves such as the hypoglossal nerve or contralateral facial nerve are added is often applied. Using 10-week-old rats (n = 10), the masseteric and hypoglossal nerves were cut, and the distal stump of the masseteric nerve and the proximal stump of the hypoglossal nerve were then sutured (suture group). In the other group, the masseteric nerve was cut and cauterized (cut group). Immunohistochemistry and microarray were performed on the extracted masseter muscle. The immunohistochemistry results suggested that the muscles in the suture group obtained oxidative characteristics. The microarray showed the genes involved in mitochondrial function, including Perm1. In summary, our data support the validity of the dualinnervation technique for facial paralysis treatment.

Evaluation of the effect of age of the younger mice on the rejuvenation of the older mice by heterochronic parabiosis.

Heterochronic parabiosis is used to study the systemic effects of aging and involves surgically connecting two animals of different ages such that they have common blood circulation. Although this technique has been prevalent for a long time, there is no scientific consensus on the age of the animals that should be used. We hypothesized that the younger the animal, the greater would be its rejuvenating effect. Hence, to test this hypothesis, we created parabiosis of 67-week-old mice with younger mice of different ages (4-week-old and 8-week-old). We evaluated the changes in appearance and the expression IL-1A, IL-6, and Cdkn2a (p16) in the liver, kidney, brain, and skin. These cytokines belong to the senescence-associated secretory phenotype (SASP) factors, and are indicators of aging. Although we did not find any significant changes in the appearance of the mice, we found statistically significant differences in some SASP factors between the liver of the 4-week-old and 8-week-old pairs. However, overall, compared to the 8-week-old mice, the 4-week-old does not exert a significantly higher rejuvenation effect on the older mice. Hence, we concluded that the rejuvenation of older mice during heterochronic parabiosis might not be affected by the exact age of the younger mice.

Application of Photoacoustic Imaging for Lymphedema Treatment.

BACKGROUND: Lymphatic vessels are difficult to identify using existing modalities as because of their small diameter and the transparency of the lymph fluid flowing through them. METHODS: Here, we introduce photoacoustic lymphangiography (PAL), a new modality widely used for lymphedema treatment, to observe limb lymphatic vessels. The photoacoustic imaging system used in this study can simultaneously visualize lymphatic vessels and veins with a high resolution (0.2 mm) and can also observe their three-dimensional relationship with each other. RESULTS: High-resolution images of the lymphatic vessels, detailed structure of the dermal back flow, and the three-dimensional positional relationship between the lymphatic vessels and veins were observed by PAL. CONCLUSION: The clear image provided by PAL could have a major application in pre- and postoperative use during lymphaticovenular anastomosis for lymphedema treatment.

Photoacoustic lymphangiography exhibits advantages over near-infrared fluorescence lymphangiography as a diagnostic tool in patients with lymphedema.

OBJECTIVE: Photoacoustic imaging is a new technique that can evaluate the vascular system using photoacoustic effects. The present study compared the ability of the new photoacoustic lymphangiography (PAL) method and more standard near-infrared fluorescence (NIRF) to image the lymphatic system in patients with secondary lymphedema after gynecological cancer surgery. METHODS: Patients with secondary lymphedema in the lower extremities after gynecologic cancer surgery, who were assessed using PAL between May 2018 and January 2019, were recruited. NIRF was performed first using 5.0 mg/mL of indocyanine green injected using a 0.2-cc 30-gauge needle. Correlations between NIRF and PAL findings on patient images were subsequently examined. RESULTS: Seventeen patients with secondary lymphedema were enrolled. The mean age of the patients was 61 ± 11 years. The imaging sites were the medial lower leg in 15 patients, the posterior lower leg in 9 patients, the lateral lower leg in 7 patients, the medial knee in 4 patients, and other areas in 3 patients. A total of 38 pictures were obtained. Five distinct lymphatic patterns were observed over the entire sample using PAL: straight, winding, spiderweb, nebulous, and black-out pattern. Eighteen of the 24 limbs (75%) that exhibited a linear pattern in NIRF exhibited a straight pattern in PAL, and 19 of the 20 limbs (95%) that exhibited a splash pattern in NIRF exhibited a winding or spiderweb pattern in PAL. Eight limbs exhibiting diffuse patterns without linear or splash patterns with NIRF were all nebulous or black-out patterns in PAL. This suggests that more severe lymphatic degeneration was associated with poorer visualization in PAL. CONCLUSIONS: NIRF plays an important role in lymphedema treatment. In the present study, various PAL patterns were compared with those observed using NIRF. PAL provided clearer images including transectional views, which were not available using NIRF, and may promote further understanding of the changes in the lymphatic structure and function in patients with secondary lymphedema.

Associations of Dietary Salt and Its Sources with Hemoglobin A1c in Patients with Type 2 Diabetes Not Taking Anti-Diabetic Medications: Analysis Based on 6-Month Intervention with a Moderate Low-Carbohydrate Diet.

OBJECTIVE: Based on biological studies, the hyperglycemic effect mediated by sodium-glucose co-transporter 1 in the intestine is stronger for foods containing more sodium chloride. Observational studies have demonstrated that type 2 diabetes (T2DM) incidence increases as salt intake increases. We aimed to elucidate associations of total salt and its sources with hemoglobin A1c (HbA1c) in patients with T2DM. METHODS: We conducted an observational study using data from a 6-month moderate low-carbohydrate dietary intervention in 245 outpatients with T2DM (138 men) without antidiabetic medication. Intakes of total salt and its sources, carbohydrate and total energy were assessed at baseline and 6 months based on 3-day dietary records. Multiple regression analyses were performed to examine associations of Δtotal salt or its sources with ΔHbA1c. RESULTS: Salt intake significantly decreased in men (change: -0.92 ± 3.53 g/day) but not in women (0.11 ± 2.28). HbA1c (men: -1.5 ± 1.6%; women: -0.9 ± 1.3%), carbohydrate (men: -115 ± 104 g/day; women: -64 ± 71) and total energy (men: -439 ± 660 kcal/day; women: -192 ± 438) significantly decreased in both sexes. Multiple regression analysis revealed that reducing intakes of total salt and salt from salty snacks, meat processed foods, Chinese noodles with soup and table salt by 1.0 g was associated with decreases in HbA1c of 0.11% 1.18% 0.47% 0.38% and 0.26%, respectively, in men, while reducing salt from miso by 1.0 g was associated with a decrease in HbA1c of 0.30% in women. The associations were dependent on Δcarbohydrate or Δtotal energy in men, while the association of Δsalt from miso in women was independent of them. CONCLUSION: Reducing total salt and its sources had differential associations with HbA1c. Individual associations depended on Δcarbohydrate or Δtotal energy in men, while that of salt from miso in women was independent of them.

Seasonal and annual changes in the microbial communities of Ofunato Bay, Japan, based on metagenomics.

Five years of datasets from 2015 to 2019 of whole genome shotgun sequencing for cells trapped on 0.2-µm filters of seawater collected monthly from Ofunato Bay, an enclosed bay in Japan, were analysed, which included the 2015 data that we had reported previously. Nucleotide sequences were determined for extracted DNA from three locations for both the upper (1 m) and deeper (8 or 10 m) depths. The biotic communities analysed at the domain level comprised bacteria, eukaryotes, archaea and viruses. The relative abundance of bacteria was over 60% in most months for the five years. The relative abundance of the SAR86 cluster was highest in the bacterial group, followed by Candidatus Pelagibacter and Planktomarina. The relative abundance of Ca. Pelagibacter showed no relationship with environmental factors, and those of SAR86 and Planktomarina showed positive correlations with salinity and dissolved oxygen, respectively. The bacterial community diversity showed seasonal changes, with high diversity around September and low diversity around January for all five years. Nonmetric multidimensional scaling analysis also revealed that the bacterial communities in the bay were grouped in a season-dependent manner and linked with environmental variables such as seawater temperature, salinity and dissolved oxygen.

Micro-arteriovenous fistula in patients with lower limb lymphedema.

BACKGROUND: A micro-arteriovenous fistula (AVF) is a minute, short shunt between an artery and a vein that does not pass through a capillary. We investigated the association between micro-AVFs and lymphedema using computed tomography angiography (CTA) and venous blood gas analysis. METHODS: In 95 patients with lower limb lymphedema, the presence or absence of early venous return (EVR) was compared between patients with primary and secondary lymphedema. Furthermore, we investigated the difference in the timing of edema onset in patients with secondary lymphedema with or without EVR using CTA. In 20 patients with lower limb lymphedema with confirmed early EVR in a unilateral lower limb, the partial pressure of oxygen (PO2) was compared between the lower limb with EVR and the contralateral lower limb. RESULTS: Secondary lymphedema with or without EVR occurred at an average of 36.0±59.3 months and 93.5±136.1 months, respectively; however, no significant difference was noted. PO2 was 57.6±11.7 mmHg and 44.1±16.4 mmHg in the EVR and non-EVR limbs, respectively, which was a significant difference (P=0.005). CONCLUSIONS: EVR and venous blood gas analysis suggested the presence of micro-AVFs in patients with lower extremity edema. Further research is warranted to examine the cause of micro-AVFs, to advance technology to facilitate the confirmation of micro-AVFs by angiography, and to improve lymphedema by ligation of micro-AVFs.

Effect of Carbon Black Nanoparticle on Neonatal Lymphoid Tissues Depending on the Gestational Period of Exposure in Mice.

Introduction: Particulate air pollution, containing nanoparticles, enhances the risk of pediatric allergic diseases that is potentially associated with disruption of neonatal immune system. Previous studies have revealed that maternal exposure to carbon black nanoparticles (CB-NP) disturbs the development of the lymphoid tissues in newborns. Interestingly, the CB-NP-induced immune profiles were observed to be different depending on the gestational period of exposure. It is important to identify the critical exposure period to prevent toxic effects of nanoparticles on the development of the immune system. Therefore, the present study was aimed to investigate the effect of CB-NP on the development of neonatal lymphoid tissues in mice, depending on the gestational period of exposure. Methods: Pregnant ICR mice were treated with a suspension of CB-NP (95 µg/kg body weight) by intranasal instillation; the suspension was administered twice during each gestational period as follows: the pre-implantation period (gestational days 4 and 5), organogenesis period (gestational days 8 and 9), and fetal developmental period (gestational days 15 and 16). The spleen and thymus were collected from offspring mice at 1, 3, and 5-days post-partum. Splenocyte and thymocyte phenotypes were examined by flow cytometry. Gene expression in the spleen was examined by quantitative reverse transcription-polymerase chain reaction. Results: The numbers of total splenocytes and splenic CD3-B220- phenotype (non-T/non-B lymphocytes) in offspring on postnatal day 5 were significantly increased after exposure to CB-NP during the organogenesis period compared with other gestational periods of exposure and control (no exposure). In contrast, expression levels of mRNA associated with chemotaxis and differentiation of immune cells in the spleen were not affected by CB-NP exposure during any gestational period. Conclusion: The organogenesis period was the most susceptible period to CB-NP exposure with respect to lymphoid tissue development. Moreover, the findings of the present and previous studies suggested that long-term exposure to CB-NP across multiple gestational periods including the organogenesis period, rather than acute exposure only organogenesis period, may more severely affect the development of the immune system.

Surgical Applications of Lymphatic Vessel Visualization Using Photoacoustic Imaging and Augmented Reality.

Lymphaticovenular anastomosis (LVA) is a widely performed surgical procedure for the treatment of lymphedema. For good LVA outcomes, identifying lymphatic vessels and venules is crucial. Photoacoustic lymphangiography (PAL) is a new technology for visualizing lymphatic vessels. It can depict lymphatic vessels at high resolution; therefore, this study focused on how to apply PAL for lymphatic surgery. To visualize lymphatic vessels, indocyanine green was injected as a color agent. PAI-05 was used as the photoacoustic imaging device. Lymphatic vessels and veins were visualized at 797- and 835-nm wavelengths. First, it was confirmed whether the branching of the vasculature as depicted by the PAL was consistent with the actual branching of the vasculature as confirmed intraoperatively. Second, to use PAL images for surgical planning, preoperative photoacoustic images were superimposed onto the patient limb through augmented reality (AR) glasses (MOVERIO Smart Glass BT-30E). Lymphatics and venule markings drawn using AR glasses were consistent with the actual intraoperative images obtained during LVA. To anastomose multiple lymphatic vessels, a site with abundant venous branching was selected as the incision site; and selecting the incision site became easier. The anatomical morphology obtained by PAL matched the surgical field. AR-based marking could be very useful in future LVA.

Reducing Carbohydrate from Individual Sources Has Differential Effects on Glycosylated Hemoglobin in Type 2 Diabetes Mellitus Patients on Moderate Low-Carbohydrate Diets.

Background: We evaluated decreases in glycosylated hemoglobin (HbA1c) achieved by reducing carbohydrate from various sources in type 2 diabetes mellitus patients. Methods: We followed up 138 male and 107 female outpatients on a moderate low-carbohydrate diet without diabetic medication for 6 months. Changes in carbohydrate sources (Δcarbohydrate) were assessed from 3-day dietary records at baseline and 6 months, and associations with changes in HbA1c (ΔHbA1c) were examined with Spearman's correlation coefficients (rs) and multiple regression analysis. Results: ΔHbA1c was -1.5%±1.6% in men and -0.9%±1.3% in women, while Δtotal carbohydrate was -115.3±103.7 g/day in men and -63.6±71.1 g/day in women. Positive associations with ΔHbA1c were found for Δtotal carbohydrate (rs=0.584), Δcarbohydrate from soft drinks (0.368), confectionery (0.361), rice (0.325), bread (0.221), Chinese soup noodles (0.199) in men, and Δtotal carbohydrate (0.547) and Δcarbohydrate from rice (0.376) and confectionery (0.195) in women. Reducing carbohydrate sources by 50 g achieved decreases in HbA1c of 0.43% for total carbohydrate, 1.33% for soft drinks, 0.88% for confectionery, 0.63% for bread, 0.82% for Chinese soup noodles and 0.34% for rice in men and 0.45% for total carbohydrate, 0.67% for confectionery and 0.34% for rice in women, although mean reductions in carbohydrate from these sources were much smaller than that from rice. Conclusion: Decreases in HbA1c achieved by reducing carbohydrate from soft drinks, confectionery, bread and Chinese soup noodles were 2- to 4-fold greater than that for rice. Our results will enable patients to decrease HbA1c efficiently (UMIN000009866).

The Internal Oblique Muscle Flap with Synthetic Mesh Reinforcement for a Large, Contaminated Abdominal Wall Defect.

We report a case of a large mediocaudal abdominal defect in contaminated circumstances with no residual rectus abdominis muscle that was reconstructed using an internal oblique muscle flap with large-pore polypropylene mesh reinforcement. The internal oblique muscle flap can reconstruct the lower abdominal midline without leaving any additional conspicuous scar. Previous studies showed that large-pore polypropylene mesh in contaminated wounds has a minimal difference in terms of infection rate, and less frequent occurrence of hernia, compared even with biological meshes. We believe that this method could be a strong and cosmetically satisfying option for large mediocaudal abdominal wall reconstruction.

Chemotherapy-induced Nasopharyngeal Stenosis Treated with Bilateral Facial Artery Musculomucosal Flaps.

We report the first case of a 50-year-old woman who developed nasopharyngeal stenosis (NPS) after chemotherapy for malignant lymphoma. The chemotherapy was effective, but NPS developed following treatment. The tumors of the pharynx and soft palate became necrotic and turned into scar tissue, which caused NPS, especially in the caudal part of the soft palate. The patient developed nasal obstruction and obstructive sleep apnea due to the stenosis. The patient underwent 2 surgeries to resolve the NPS: the first was a simple incision of the stenosis, and the second was Z-plasty and mucous membrane transplantation from the posterior pharyngeal wall. However, the NPS recurred soon after these 2 surgeries. We used bilateral inferior-based facial artery musculomucosal (FAMM) flaps as a solution for recurrent NPS, and it was effective in preventing further stenosis. The blood supply to the flaps was stable, and the size of the flaps was enough to compensate for the area of tissue deficit. The use of bilateral FAMM flaps allowed both sides of the NPS to be corrected, and the flaps provided sufficient retracting strength to keep expanding the nasopharyngeal space by pulling from both sides. After the operation, nasal obstruction was decreased, and the sleep quality of the patient improved significantly. The velopharyngeal function was maintained, and there was no symptom of nasopharyngeal insufficiency. Our results suggest that the bilateral FAMM flap is a suitable method to rescue intractable cases of NPS.