Simultaneous Ipsilateral Vascularized Lymph Node Transplantation and Contralateral Lymphovenous Anastomosis in Bilateral Extremity Lymphedema with Different Severities.

BACKGROUND: Extremity lymphedema can occur bilaterally with different severities on each side. The aim of this study is to investigate the treatment outcomes of such patients with bilateral extremity lymphedema of different severities. PATIENTS AND METHODS: Between 2013 and 2017, patients with bilateral extremity lymphedema of different severities according to the Taiwan Lymphoscintigraphy Staging (TLS) system were retrospectively reviewed. Ipsilateral vascularized lymph node transplantation (VLNT) was indicated in TLS total obstruction and contralateral lymphovenous anastomosis (LVA) in TLS partial obstruction with patent lymphatic vessels on indocyanine green lymphography. Outcomes were assessed using circumference improvement, frequency of cellulitis, and lymphedema-specific quality of life (LYMQoL) questionnaires. RESULTS: A total of 10 patients with bilateral extremity lymphedema with median age of 63 (range 12-75) years were included. The median symptom duration of the lymphedematous limb was 60 (range 36-168) months and 12 (range 1-60) months in the VLNT and LVA group, respectively (p < 0.05). At average follow-up of 37.5 (range 14-58) months, the average limb circumference improvement was 2.4 (range - 3.3 to 7.8) cm in the VLNT group and 2.3 (range 0.3-7) cm in the LVA group (p = 1). The median episodes of cellulitis decreased significantly from 4 to 0.5 and 1 to 0 times/year in the VLNT and LVA group, respectively (p = 0.02, p = 0.06). The overall LYMQoL score improved from 4.5 preoperatively to 7.5 postoperatively (p < 0.01). CONCLUSIONS: Limb-specific VLNT and LVA selected by TLS effectively treated bilateral extremity lymphedema with different severities.

Risks to healthcare workers following tracheal intubation of patients with COVID-19: a prospective international multicentre cohort study.

Healthcare workers involved in aerosol-generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID-19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID-19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self-reporting. The primary endpoint was the incidence of laboratory-confirmed COVID-19 diagnosis or new symptoms requiring self-isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure-related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow-up of 32 (18-48 [0-116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID-19 subsequently reported a COVID-19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID-19 transmission.

Cultivation of auricular chondrocytes in poly(ethylene glycol)/poly(ε-caprolactone) hydrogel for tracheal cartilage tissue engineering in a rabbit model.

Tissue engineering has the potential to overcome the limitations of tracheal reconstruction. To tissue-engineer a tracheal cartilage, auricular chondrocytes were encapsulated in a photocurable poly(ethylene glycol)/poly(ε-caprolactone) (PEG/PCL) hydrogel. Chondrogenic genes, including Sox9, Acan and Col2a1, were up-regulated in auricular chondrocytes after 2 weeks of in vitro cultivation in the PEG/PCL hydrogel. Co-cultivation of 70 % auricular chondrocytes and 30 % bone marrow mesenchymal stem cells (BMSCs) accelerated the chondrogenic genes' expression in the PEG/PCL hydrogel. Cartilaginous matrix markers, including proteoglycans and collagen type II, were detected in the chondrocytes-encapsulated PEG/PCL hydrogel after 4 weeks of in vitro cultivation. The higher expression level of cartilaginous matrix markers was observed in the PEG/PCL hydrogel with co-cultivation of 70 % chondrocytes and 30 % BMSCs. After 4 weeks of ectopic cultivation in rabbits, the cylindrical PEG/PCL structure was sustained with the use of a luminal silicon stent. However, without the stent, the construct collapsed under a compression force. No fibrosis or vessel ingrowth were found in the PEG/PCL hydrogel after 4 weeks of ectopic cultivation, whereas the auricular chondrocytes showed proteoglycans' accumulation and collagen type II production. Rabbit auricular chondrocytes could survive and retain chondrogenic ability in the PEG/PCL hydrogel under both in vitro and in vivo conditions. While the PEG/PCL hydrogel did not show sufficient mechanical properties for supporting the cylindrical shape of the construct, the high chondrogenesis level of chondrocytes in the PEG/PCL hydrogel displayed the potential of this material for tracheal tissue engineering.

Seroprevalence of Aspergillus IgG and disease prevalence of chronic pulmonary aspergillosis in a country with intermediate burden of tuberculosis: a prospective observational study.

OBJECTIVES: Chronic pulmonary aspergillosis (CPA) is an emerging global disease with tuberculosis (TB) being the most important risk factor. Epidemiologic data on the seroprevalence of Aspergillus IgG and prevalence of CPA in different areas, especially in country with intermediate burden of TB, are lacking. METHODS: We prospectively recruited healthy volunteers, TB close contacts, active TB patients and participants with old pulmonary TB in Taiwan during 2012-2019. We measured serum Aspergillus fumigatus and niger-specific IgG levels and assessed if the participants were having CPA. RESULTS: A total of 1242 participants (including 200 healthy volunteers, 326 TB close contacts, 524 active TB patients and 192 old TB cases) were recruited. Using 27 mgA/L (milligrams of antigen-specific antibodies per liter) as cut-off level, the seropositive rate of A. fumigatus-specific IgG was 33.0% (66/200), 37.7% (123/326), 26.5% (139/524) and 43.2% (83/192) among the four groups, respectively. In multivariate logistic regression, pulmonary cavitation (OR 1.73; 95% CI 1.07-2.80), female sex (OR 1.49; 95% CI 1.14-1.95), old TB (OR 1.59; 1.05-2.42) were independent risk factors for Aspergillus IgG positivity. One (0.2%) active TB patient and four (2.1%) old TB patients developed CPA. Correlation between A. fumigatus and A. niger-specific IgG was high (Spearman correlation coefficient: 0.942). DISCUSSION: Geographic variation in Aspergillus IgG seroprevalence and CPA prevalence exists. A universal cut-off value for Aspergillus IgG may not exist. In areas and populations in which background Aspergillus IgG level is unknown, Aspergillus IgG may be better used as a test of exclusion for CPA using prespecified cut-off level.

Effect of a rosmarinic acid supplemented hemodialysis fluid on inflammation of human vascular endothelial cells.

Chronic systemic inflammation and repetitive damage of vascular endothelia by incompatible dialysis system are probable causes of cardiovascular disease in patients on dialysis. The present study aimed to assess in vitro biocompatibility and anti-inflammatory effect of hemodialysis fluid supplemented with rosmarinic acid (RA) using human umbilical vein endothelial cells (HUVEC). HUVECs (5×106 cells/mL) were pre-exposed to 1 µg/mL of lipopolysaccharides (LPS) and incubated with RA-supplemented hemodialysis fluid (HDF). Cytotoxicity was assessed qualitatively by morphologic assessment and quantitatively by MTT assay. Expressions of proinflammatory mediators were assessed using quantitative real-time PCR and production of NO was quantified. Phosphorylation of AKT and nuclear localization of nuclear factor kappa B (NF-κB) were examined using western blotting. Exposure of HUVECs to RA-supplemented HDF had no influence on morphology and viability. Inhibition of proinflammatory mediator production in HUVECs by RA supplementation to HDF was significant in a dose-dependent manner. Exposure to RA-supplemented HDF resulted in a decrease in nitric oxide synthase expression and reduction of NO production in LPS-stimulated HUVECs. RA supplementation of HDF suppressed Akt activation in LPS-stimulated HUVECs. In addition, the level of cellular IκB was increased in parallel to a reduced nuclear translocation of NF-κB in LPS-induced endothelial cells. Our results suggest that RA-supplemented HDF is biocompatible and significantly suppressed inflammation induced in endothelial cells. In this respect, the use of HDF supplemented with RA could alleviate inflammation and improve long-term treatment of patients with renal failure on dialysis. Further clinical studies are required to confirm the effects.

Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy.

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.

Reliability of zone IV in the deep inferior epigastric perforator flap: a single center's experience with 74 cases.

From March 2000 to June 2002, 74 deep inferior epigastric perforator (DIEP) flaps were performed in 73 female patients for oncological post-mastectomy breast reconstruction in Chang Gung Memorial Hospital. The mean age was 44.2 years and mean body weight was 56.6 kg. Twenty-five breast reconstructions were immediate and 49 were delayed. The average size of the flap was 30.1x12.0 cm and the mean number of perforators was 2.2. The average weight of the harvested flap was 595 g and 85.6% (mean: 509 g) of the flap was used for shaping the new breast mound. Zone IV was not discarded, except in one case. Total flap failure and donor site morbidity was not encountered. Only one flap was revised due to venous congestion (1.4%) and successfully salvaged. Partial flap loss occurred in two patients (2.7%). Fat necrosis was detected in 10 cases (13.5%) and sizes ranged from 2x2 to 4x5 cm. The numbers of perforators and the percentage of the used flap weight/total flap weight were not related to the complications. The free DIEP flap and inclusion of zone IV is a reliable and valuable method of breast reconstruction and provides superior aesthetic outcomes.

Redistribution of body composition in patients with Graves' disease after iodine-131 treatment.

OBJECTIVE: The objective of this study was to investigate body composition redistribution at 3 months after radioactive iodine therapy (RAI). METHODS: Eighty patients with Graves' disease (GD) for RAI and 18 volunteers were recruited. All patients underwent thyroid status test and dual-energy x-ray absorptiometry at baseline and 3 months after RAI. According to the second thyroid status test, patients were divided into the following groups: A, with aggravated hyperthyroidism; B-1, with improved hyperthyroidism; B-2, with euthyroidism; and B-3, with hypothyroidism. RESULTS: Total lean mass (LM) but fat mass (FM) and bone mineral content (BMC) of whole GD patients after RAI recovered to be not different with controls. Compared with baseline, in group A, FM in the left leg increased, and LM in left arm, right arm, trunk and total LM decreased (P<0.05). In B-2, FM in the head increased, and LM in the head, right arm, trunk and total LM increased (P<0.05). In B-3, FM in the right leg and total body fat percentage decreased, but FM in the head, android-to-gynoid fat ratio and body mass index increased (P<0.05); LM of all sites, weight and total mass increased (P<0.05); BMC in lumbar spine and left leg, and total BMC decreased (P<0.05). Body composition of unmentioned sites was retained after RAI in each group (P>0.05). CONCLUSIONS: Replenishment of LM gets priority rather than FM and BMC during the first 3 months after RAI, and the increase in LM starts from the upper body; head is the regional site in which FM recovery occurs first.

Effect of oral diuretics on pulmonary mechanics in infants with chronic bronchopulmonary dysplasia: results of a double-blind crossover sequential trial.

In a randomized double-blind crossover trial with sequential analysis, the effects of oral diuretics were compared with the effects of placebo on pulmonary mechanics in ten infants with bronchopulmonary dysplasia (BPD). Pulmonary mechanics were measured before and at the end of a week of treatment with oral diuretics (chlorothiazide, 20 mg/kg/dose and spironolactone, 1.5 mg/kg/dose) given twice daily, or placebo. Mean airway resistance decreased 35.3 cm H2O/L/s, mean specific airway conductance increased 0.095 1/L/s/cm H2O, and mean dynamic pulmonary compliance increased 1.74 mL/cm H2O during treatment with diuretics (all P less than .001), but not during treatment with placebo. The infants' rate of weight gain decreased on the first three days of diuretic treatment, but was thereafter comparable with weight gain during treatment with placebo. Fluid intake was similar in infants receiving diuretics and placebo. But, infants receiving diuretics not only had significantly increased urine output, osmolal clearance, and potassium and phosphorus excretion, but these infants also retained less fluid, and, in addition, excreted less calcium than infants receiving placebo. It is concluded that oral diuretics improve lung function in infants with chronic bronchopulmonary dysplasia; however, potassium and phosphorus depletion are potential complications of treatment.

Tensile properties, tension-tension fatigue and biological response of polyetheretherketone-hydroxyapatite composites for load-bearing orthopedic implants.

Polyetheretherketone-hydroxyapatite composites were developed as alternative materials for load-bearing orthopedic applications. The amount of hydroxyapatite (HA) incorporated into the polyetheretherketone (PEEK) polymer matrix ranges from 5 to 40 vol% and these materials were successfully fabricated by injection molding. This study presents the mechanical and biological behavior of the composite materials developed. It was found that the amount of HA in the composite influenced the tensile properties. Dynamic behavior under tension-tension fatigue revealed that the fatigue-life of PEEK-HA composites were dependent on the HA content as well as the applied load. The biological responses of PEEK-HA composites carried out in vivo verified the biocompatibility and bioactive nature of the composite materials.

Comparison of cyclosporine determinations in whole blood by three different methods. HPLC, 125I RIA and 3H RIA.

The authors have analyzed and compared the cyclosporine concentrations in whole blood specimens from pediatric renal transplant patients using three different methods: high-performance liquid chromatography (HPLC) (5u C18 reverse-phase column), 3H radioimmunoassay (RIA) (Sandoz, E. Hanover, NJ), and 125I RIA (substituted 3H-tracer in Sandoz Kit with 125I tracer made by Immuno Nuclear Corporation, Stillwater, MN). Results obtained by the 125I RIA correlated well with results obtained by the 3H RIA. Both RIA methods had similar correlation with the HPLC method. The 125I RIA method showed higher sensitivity and greater precision than the 3H RIA method. The authors conclude that the 125I RIA method can be used for cyclosporine determination in whole blood specimens. The use of the 125I RIA provides a simple and rapid method with higher counting efficiency and less background quenching than the 3H RIA method, which requires cumbersome liquid scintillation counting procedures.

Target-dependent axonal sprouting following vagal-hypoglossal nerve anastomosis in cats.

PURPOSE: To investigate the relationships between the axonal sprouting and target neurotization by central neurons after nerve heteroconnection. METHODS: Unilateral (right) vagal-hypoglossal nerve anastomosis (VHA) was performed in adult cats. Following 3-315 days postoperation (dpo), quantitative analyses and ultrastructural changes in the proximal portion of the vagal-hypoglossal heteroconnected nerve as well as the time course of neuronal regeneration were studied. Along with this, horseradish peroxidase (HRP) retrograde tracing technique was used to label the neurons of dorsal motor vagal nucleus (DMV) and nucleus ambiguus (NA) to ascertain if target neurotization was established. RESULTS: The contralateral (left) intact vagus nerve proximal to the level of ansa cervicalis showed an average of 33 ± 1 myelinated and 74 ± 4 unmyelinated axons in 727 µm2 sectional area of the nerve. In the heteroconnected nerve at the corresponding level just proximal to the anastomosis site, there was a marked increase in the number of small axons sprouting from the unmyelinated nerve fibers between 18 and 25 dpo. The number of these axonal sprouts appeared to decline at 32 dpo but its increase of 131 % was sustained until the late regeneration stage at 315 dpo when compared with the contralateral nerve serving as a control. The mean number of myelinated axons per area unit (727 µm2) was reduced to 18 at 3 dpo but was immediately restored to the normal range at 7 dpo. The retrograde labelling of neurons in both the DMV and NA was first detected at 22 dpo and was progressively increased peaking by about 67 dpo. CONCLUSIONS: We conclude that compared with the unmyelinated axons, the myelinated axons may acquire a superior interaction with the new target. Furthermore, the postoperative neurotization of tongue muscles may initiate and facilitate the retraction of the redundant axonal sprouts.

Microvascular vastus lateralis muscle flap for chronic empyema associated with a large cavity.

Thoracic empyema can be disabling and may need microvascular free flaps in some intractable cases. After repeated failure of conventional thoracic surgical procedures, 2 patients with empyema were treated with microvascular free vastus lateralis muscle flaps for obliteration of the large empyema cavity. The reconstruction was successful in wound closure and eradication of infection. The donor site morbidity was minimal, and the patients resumed normal daily activities. Microvascular vastus lateralis muscle flap is the best option if free flaps are required for reconstruction of empyema.

Presence of Gc (vitamin D-binding protein) and interactions with actin in human placental tissue.

The distribution of Gc protein and actin and their interactions were studied in normal full-term human placentae. Both Gc and actin were detected by physicochemical analysis of isolated trophoblast membranes. Immunofluorescence of native placental sections showed fluorescence for both proteins on smooth muscle cells lining the fetal stem vessels, intervillous fibrin, villous fibrinoid, trophoblast membrane, and cytoplasm of villous stromal cells. Binding of Gc was demonstrated by prior incubation of sections with purified Gc which led to a striking increase in intensity of Gc fluorescence, but actin fluorescence was unaffected by this procedure and by preincubation with actin. Endogenous Gc and actin could also be removed by washing of tissue sections with chaotrope--3 M KCl or 3 M NH4SCN, denaturant--6 M urea, or glycine-HCl pH 3.8, as judged by fluorescence and SDS-PAGE of the wash supernatant. Phenotypic analysis of Gc eluted from trophoblast membranes and of corresponding matched maternal and fetal cord sera by isoelectric focusing indicated that trophoblast Gc was of predominantly maternal origin. Although the roles of Gc and actin in the placenta are unknown, these results indicate that Gc may be another maternal protein for which specific binding sites are expressed on the membrane of placental trophoblast.

Atlantal stenosis: a rare cause of quadriparesis in a child. Case report.

The authors report the case of a 3-year-old boy who suffered from quadriparesis and respiratory distress after failing to execute a somersault properly. Neuroimaging revealed spinal cord contusion with marked spinal canal stenosis at the level of the atlas. No subtle instability, occult fracture, or other congenital abnormalities were confirmed. Spinal cord contusion with marked canal stenosis is rare, and only several adult cases have been reported. Severe stenosis at the level of the atlas may predispose individuals to severe spinal cord contusion, as occurred in our patient after sustaining trivial trauma.

In vitro evaluation of the cytotoxicity and genotoxicity of root canal medicines on human pulp fibroblasts.

An intracanal medicine is often required because microorganisms in the dentinal tubes may be difficult to eliminate completely by instrumentation. Phenolic compounds are widely used in dental treatment as sedatives for the dental pulp or as disinfectants for caries and the root canal. In this study, propidium iodide fluorescence and DNA precipitation assay were used to investigated the cytotoxic and genotoxic effects of camphorated phenol and camphorated parachlorophenol on cultured human pulp fibroblasts in vitro. Both medicines reduced the content of double-stranded polynucleic acid of fibroblasts over a 24-h culture period in a concentration-dependent manner. Camphorated parachlorophenol was more cytotoxic than camphorated phenol. But, both medicines did not cause genotoxicity on pulp cells. The advantage of these experimental methods are simplicity and rapidity. Furthermore, this experimental system may be useful for preliminary cytotoxicity and genotoxicity screening of various dental medicines in vitro.

Effects of stimulus intensity on latency and conduction time of short-latency somatosensory evoked potentials.

We studied the effect of stimulus intensity on latencies of short-latency somatosensory evoked potentials (SSEP) by measuring both onset and peak latencies individually. The latencies of N9, N13, N20 and N9-N13 peripheral conduction time (PCT) of median nerve (MN) SSEP, and N8, N23, P37 and N8-N23 PCT of tibial nerve (TN) and sural nerve (SN) SSEP significantly shortened with increasing stimulus intensity by onset latency measurement. However, those latencies by peak latency measurement were less significantly shortened or had only a trend of latency shortening without statistical significance. In contrast to PCT, N13-N20 central conduction time (CCT) of MN-SSEP and N23-P37 CCT of TN- or SN-SSEP showed no latency changes with the increased stimulus intensity by both onset and peak latencies measurement. As peak latencies had greater interindividual variability than onset latencies shown by larger standard deviation, shortening of onset latencies were more consistent than that of peak latencies. We think shortening of onset latencies indicates the recruitment of faster conduction fiber along with increased stimulus intensity. As the degree of latency shortening was less if stimulus intensity was above 2.5 times sensory threshold, the stimulus intensity greater than 2.5 times the sensory threshold should be used for clinical application.

Capillary plasma ammonia concentration in neonates receiving total parenteral nutrition. Comparison with arterial and venous concentrations.

Plasma ammonia concentration in neonates has routinely been determined using arterial or venous blood. Expected plasma ammonia values in capillary blood obtained by heelstick have not been determined. We compared ammonia levels in 20 sets of plasma from simultaneously drawn arterial, venous, and capillary blood in a group of neonates receiving total parenteral nutrition. Mean ammonia concentrations in venous (107 +/- 44) and capillary blood (112 +/- 33) were 45% and 51% higher, respectively, than corresponding arterial (74 +/- 22) values (P less than .001). Ammonia levels in blood obtained by venipuncture (Ven), however, did not correlate consistently with arterial (Art) values (r = .43; Art = 51 + 0.21 Ven; P greater than .05). In contrast, ammonia levels in capillary blood (Cap) correlated well with arterial values (r = .86; Art = 10.3 + 0.6Cap; P less than .001). Ammonia levels in neonates may be reliably interpreted using the latter regression equation when blood for analysis is obtained by a properly performed heelstick, allowing the preservation of arteries and veins, and sparing the infant from repetitive needle punctures. Ammonia levels in blood obtained by venipuncture do not adequately correlate with arterial values and therefore may be therapeutically misleading.

Single versus double arterial anastomoses in combined second- and third-toe transplantation.

Combined second and third toe transplantation is one good option for reconstruction of multiple digit amputation. However, the use of one or two arteries for pedicle anastomoses, which may influence the vascular complication and success rate, has never been addressed in the literature. This study includes a retrospective review of 57 combined second and third toe transplantation in 54 patients performed from February of 1983 through December of 1996. Group I, composed of 41 transplantations, underwent one arterial anastomosis, and group II, composed of 16 transplantations, underwent double arterial anastomoses during surgery if there were two recipient arteries available or whenever the second and third toes showed inadequate blood perfusion after one arterial anastomosis. In group I, 10 transplantations (24.4 percent) required re-exploration with a success rate of 92.7 percent (38 out of 41 transplantations). In group II, only one transplantation (6.2 percent) required re-exploration with successful flap salvage. The success rate was 100 percent for group II. Because the re-exploration and success rates between groups I and II were not statistically significant according to two-tailed Fisher's exact test, the combined second and third toe transplantation is a reliable procedure using either single or double arterial anastomoses.