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Kawasaki S, Nishimura Y, Kouda K, Umemoto Y, Kinoshita T, Hashizaki T, Kawanishi M, Nakamura T, Tajima F. Follow-Up Study of Subdermal Low-Echoic Lesions in the Ischial Region in Wheelchair Users With Spinal Cord Injuries. Front Med (Lausanne) 2022; 9:848338. [PMID: 35355614 PMCID: PMC8959625 DOI: 10.3389/fmed.2022.848338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/14/2022] [Indexed: 11/19/2022] Open
Abstract
Objective: To follow up patients with spinal cord injuries with subdermal low-echoic lesions in the ischial region for abnormalities after 1 year. Design A retrospective cohort study. Setting A Japanese rehabilitation center. Participants We included patients with chronic spinal cord injuries and subdermal low-echoic lesions who underwent routine inspection and palpation examinations (n = 7). Interventions Education on pressure injury and instruction on pressure relief and seating was provided and the patients were followed up for abnormalities after 1 year. Self-reports were obtained on wheelchair sitting time, and interface pressure was recorded while the patients were seated on the wheelchair. Interface pressure measurements at the bilateral ischial regions were recorded with a force-sensitive application pressure mapping system. Outcome Measures The primary outcome was the presence of subdermal low-echoic lesions in the bilateral ischial regions on ultrasonography at the 1-year follow-up examination. Secondary outcomes included wheelchair sitting time and interface pressure in the bilateral ischial regions. Results Of the 10 areas that showed subdermal low-echoic lesions on ultrasonography, nine had improved after 1 year. One area that did not improve was an open wound. At the follow-up examination, the pressure duration was reduced in all patients, and the interface pressure could be reduced in 5/7 patients. Conclusions This is the first study to follow up with patients having spinal cord injuries and subdermal low-echoic lesions in the ischial region using ultrasonography. The low-echoic lesions improved within 1 year by reducing the pressure duration and interface pressure. Pressure injury prevention in patients with spinal cord injuries relies on the early detection of skin abnormalities, and education and instruction to change self-management behaviors are recommended.
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Affiliation(s)
- Shinji Kawasaki
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan.,Division of Rehabilitation, Wakayama Medical University Hospital, Wakayama, Japan
| | - Yukihide Nishimura
- Department of Rehabilitation Medicine, Iwate Medical University, Iwate, Japan
| | - Ken Kouda
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasunori Umemoto
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tokio Kinoshita
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan.,Division of Rehabilitation, Wakayama Medical University Hospital, Wakayama, Japan
| | - Takamasa Hashizaki
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan.,Division of Rehabilitation, Wakayama Medical University Hospital, Wakayama, Japan
| | - Makoto Kawanishi
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan.,Division of Rehabilitation, Wakayama Medical University Hospital, Wakayama, Japan
| | - Taro Nakamura
- Department of Rehabilitation Medicine, Oita Nakamura Hospital, Oita, Japan
| | - Fumihiro Tajima
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
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Kawasaki S, Nishimura Y, Kamijo YI, Uenishi H, Nakamura T, Kouda K, Koike Y, Nakamura T, Tajima F. Relationship between ultrasonographically low-echoic lesions under the skin, wheelchair sitting time, and interface pressure on ischial region in individuals with chronic spinal cord injury. J Spinal Cord Med 2021; 44:978-984. [PMID: 32441562 PMCID: PMC8725746 DOI: 10.1080/10790268.2020.1746873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Objective: To determine the relationship between physical findings, wheelchair sitting time, and interface pressure on ischial region in subjects with spinal cord injury (SCI).Design: Cross-sectional study.Setting: Rehabilitation center in Japan.Participants: Manual wheelchair users with chronic SCI (n = 45).Interventions: Pressure ulcers (PU) were diagnosed by inspection, palpation, and ultrasonography. Self-reports were obtained on wheelchair sitting time and pressure mapping was recorded while the subject was seated on the wheelchair.Outcome measures: Subjects were divided into those with ultrasonographically low-echoic lesions (PU-positive group, n = 11) and no such lesions (PU-negative group, n = 34). Outcome measures included wheelchair sitting time and interface pressure at bilateral ischial regions.Results: Using ultrasonography, 13 low-echoic lesions were identified in 11 subjects of the PU-positive group. The pressure duration was longer and interface pressure was significantly higher in subjects of the PU-positive group compared with those of the PU-negative group (P < 0.05 and P < 0.001, respectively).Conclusions: This is the first study to evaluate the interrelationship between physical findings, sitting time, and ultrasonographically measured interface pressure on ischial region area in subjects with spinal cord injury. To prevent pressure ulcers, we recommend avoidance of prolonged wheelchair sitting and measures that can reduce the interface pressure. These variables should be carefully tailored to the needs of the individual subjects with SCI.
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Affiliation(s)
- Shinji Kawasaki
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yukihide Nishimura
- Department of Rehabilitation Medicine, Iwate Medical University, Morioka, Japan,Correspondence to: Yukihide Nishimura, Department of Rehabilitation Medicine, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate020-8505, Japan; Ph: +81-19-651-5111.
| | - Yoshi-ichiro Kamijo
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroyasu Uenishi
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Taro Nakamura
- Department of Rehabilitation Medicine, Oita Nakamura Hospital, Oita, Japan
| | - Ken Kouda
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yumi Koike
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
| | - Takeshi Nakamura
- Department of Rehabilitation Medicine, Yokohama City University, Yokohama, Japan
| | - Fumihiro Tajima
- Department of Rehabilitation Medicine, Wakayama Medical University, Wakayama, Japan
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Kenji N, Ihama Y, Fukasawa M, Nagai T, Fuke C, Miyazaki T. Morphologic investigation of injury caused by locally applied negative pressure in a rat model. Leg Med (Tokyo) 2012; 14:21-6. [DOI: 10.1016/j.legalmed.2011.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 11/11/2011] [Accepted: 11/20/2011] [Indexed: 10/14/2022]
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Bächle AC, Mörsdorf P, Rezaeian F, Ong MF, Harder Y, Menger MD. N-acetylcysteine attenuates leukocytic inflammation and microvascular perfusion failure in critically ischemic random pattern flaps. Microvasc Res 2011; 82:28-34. [PMID: 21513718 DOI: 10.1016/j.mvr.2011.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 03/14/2011] [Accepted: 03/31/2011] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Microcirculatory dysfunction causes ischemia resulting in tissue necrosis. N-acetylcysteine (NAC) has been shown capable of protecting tissue from ischemic necrosis. However, the mechanism of action of NAC is yet not fully understood. OBJECTIVE Herein, we studied whether NAC is capable of attenuating microvascular perfusion failure in critically ischemic musculo-cutaneous tissue. MATERIAL AND METHODS A laterally based skin flap was elevated in the dorsum of C57BL/6 mice and fixed into a dorsal skinfold chamber. Arteriolar perfusion, functional capillary density, leukocytic inflammation, apoptotic cell death, and non-perfused tissue area were repetitively analyzed over 10 days by intravital fluorescence microscopy. Treatment with either 100mg/kg NAC or saline (control) was started 30 min before surgery and was continued until day 10 after flap elevation. RESULTS Surgery induced leukocytic inflammation, microvascular perfusion failure, apoptosis, and tissue perfusion failure. NAC was capable of significantly attenuating the area of non-perfused tissue. This was associated by a marked arteriolar dilation and an increased capillary perfusion. NAC further reduced the ischemia-associated leukocytic response and significantly attenuated apoptotic cell death in all areas of the flap. CONCLUSION NAC is effective to attenuate leukocytic inflammation and microvascular perfusion failure in critically ischemic tissue. Thus, NAC treatment may represent a promising approach to improve the outcome of ischemically endangered flap tissue.
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Affiliation(s)
- A C Bächle
- Institute for Clinical and Experimental Surgery, University of Saarland, 66421-Homburg/Saar, Germany.
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The Effect of Epidural Anesthesia on Muscle Flap Tolerance to Venous Ischemia. Plast Reconstr Surg 2010; 125:89-98. [DOI: 10.1097/prs.0b013e3181c49544] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Diederich RS, Mowlavi A, Meldrum G, Medling B, Bueno RA, Neumeister MW. Local cooling provides muscle flaps protection from ischemia-reperfusion injury in the event of venous occlusion during the early reperfusion period. Hand (N Y) 2009; 4:19-23. [PMID: 18814018 PMCID: PMC2654943 DOI: 10.1007/s11552-008-9131-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Accepted: 08/19/2008] [Indexed: 11/30/2022]
Abstract
Clinicians often place patients in heated rooms following muscle flap transfers. We hypothesize that exposure of flaps to heated room temperatures could result in an unnecessary hyperthermic ischemic insult if the flaps were to be compromised by venous outflow obstruction, while exposure of elective flaps to local cooling during early perfusion may provide protection in the event of venous occlusion. The rat rectus femoris muscle flap was elevated and clamped for 1 h. The muscle was then exposed to various temperatures for 1 h of perfusion followed by complete venous occlusion for 3 h. Occlusion clamps were removed and flaps were allowed to reperfuse for 24 h. Flaps were assessed for muscle necrosis and edema. Venous occluded muscles demonstrated decreased muscle necrosis and edema in the locally cooled group (8.5 +/- 6.7%, 3.06 +/- 0.14; P < 0.001) compared to the room temperature group (76.2 +/- 23.0%, 3.73 +/- 0.13), and the local warming group (97.3 +/- 1.4%, 3.84 +/- 0.29) respectively. No difference was noted in muscle necrosis nor edema amongst non-ischemic muscles irrespective of temperature exposure. These results suggest a beneficial role for exposure of elective flaps to local cooling during the early perfusion period in order to provide protection from ischemia reperfusion injury in the event of a venous occlusion insult. The prophylactic exposure of flaps to local cooling is further supported by the lack of a harmful effect when flaps were not compromised by venous occlusion.
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Affiliation(s)
- Ryan S. Diederich
- Southern Illinois University School of Medicine, Plastic Surgery Institute, Springfield, IL 62702 USA
| | - Arian Mowlavi
- Southern Illinois University School of Medicine, Plastic Surgery Institute, Springfield, IL 62702 USA
| | - Garth Meldrum
- Southern Illinois University School of Medicine, Plastic Surgery Institute, Springfield, IL 62702 USA
| | - Brad Medling
- Southern Illinois University School of Medicine, Plastic Surgery Institute, Springfield, IL 62702 USA
| | - Reuben A. Bueno
- Southern Illinois University School of Medicine, Plastic Surgery Institute, Springfield, IL 62702 USA
| | - Michael W. Neumeister
- Southern Illinois University School of Medicine, Plastic Surgery Institute, Springfield, IL 62702 USA
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Significant [C3a] Increase in Free Flaps After Prolonged Ischemia. J Surg Res 2008; 150:125-30. [PMID: 18694577 DOI: 10.1016/j.jss.2008.02.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2007] [Revised: 12/19/2007] [Accepted: 02/22/2008] [Indexed: 01/22/2023]
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Hua HT, Albadawi H, Entabi F, Conrad MF, Stoner MC, Houser S, Watkins MT. Effects of acute global venous obstruction and unfractionated heparin on muscle cytokine synthesis. Ann Vasc Surg 2008; 23:108-15. [PMID: 18640815 DOI: 10.1016/j.avsg.2008.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Revised: 05/05/2008] [Accepted: 05/09/2008] [Indexed: 10/21/2022]
Abstract
Phlegmasia cerulea dolens is a devastating complication of massive deep venous thrombosis, which is clinically characterized by massive lower extremity tissue edema and subsequent arterial insufficiency. These experiments evaluated the local tissue effects of acute global venous obstruction combined with partial arterial ischemia. Experiments were performed to assess the effects of heparin on the cytokine response to simultaneous venous and partial arterial obstruction. Murine hind limbs were subjected to conditions of unilateral venous occlusion and partial tourniquet limb ischemia, which was confirmed by laser Doppler imaging (LDI). Mice underwent either hind limb venous obstruction with intravenous unfractionated heparin (200IU/kg) or intravenous saline 5min before venous occlusion. Sham-treated mice were subjected to anesthesia alone without venous occlusion. After 3hr, the mice were killed and tissue was harvested for measurement of edema (wet to dry weight ratio, W/D), muscle viability, indices of local thrombosis (thrombin-antithrombin complex [TAT]), and cytokine analysis for growth-related oncogene-1 (GRO-1) and interleukin-6 (IL-6, protein via enzyme-linked immunoassay and mRNA via reverse transcriptase polymerase chain reaction). Bleeding time and volume were documented in saline- and heparin-treated mice to confirm systemic anticoagulation. Administration of intravenous heparin resulted in a marked increase in bleeding time and volume. LDI confirmed venous obstruction and ongoing arterial inflow. Venous obstruction resulted in severe visible edema that correlated with a significantly higher W/D ratio but was not associated with a significant decrease in muscle viability. GRO-1 and IL-6 protein and mRNA levels were significantly elevated in the venous occlusion group compared to sham. Heparin therapy significantly decreased TAT3 levels but did not alter the profile of GRO-1 or IL-6 protein levels seen with venous occlusion. Venous occlusion with partial ischemia induces a unique and potent local cytokine expression. Heparin therapy did not ameliorate the cytokine response. These data indicate that heparin therapy does not modulate the cytokine response to venous obstruction.
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Affiliation(s)
- Hong T Hua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Vijan SS, Tran VN. Microvascular breast reconstruction pedicle thrombosis: How long can we wait? Microsurgery 2007; 27:544-7. [PMID: 17705279 DOI: 10.1002/micr.20401] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Re-exploration plays a key role in salvaging vascularly compromised free flaps. A retrospective review of 290 free flaps in breast reconstruction was performed to determine whether the time delay between thrombosis detection and surgical re-exploration had any effect on flap salvage. Overall flap success was 97.6%. Postoperative thrombosis requiring re-exploration was documented in 6.2% cases. Fifty-five percent of take-back flaps were salvaged and 45% were lost. The median time between detection of flap compromise to surgical incision was 128 min in our saved flaps, and 228 min in the lost flap group. Our preliminary data suggests that re-exploration within 188 min may improve flap salvage.
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Affiliation(s)
- Sandeep S Vijan
- Department of General Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Free flap surgical procedures are technically challenging, and anastomosis failure may lead to arterial or venous occlusion and flap necrosis. To improve myocutaneous flap survival rates, more reliable methods to detect ischemia are needed. On the basis of theoretical considerations, carbon dioxide tension, reflecting intracellular acidosis, may be suitable indicators of early ischemia. It was hypothesized that tissue carbon dioxide tension increased rapidly when metabolism became anaerobic and would be correlated with acute venoarterial differences in lactate levels, potassium levels, and acid-base parameters. Because metabolic disturbances have been observed to be less pronounced in flaps with venous occlusion, it was hypothesized that tissue carbon dioxide tension and venoarterial differences in lactate and potassium levels and acid-base parameters would increase less during venous occlusion than during arterial occlusion. In 14 pigs, latissimus dorsi myocutaneous flaps were surgically isolated, exposed to acute ischemia for 150 minutes with complete arterial occlusion (seven subjects) or venous occlusion (seven subjects), and reperfused for 30 minutes. After arterial occlusion, pedicle blood flow decreased immediately to less than 10 percent of baseline flow. Blood flow decreased more slowly after venous occlusion but within 3 minutes reached almost the same low levels as observed during arterial occlusion. Venous oxygen saturation decreased from approximately 70 percent to approximately 20 percent, whereas oxygen uptake was almost arrested. Tissue carbon dioxide tension increased to two times baseline values in both groups (p < 0.01). The venoarterial differences in carbon dioxide tension, pH, base excess, glucose levels, lactate levels, and potassium levels increased significantly (p < 0.01). Tissue carbon dioxide tension measured during the occlusion period were closely correlated with venoarterial differences in pH, base excess, glucose levels, lactate levels, and potassium levels (median r2, 0.67 to 0.92). After termination of arterial or venous occlusion, more pronounced hyperemia was observed in the arterial occlusion group than in the venous occlusion group (p < 0.05). Oxygen uptake (p < 0.05) and venoarterial differences in lactate and potassium levels (p < 0.05) were significantly more pronounced in the arterial occlusion group. In the venous occlusion group, with less pronounced hyperemia, venoarterial differences in acid-base parameters remained significantly different from baseline values before occlusion (p < 0.01). The data indicate that tissue carbon dioxide tension can be used to detect anaerobic metabolism, caused by arterial or venous occlusion, in myocutaneous flaps. The correlations between carbon dioxide tension and venoarterial differences in acid-base parameters were excellent. Because carbon dioxide tension can be measured continuously in real time, such measurements are more likely to represent a clinically useful parameter than are venoarterial differences.
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