Simultaneous pectoralis major-latissimus dorsi myocutaneous flap: An option of reconstruction for open sternal wounds

SummaryManagement of the open sternal wound after surgery is a challenge. We report a retrospective series of cases with regard to the management of sternal wounds according to our own experience and a review of the related literature. A retrospective chart review from June 2007 to February 2010 of patients with infective and open sternal wounds after surgery was performed. There were seven patients with a previous history of type A aortic dissection treated with the Bentall operation, thymoma with excision, mitral and tricuspid regurgitation with double valve replacement, and acute myocardial infarction with a ventricular-assist device or coronary artery bypass graft. All wound cultures of the seven patients showed positive findings. All patients received the latissimus dorsi (LD) myocutaneous flap for lower sternal wound reconstruction under the decubitus position and a contralateral pedicled rotated pectoralis major (PM) myocutaneous flap for the upper sternal wound. The residual wound was covered with a split-thickness skin graft. The mean age of the seven patients, including four males and three females, was 58.1 years (range: 33–73 years). The mean follow-up was 37.7 months (range: 30–44 months). The average time span between the final débridement and the flap reconstruction procedure was 5.2 ± 1.8 days. The harvested area of LD myocutaneous flap ranged from 25 × 10 cm2 to 15 × 8 cm2, and the area of PM myocutaneous flap ranged from 15×15 cm2 to 10 × 5 cm2. Four of seven patients had an omental flap initially, but salvage surgery was performed using a simultaneous pectoralis major-LD flap. Three cases underwent simultaneous PM-LD flap directly. One patient expired on postoperative Day 4 because of sudden ventricular fibrillation, but no postoperative complications were noted in the other six patients. With long-term follow-up, all patients survived without significant complications. The simultaneous PM-LD myocutaneous flap is a reliable option for open sternal wound reconstruction

Gossypiboma (retained surgical sponge) induces septic shock after previous breast surgery: A case report

Foreign body granuloma caused by retained surgical sponge is also called gossypiboma or textiloma, is mostly described in the abdominal cavity, with only a very few cases of retained surgical sponges located in breasts. A 48-year-old female came to our emergency department due to shortness of breath with consciousness disturbance. Sixteen years previously, she had gone through modified radical mastectomy. Eight years later, she received breast reconstruction. At emergency department, her hemodynamic status was unstable. Besides, there was one mass lesion with abscess in the right axillary region, and percutaneous abscess drainage was performed. She was sent to the medical intensive care unit for further care of septic shock. Because her symptoms and signs did not improve, we decided to perform fasciectomy and surprisingly found one retained surgical sponge in her breast. After the operation, she recovered well and the wound was stable. Due to limited literature available, we present a case of gossypiboma in the breast with a clinical manifestation of septic shock

infection–induced partial failure of free anterolateral thigh musculocutaneous flap: Case report

Fusarium species, a soil-borne fungi, causes disease in animals and humans, particularly in immunocompromized patients. A 62-year-old male presented with type II diabetes mellitus, diagnosed 4 years ago. He had a motorcycle accident-caused open tibiofibular fracture of the left lower extremity (Gustilo grade IIIb). With open reduction and internal fixation, an anterolateral thigh musculocutaneous flap was harvested for coverage of exposed bone and defect reconstruction. Partial failure of the flap occurred 9 days following reconstruction, and histological examination revealed Fusarium spp. After treatment with antifungal drugs and debridement, we performed a split-thickness skin graft. At 2-year follow-up, the flap was viable with adequate bone union. This is the first reported case of partial flap failure due to a Fusarium spp. infection. Possibility of fungal infections in patients with late-onset flap failure should be noted. Prompt diagnosis and treatment are needed to prevent repeated free-tissue transfer and/or devastating outcomes

Periorbital purulent drainage of resulting from bacterial pansinusitis

Periorbital cellulitis is much more common in younger children than in adolescents or adults, and most cases of uncomplicated periorbital cellulitis can be treated with antibiotics alone. Here, we report a case of a 53-year-old man with periorbital purulent discharge. Computed tomography imaging revealed pansinusitis. Pus culture isolated a pathogen of Streptococcus constellatus, but it was refractory to 2 weeks of antibiotic therapy with amoxicillin–clavulanate. The patient underwent debridement and functional endoscopic sinus surgery, followed by 10 days of hyperbaric oxygen treatment. The above antibiotic was changed to full-dose intravenous clindamycin. Two weeks after the surgery, the patient was discharged from the hospital. At 1-month follow-up, no purulent discharge was noted; however, mild left-eyelid contracture was observed. This study suggested that if conservative therapy for periorbital purulent discharge in an adult is not effective, progressive treatment, including surgery, should be considered

The effect of atorvastatin on survival of rat ischemic flap

AbstractManagement of skin avulsion with tissue exposure is a challenge for plastic surgeons. Clinical observations have suggested that longer survival of skin flap prevents further contamination and infection. Less well known is the role of atorvastatin in avulsion skin flap. Therefore, we attempted to determine whether atorvastatin could alleviate avulsion skin flap in a rat model. Twenty male Sprague–Dawley rats were randomized into two groups: the atorvastatin group and the control. Before operation, each rat received an initial blood perfusion scan as baseline data. Then, each rat received an operation of skin flap incision, elevation, and resuturing to the original position under general anesthesia. Another blood perfusion scan was performed on each rat 30 minutes, 4 days, and 7 days postoperatively. On the 7th postoperative day, the necrotic area of skin flap was measured as the skin flap viability. The skin flap tissues at 2.5 and 5cm distal to the skin flap base were collected for histopathological analysis, as well as measurement of vascular endothelial growth factor (VEGF) mRNA expression, and vascular density. Compared with 30 minutes postoperation, there was a significant increase in the ratio of skin flap blood perfusion on the 4th and 7th days postoperation in both control and atorvastatin groups (p<0.05). Compared with the control group, there was a significant decrease in necrotic area, significant increase in ratio of skin flap blood perfusion on postoperation days 4 and 7, and significant increase in vascular density under high field at 2.5cm distal to the base of skin flap in the atorvastatin group (p<0.05). The VEGF121 and VEGF165 mRNA expression at 2.5cm distal to the base of skin flap differed significantly between the two groups (p<0.05). Compared with the control group, atorvastatin treatment improved skin flap blood perfusion, vascular density, and necrotic area dependent on VEGF mRNA expression

Fabrication and strength analysis of humanoid focusing mechanism

The human eye was constructed from the soft lens and the ciliary muscle. The ciliary muscle induces force on the lens through an array of fibrillar structure that surrounds the lens. In this paper, the humanoid focusing mechanism which consists of parylene nanofibers and soft polymer lens was presented and demonstrated. The soft polymer lens was constructed of a PDMS envelope and a silicone core. The parylene nanofrillar film was fabricated by anodic aluminum oxide (AAO) template and used to adhere to the lens and to transfer the accommodation force. For verifying the function of the fibrillar structure around the lens, an experiment stage was set up to test the normal and shear strength and to compare two bonding conditions: fibrillar bonding and plate bonding. Besides, the relation between the focal length and applied force was estimated by the lens contour measurement and the laser light focusing measurement

Establishing Aspergillus-Specific IgG Cut-Off Level for Chronic Pulmonary Aspergillosis Diagnosis: Multicenter Prospective Cohort Study

Objectives: Aspergillus-specific IgG (Asp-IgG) cut-off level in diagnosing chronic pulmonary aspergillosis (CPA) remains unknown. Methods: We prospectively recruited participants with clinical suspicion of CPA in three centers in Taiwan during 2019 June to 2020 August. Serum Aspergillus fumigatus-specific IgG (Asp-IgG) (Phadia, Uppsala, UPPS, Sweden) was examined. Optimal cut-off level was determined by Youden’s index and validated. Results: A total of 373 participants were recruited. In the derivation cohort (n = 262), Asp-IgG had an area under the receiver-operating-characteristic curve (AUC) of 0.832. The optimal cut-off level was 40.5 mgA/L. While applying this cut-off level to the validation cohort (n = 111), the sensitivity and specificity were 86.7% and 80.2%. Lowering the cut-off level from 40.5 to 27 mgA/L, the sensitivity was steady (30/36, 83.3% to 31/36, 86.1%) while specificity dropped from 81.9% (276/337) to 63.5% (214/337). Restricting CPA diagnosis to only chronic cavitary pulmonary aspergillosis (CCPA) and chronic fibrosing pulmonary aspergillosis (CFPA) yielded a cut-off level of 42.3 mgA/L in the derivation cohort with a sensitivity of 100% and specificity of 84.4% in the validation cohort. Conclusions: Serum Asp-IgG performs well for CPA diagnosis and provides a low false-positive rate when using a higher cut-off level (preferably around 40 mgA/L)

Characterisation of Physical Frailty and Associated Physical and Functional Impairments in Mild Cognitive Impairment

ObjectiveTo characterize the physical frailty phenotype and its associated physical and functional impairments in mild cognitive impairment (MCI).MethodParticipants with MCI (N = 119), normal low cognition (NLC, N = 138), and normal high cognition (NHC, N = 1,681) in the Singapore Longitudinal Ageing Studies (SLAS-2) were compared on the prevalence of physical frailty, low lean body mass, weakness, slow gait, exhaustion and low physical activity, and POMA balance and gait impairment and fall risk.ResultsThere were significantly higher prevalence of frailty in MCI (18.5%), than in NLC (8.0%) and NHC (3.9%), and pre-frailty in MCI (54.6%), NLC (52.9%) than in NHC (48.0%). Age, sex, and ethnicity-adjusted OR (95% CI) of association with MCI (versus NHC) for frailty were 4.65 (2.40–9.04) and for pre-frailty, 1.67 (1.07–2.61). Similar significantly elevated prevalence and adjusted ORs of association with MCI were observed for frailty-associated physical and functional impairments. Further adjustment for education, marital status, living status, comorbidities, and GDS significantly reduced the OR estimates. However, the OR estimates remained elevated for frailty: 3.86 (1.83–8.17), low body mass: 1.70 (1.08–2.67), slow gait: 1.84 (1.17–2.89), impaired gait: 4.17 (1.98–8.81), and elevated fall risk 3.42 (1.22–9.53).ConclusionTwo-thirds of MCI were physically frail or pre-frail, most uniquely due to low lean muscle mass, slow gait speed, or balance and gait impairment. The close associations of frailty and physical and functional impairment with MCI have important implications for improving diagnostic acuity of MCI and targetting interventions among cognitively frail individuals to prevent dementia and disability

One-Carbon Metabolism Biomarkers and Risks of Incident Neurocognitive Disorder among Cognitively Normal Older Adults

There is a lack of evidence supporting an association between folate and vitamin B12 exposure with cognitive outcomes. We examined serum folate and vitamin B12 and plasma homocysteine in 690 cognitively-normal adults (aged &ge; 55) from the Singapore Longitudinal Aging Study (SLAS-2) followed-up over 4.5 years on incident neurocognitive disorder (NCD): mild cognitive impairment (MCI) and dementia. At follow-up, 5.7% (39) of participants developed NCD (34 MCI and 5 dementia). Comparing with those who remained cognitively-normal, participants progressed to NCD had significantly lower mean baseline vitamin B12 (420 [SD &plusmn; 221] vs. 510 [SD &plusmn; 290] pmol/L, p = 0.026), higher homocysteine (14.6 [SD &plusmn; 4.2] vs. 12.9 [SD &plusmn; 4.3], p = 0.018) and lower one-carbon index (Z-scores: &minus;0.444 [SD &plusmn; 0.819] vs. &minus;0.001 [SD &plusmn; 0.990], p = 0.006). Adjusted for confounders, significant associations with incident NCD were found for lower vitamin B12 (per-SD OR = 2.10, 95%CI = 1.26&ndash;3.52), higher homocysteine (per-SD OR = 1.96, 95%CI = 1.18&ndash;3.24) and lower one-carbon index (per-SD OR = 1.67, 95%CI = 1.06&ndash;2.64). Folate was not significantly associated with progression to NCD. Notably, low B12 in the presence of high folate was significantly associated with incident NCD (adjusted OR = 3.81, 95%CI = 1.04&ndash;13.9). Low B12, high homocysteine, low B12 in the presence of high folate, and a one-carbon index of hypo-methylation were independently associated with progression to NCD among cognitively normal