Simultaneous or Delayed Free Tissue Transfer in Combination with Replantation Surgery

In hand and upper extremity replantation surgery, simultaneous free flap reconstruction restores the physiologic circulation to the amputated part, ensuring its survival, and promotes wound healing through anatomic restoration. Especially in digit replantation, an arterialized venous flap serves to reconstruct both vessel and soft tissue defects simultaneously. Delayed free flap reconstruction aims to enhance both functional improvement and cosmetic acceptance in a successfully replanted part using flaps that include functioning muscle, bone, joint, nerve, and soft tissue.

Correction of Congenital Syndactyly of the Hand with Minimal Full-Thickness Skin Graft from the Weight-Bearing Midline Plantar Area

BACKGROUND

Traditional skin grafts for syndactyly often cause color mismatches and unsightly donor sites, whereas no-skin-graft methods leave noticeable dorsal hand scars. This study presents plantar full-thickness skin graft (FTSG) from the weight-bearing midline area for syndactyly repair, a novel approach not previously reported in the literature.

METHODS

The study included three groups of patients with congenital syndactyly of the hand who underwent primary operations with plantar FTSG (n=70), groin FTSG (n=20), and no-skin-graft techniques (n=22). Postoperative outcomes were evaluated by an assessment panel, and guardians' satisfaction scores were measured. Color similarity between the graft and surrounding skin was assessed using a three-dimensional color space.

RESULTS

The plantar FTSG group demonstrated a significantly higher likelihood of receiving an 'excellent' rating compared to the groin FTSG group, with an odds ratio of 6.30 (p<0.001). Color difference analysis showed that plantar FTSG more closely matched surrounding skin color than groin FTSG (6.33 vs. 22.57, p<0.001). Guardians reported greater satisfaction with outcomes on the hand in the plantar FTSG group compared to the groin FTSG and no-skin-graft groups (7.16 vs. 5.05 and 4.36, p<0.001). Satisfaction with donor sites was also significantly higher in the plantar FTSG group than in the groin FTSG group (8.23 vs. 6.30, p<0.001).

CONCLUSION

Correction of congenital hand syndactyly using midline plantar FTSG from the weight-bearing area can reduce scarring on the hand dorsum, ensure superior color similarity with surrounding skin, and offer inconspicuous donor sites compared to no-skin-graft or groin FTSG techniques.

The Expanded Application of the Acellular Dermal Matrix: Traumatic Nail Bed Defect of the Digits

Reconstruction of traumatic nail bed defects in the digits is a frequently encountered procedure, yet often presents many challenges. In such scenarios, staged procedures may be required with significant limitations in shape and increased donor site morbidity, particularly when multiple defects are present. In this study, we introduce a simple method for the reconstruction of nail bed defects using an acellular dermal matrix (ADM). The study involved 19 digits with nail defects, which underwent reconstruction using an ADM graft. The surgical procedure was performed on all patients on the day of injury, after which they were promptly discharged. The dimensions of the defect ranged from 0.5 × 0.5 cm to a maximum of 2 × 3 cm (average, 0.9 × 1.4 cm). Final examinations were performed at postoperative 5-11 months (average, 6.6 months). All ADM grafts were successfully taken. Nail growth was observed at an average of 4 months after surgery in the treated finger. The surgical results were retrospectively evaluated using the Zook criteria. Outcomes were "excellent" in 11 patients (57.9%), "very good" in five patients (26.3%), "good" in two patients (10.5%), and "fair" in one patient (5.2%). The expanded application of ADM explored in this study illustrates a straightforward method for the reconstruction of traumatic nail bed defects, providing effective results in a single stage without incurring donor site morbidity.

Process of Obtaining Social Consensus and 3-Year Functional Outcomes of the First Hand Allotransplantation in Korea

BACKGROUND

On February 2, 2017, the surgical team of ten board-certified hand specialists of W Hospital in Korea successfully performed the nation's first hand transplantation at Yeungnam University Medical Center (YUMC). This paper reports on the legal, financial, and cultural hurdles that were overcome to open the way for hand transplantation and its functional outcomes at 36 months after the operation.

METHODS

W Hospital formed a memorandum of understanding with Daegu city and YUMC to comply with government regulations regarding hand transplantation. Campaigns were initiated in the media to increase public awareness and understanding. With the city's financial and legal support and the university's medical cooperation, a surgical team performed a left distal forearm hand transplantation from a brain-dead 48-year-old man to a 35-year-old left-handed man.

RESULTS

With this successful allotransplantation, the Korean Act on Organ Transplantation has now been amended to include hand transplantation. Korean national health insurance has also begun covering hand transplantation. Functional outcome at 36 months after the operation showed satisfactory progress in both motor and sensory functions. The disabilities of the arm, shoulder, and hand score were 23. The final Hand Transplantation Score was 90 points. Functional brain magnetic resonance imaging shows significant cortical reorganization of the corticospinal tract, and reinnervation of intrinsic muscle is observed.

CONCLUSIONS

Hand transplantation at the distal forearm shows very satisfactory outcomes in functional, aesthetical, and psychological aspects. Legal and financial barriers against hand transplantation have long been the most burdensome issues. Despite this momentous success, there have been no other clinical applications of vascularized composite allotransplantation due to the limited acceptance by Korean doctors and people. Further public education campaigns for vascularized composite allotransplantation are needed to increase awareness and acceptance.

Practical Tips to Improve Efficiency and Success in Upper Limb Replantation

LEARNING OBJECTIVES

After reading this article, participant should be able to: 1. Describe the technique of replantation for very distal amputation of the digit and salvage procedures for venous drainage. 2. Perform single-digit replantation after viewing the videos. 3. Recognize appropriate cases for joint salvage techniques in periarticular amputation at each joint of the digit and wrist. 4. Outline the methods of flexor and extensor tendon reconstruction in an avulsed amputation of the digit or thumb. 5. Understand the order of digital replantation and transpositional replantation for a restoration of pinch or grip in multiple-digit amputation.

SUMMARY

This article provides practical tips and caveats for the latest replantation surgical techniques for digit, hand, and upper extremity amputation. Four videos, clinical photographs, and drawings highlight important points of operative technique and outcomes of replantation.

The fate of delayed revascularization for neglected vascular injury of incompletely amputated digits and hands

We report the fate of neglected vascular injury in cases of incomplete amputation of the digits and hand after delayed revascularization. Twelve patients underwent primary bone fixation, tendon or skin repair for hand injuries without vessel repair despite ischaemic findings. There was discoloration or necrosis of the fingertips during follow-up examination and the patients were referred to us for treatment. The mean warm ischaemic time was 53 hours (range 17-120). Delayed revascularization was performed with end-to-end anastomosis of the digital arteries in eight and vein graft in four cases. Digital nerves were repaired in four cases and flexor tendons in two cases. Of the 12 cases, eight cases showed complete survival. However, in four patients, complete necrosis of the fingers occurred, with one finger surviving partially. Revision amputation was performed in the four cases where necrosis occurred. We conclude that neglected vascular injury associated with incomplete amputation of digits and hands can be overcome in some patients by delayed revascularization even after prolonged warm ischaemic time. Level of evidence: IV.

Factors associated with HIV/AIDS-related stigma and discrimination by medical professionals in Korea: A survey of infectious disease specialists in Korea

Objectives

This study sought to identify factors associated with this discrimination by medical professionals in Korea.

Subjects and Methods

This study was a cross-sectional survey. We conducted web-based surveys against infectious disease specialists and infectious disease nurse. We evaluated the frequency of human immunodeficiency virus (HIV)/AIDS-related discrimination by medical professionals by health service type on the 5-point scale. We identified the association between several factors and HIV/AIDS-related stigma and discrimination by medical professionals on the 5-point scale.

Results

A total of 81 experts, 57 infectious disease specialists (approximately 27% of all infectious disease specialists in Korea) and 24 infectious disease nurse practitioners, participated in this study. The frequency of stigma and discrimination increased significantly when invasive treatment included both outpatient and inpatient services (both P < 0.05). Medical professional's preconceptions, fear of infection, and lack of knowledge have an association with HIV/AIDS-related stigma and discrimination by medical professionals.

Conclusion

HIV/AIDS-related stigma and discrimination by medical professionals in Korea might be associated with factors related to the fear of medical professionals.

Lessons Learned in the Authors' First Years of Wide-Awake Hand Surgery at the W Hospital in Korea

Wide-awake local anesthesia no tourniquet (WALANT) is a promising development for surgeons and patients through improved operation outcomes in hand and wrist surgery. The authors have mostly used WALANT for flexor and extensor tendon repair, tenolysis, and tendon transfer. Its application at W Hospital in korea has bolstered surgeon confidence in tendon repair integrity, gliding ability, and transfer tension via direct observation and patient feedback. The authors do not use WALANT in complicated tenolysis or in secondary surgeries in previous severe injury situations. The procedure has proven similarly unsuitable in incomplete or complete digit replantation.

Repair of soft tissue defects in finger, thumb and forearm: less invasive methods with similar outcomes

We review recent developments in using occlusive dressings, dermal templates, and venous flaps for less invasive approaches to treat soft tissue defects of the forearm and fingers. Occlusive dressings can be used for thumb tip or fingertip trauma with soft tissue defects of small or moderate sizes. They permit skin regeneration without use of skin graft or a flap transfer. This is currently a popular way to treat tip soft tissue defects in European countries. Extensive soft tissue defects in the thumb, fingers, hand and forearm require flap transfers traditionally, but in recent years, surgeons use dermal templates to cover the defect site to allow regeneration of subcutaneous tissues, over which a skin graft is used in lieu of a flap. Transfer of a venous flap is currently a reliable procedure and is less invasive compared with conventional flaps, which usually damage a named artery in the donor. We advocate that less invasive methods should be considered for soft tissue defects in the hand and forearm.

Palmaris longus tendocutaneous arterialized venous free flap to reconstruct the interphalangeal collateral ligament in composite defects

We present 12 cases in which palmaris longus tendocutaneous arterialized venous free flaps were used for the reconstruction of the collateral ligament in compound defects of digits. There were nine cases involving the interphalangeal joint of the fingers and three of the interphalangeal joints of the thumb. The venous flaps survived completely in 10 of the 12 cases. In 11 cases, there were excellent functional results for joint stability, pain, total active motion and pinch power. In all 12 cases, a pain-free joint with excellent stability was achieved after surgery. The palmaris longus tendocutaneous arterialized venous free flap is a good option for reconstruction of composite defects of the collateral ligament of the interphalangeal joint.

LEVEL OF EVIDENCE

IV.

The accuracies of abdominal computed tomography and the neutrophil-to-lymphocyte ratio used to predict the development of clinically severe acute cholecystitis in elderly patients visiting an emergency department

Background

Mortality in patients with severe acute cholecystitis (AC) remains high, and the prognosis for elderly patients tends to be poor. A comparative analysis of clinical, laboratory, and abdominal computed tomography (CT) parameters was conducted in this study to investigate the effectiveness of each index for predicting clinically severe AC in elderly patients in the emergency department (ED).

Methods

This was a single-center, retrospective study that included 156 patients (≥65 years of age) with AC who were admitted in the ED between January 2012 and December 2014. Parameters including age, gender, initial clinical findings, laboratory findings, and CT findings in the ED were examined for their ability to predict severity.

Results

Forty-five patients were diagnosed with clinically severe AC. The white blood cell count, neutrophil count, neutrophil-to-lymphocyte ratio (NLR), C-reactive protein, erythrocyte sedimentation rate, protein, albumin, and prothrombin time/International Normalized Ratio values were significantly higher in the severe group than in the nonsevere group (P < 0.05). In addition, the CT parameters of increased pericholecystic fat stranding and pericholecystic fluid collection were significantly higher in the severe group than in the nonsevere group (P < 0.001, P < 0.001). Increased pericholecystic fat stranding (odds ratio [OR], 8.17; 95% confidence interval [CI], 2.29-29.22; P = 0.001), pericholecystic fluid collection (OR, 6.55; 95% CI, 1.39-30.92; P = 0.018), and an NLR cutoff value of 9.9 (OR, 4.20; 95% CI, 1.01-17.53; P = 0.049) were independent predictors of severe AC in elderly patients.

Conclusions

The CT parameters of increased pericholecystic fat stranding and pericholecystic fluid collection with an NLR cutoff of 9.9 were useful for predicting the severity of AC in elderly patients in the ED.

The clinical usefulness of initial serum procalcitonin as an aggravation predictor in a hepatobiliary tract infection at emergency department

BACKGROUND AND OBJECTIVES

The ability to predict future clinical deterioration early in patients who present to an emergency care center with a hepatobiliary tract infection is difficult. We studied the clinical usefulness of the initial serum levels of procalcitonin in a hepatobiliary tract infection as an indicator for predicting aggravation in the early stages.

METHODS

Of the patients who presented with the clinical symptoms of a hepatobiliary tract infection, 99 were diagnosed with a hepatobiliary tract infection by imaging studies and subsequently enrolled in the study. Laboratory tests were obtained in the early stage of disease after presentation to an emergency care center. We assessed and compared the serum levels of many early inflammatory markers (white blood cell [WBC] counts, C-reactive protein and procalcitonin) between patients whose symptoms were initially stable upon arrival to an emergency care center but then deteriorated to, those whose symptoms remained consistently stable. Thus, we examined if the above serum markers are useful in predicting the possibility of future symptom aggravation.

RESULTS

Of a total of 99 patients, 27 were assigned to the symptom aggravation group. The serum levels of WBC counts and C-reactive protein in the aggravation group were elevated. However, the median value (interquartile range) of procalcitonin was relatively increased at 2.28 (0.41-7.84 ng/ml), demonstrating a significant difference.

CONCLUSIONS

In conclusion, initial serum levels of procalcitonin might be used as an indicator for aggravation in patients with hepatobiliary tract infection at the emergency department, even though there is hemodynamic stability.

Microsurgical thumb repair and reconstruction

In this article, we review microsurgical reconstructive techniques available to treat thumb amputation at different levels based on our experience. We reference techniques used by other surgeons and identify the most suitable technique for different clinical situations. Indications and techniques for microsurgical partial or composite transfer of the great or second toe for thumb reconstruction are summarized. Different microsurgical transfer techniques suggest a great freedom of surgical choices. However, the choices are considerably restricted if all functional and cosmetic requirements are to be met. We recommend individualized surgical design and reconstruction because each case of thumb amputation is unique.

Iliacus abscess with radiculopathy mimicking herniated nucleus pulposus: Additional diagnostic value of magnetic resonance imaging

An iliacus abscess is an extremely rare cause of low back pain. With an iliacus abscess, the classical signs seen with a psoas abscess are frequently absent. Therefore, a timely diagnosis at the initial visit is difficult and inadequate treatment usually results in high mortality. Here, we report the case of 19-year-old man who presented with acute low back pain with radiculopathy and was ultimately diagnosed with an iliacus muscle abscess.

Clinical features of emergency department patients with depression who had attempted to commit suicide by poisoning

BACKGROUND

Many patients present to the emergency department (ED) complaining of intentional poisoning. Of those, some have major depressive disorder (MDD) in their medical history. The aim of this study was to investigate the prevalence of MDD patients who were treated for poisoning in the ED.

MATERIALS AND METHODS

A retrospective review was performed on 268 patients who were treated with poisoning between July 2007 and November 2011. Of these patients, we only included those who were over 18 years of age. Information regarding age, gender, cause, time of ingestion, type of drug, history of attempting suicide, and outcome, among other characteristics, was collected and compared to patients who did not have MDD.

RESULTS

A total of 244 patients were included in this study. Of those, 52 patients (21.3%) had a history of MDD. Compared to non-MDD patients, a majority (34.6% vs. 19.8%) of those in the MDD group had a history of suicide attempts (P = 0.027), and 34 (65.4% in the MDD group vs. 34.4% in the non-MDD group) took more than two types of drugs (P < 0.001). There were no differences in age, sex, time of ingestion or disease severity between MDD and non-MDD patients.

CONCLUSION

In poisoning patients with MDD, physicians in the ED must consider that they have a higher tendency to show suicidal behavior and to have ingested multiple types of drugs.

A comparative study of the feet of middle-aged women in Korea and the Maasai tribe

Background

Members of the Maasai tribe spend their days either barefoot or wearing traditional shoes made from recycled car tires. Although they walk long distances (up to 60 km) daily, they do not generally experience foot ailments. Here, we compared parameters associated with the feet, ankles, and gait of middle-aged women in Korea and the Maasai tribe.

Methods

Foot length, calf circumference, hindfoot alignment, step length, cadence, and walking velocity were compared among 20 middle-aged Korean and bush-living Maasai women. Static and dynamic Harris mat footprints were taken to determine the distribution of forefoot pressure patterns during walking. We also compared several radiographic parameters with standing foot and ankle radiographs.

Results

The mean foot length and width were significantly longer in Maasai women. Interestingly, 38 ft (96 %) in the Maasai group showed a claw deformity of the toe (s). There were no statistically significant differences in gait-related indices and Harris mat findings between the two groups. On radiographic analysis, tibial anterior surface angle, tibial lateral surface angle, talonavicular coverage angle, talo-first metatarsal angle, Meary angle, and naviculo-cuboidal overlap were significantly greater in the Maasai group, whereas hallux valgus angle and the first and second intermetatarsal angle were greater in the Korean group.

Conclusions

Middle-aged women from the Maasai tribe showed a higher prevalence of abducted forefeet, everted hindfeet, and fallen medial longitudinal arches than did Korean women, while Korean women showed a higher prevalence of hallux valgus, a preserved medial longitudinal arch, and toes that are free from claw deformity.

Effect of tamsulosin on stone expulsion in proximal ureteral calculi: an open-label randomized controlled trial

AIM

Medical expulsive therapy (MET) using alpha-blockers is effective for distal ureteral calculi (UC). We aimed to evaluate the efficacy of tamsulosin for proximal UC expulsion.

MATERIALS AND METHODS

An open-label randomized controlled trial was conducted with 108 patients who agreed to conservative management for single, radiopaque, proximal UC ≤ 6 mm and were randomized into group A (n = 54, conservative managements only) or B (n = 54, 0.2 mg tamsulosin once a day). The primary end-point was stone passage rates (SPR) in the intention-to-treat population in 4 treatment weeks. The secondary end-points were estimated in per-protocol population and were time to stone passage, post-trial Euro-quality-of-life (EuroQOL) score, oral analgesic requirements, and willingness to undergo conservative treatment again.

RESULTS

The two groups were well balanced in terms of baseline patient and stone characteristics. Seventy nine patients (73.2%; 35 of group A and 44 of group B) completed the study protocol. The overall SPR was 60.2% (65/108). Group B had a higher SPR (74.1%; 40/54) than group A (46.3%; 25/54; p = 0.003) and a significantly shorter time to stone passage (mean days, A: 19.6 vs. B: 14.3, p = 0.005). The groups did not differ in post-trial EuroQOL score or oral analgesic requirements, whereas 74.3% (26/35) of group A and 90.9% (40/44) of group B were willing to undergo conservative treatment again (p = 0.048). Univariate logistic regression analysis showed that stone size (OR = 1.447, p = 0.045) and tamsulosin treatment (OR = 3.314, p = 0.004) significantly predicted stone expulsion. On multivariate analysis, only tamsulosin was statistically significant (OR=3.198, p = 0.021).

CONCLUSIONS

Tamsulosin was associated with significantly higher stone expulsion rate and shorter expulsion time in proximal UC ≤ 6 mm compared with conservative managements only. Our results indicate that similar to patients with distal UC, MET using tamsulosin is a reasonable treatment option for patients with proximal UC.

A dual anteroposterior approach to the Bernese periacetabular osteotomy

When the Bernese periacetabular osteotomy is performed through an anterior approach, the ischial and retroacetabular osteotomies and manual fracture of the incompletely osteotomized ischium are conducted with an incomplete view resulting in increased risk and morbidity. We have assessed the dual anteroposterior approach which appears to address this deficiency. We compared the results of the Bernese periacetabular osteotomy performed in 11 patients (13 osteotomies) through a single anterior approach with those in 12 patients (13 osteotomies) in whom the procedure was carried out through a dual anteroposterior approach. The estimated blood loss, the length of anaesthesia, duration of surgery and radiological parameters were measured. The mean operative time and length of anaesthesia were not significantly different in the two groups (p = 0.781 and p = 0.698, respectively). The radiological parameters improved to a similar extent in both groups after the operation but there was significantly less blood loss in the dual osteotomy group (p = 0.034). The dual anteroposterior approach provides a direct view of the retroacetabular and ischial parts of the osteotomy, within a reasonable operating time and with minimal blood loss and gives a satisfactory outcome.

Apparatus and method for achieving reproducible measurements of diauxic lag length and anoxic net maximum specific growth rate

An apparatus for continuous growth of pure bacterial cultures under oxic conditions followed by a switch to anoxic batch conditions was designed. The application of this apparatus gave variability of measured parameters (diauxic lag length, anoxic net maximum specific growth rate) which were significantly lower than the variability of previously reported data. The improvement is attributed to more consistent nitrate reductase levels as a result of achieving steady state under oxic condition prior to switching to anoxic batch conditions.

Soil washing using various nonionic surfactants and their recovery by selective adsorption with activated carbon

The performance of activated carbon in soil washing and subsequent selective adsorption for surfactant recovery from the washed solution was investigated. Sandy loam soil contaminated with phenanthrene at 200 mg kg(-1) was washed with four different nonionic surfactants: Tween 40, Tween 80, Brij 30 and Brij 35. The efficiency of soil washing was highest when using Brij 30 with the highest solubilizing ability for phenanthrene and low adsorption onto soil. In the selective adsorption step, surfactant recovery was quite effective for all surfactants ranging from 85.0 to 89.0% at 1 g L(-1) of activated carbon (Darco 20-40 mesh). Phenanthrene removal from the solution washed with Brij 30 was only 33.9%, even though it was 54.1-56.4% with other surfactants. The selectivity was larger than 7.02 except for Brij 30 (3.60). The overall performance considering both the washing and surfactant recovery step was effective when using Tween 80 and Brij 35. The results suggest that higher solubilizing ability of surfactants is a requirement for soil washing but causes negative effects on phenanthrene removal in the selective adsorption. Therefore, if a surfactant recovery process by selective adsorption is included in soil remediation by washing, the overall performance including the two steps should be considered for properly choosing the surfactant.

A study for the hierarchical artificial neural network model for Giemsa-stained human chromosome classification

A hierarchical multi-layer neural network with an error back-propagation training algorithm has been adopted for the automatic classification of Giemsa-stained human chromosomes. The first step classifies chromosomes data into 7 major groups based on their morphological features such as relative length, relative area, centromeric index, and 80 density profiles. The second step classifies each 7 major groups into 24 subgroups using each group classifier. The classification error decreased by using two steps of classification and the classification error was 5.9%. The result of this study shows that a hierarchical multi-layer neural network can be accepted as an automatic human chromosome classifier.

Cloning and characterization of six highly similar endo-1,3-beta-glucanase genes in hexaploid wheat

Pathogenesis-related (PR) proteins are often used as a marker of plant defense reactions. Some endo-1,3-beta-glucanase (Gns) genes encode proteins that belong to the PR protein family 2 (PR-2). Although the number of homologous family member genes is significantly greater in hexaploid wheat (Triticum aestivum L.) compared to other model plants, earlier studies did not evaluate the possible contribution of their homologs to hybridization signals in Northern blot analysis. In this study, we have examined whether routine transcriptional analyses of a PR gene is of high reliability or not by isolating six highly similar Gns genes (TaGlb2a, TaGlb2b, TaGlb2c, TaGlb2d, TaGlb2e, and TaGlb2f) and characterizing their expression patterns in detail. While TaGlb2b was shown to be a PR-2 gene, transcription of TaGlb2c and TaGlb2d was not induced upon infection with either powdery mildew (Erysiphe graminis) or head blight (Fusarium graminearum) pathogens; their transcripts were most abundant in healthy spikes (lemmas and in particular paleae). Therefore, in some cases, the conventional analyses do not necessarily provide accurate information on expression pattern of a PR gene in hexaploid wheat. This is also the first report of wheat genes that are specifically expressed in lemma/palea tissues of flowering spikelets.

Salvage of the lower extremity free flap using cross-leg venous repair

This retrospective study was designed to evaluate a salvage technique for free flaps suffering venous congestion by using a cross-leg vein repair in patients with venous-impaired lower extremities. Four free flap reconstructions were performed using the latissimus dorsi muscle to reconstruct soft tissue defects in the lower extremity. The recipient artery was confined to the ipsilateral leg and the venous anastomosis was performed with a long saphenous vein from the contralateral side. The legs were immobilised together by means of an external fixator. All patients were males with a mean age of 31 years. The mean time of pedicle division was 8.8 days (7-10). The mean size of the free flap was 186.5 cm(2). All flaps survived after pedicle division without venous congestion. There were no complications such as joint stiffness or donor site morbidity except for a linear scar. The cross-leg venous repair is a refinement of a salvage procedure for compromised free flaps used in the reconstruction of severe soft tissue defects in vascularly compromised lower extremities.

Cosmetic reconstruction of distal finger absence with partial second toe transfer

The authors successfully performed a series of 32 distal finger reconstructions using partial second toe-to-finger transfers solely for aesthetic indications. The resulting hand function shows an average static 2-point discrimination of 8 mm. Total active range of motion was 205 degrees. Key-pinch strength and grip strength averaged 65 and 90% of the normal contralateral side, respectively. Patient satisfaction, as reflected by the average subjective satisfaction scores for aesthetic appearance and function (SSSAF) of the reconstructed distal finger, was high at 82 and 78, respectively. The SSSAF for the donor site averaged 88 for function and 75-80 for aesthetic appearance, which is statistically significant (p<0.05). The authors modified the technique of distal finger reconstruction using second toe transfers in three ways. One is to skeletonize the neurovascular bundle of the harvested toe and pass it through a subcutaneous tunnel between the distal finger incision and the web space incision to avoid lengthy and unsightly scars on the reconstructed finger. Another is to defat the skin flaps developed at the amputated stump and to use a zigzag incision on the toe flap to create a smoother skin junction between the stump and the transferred toe. The third refinement is to perform the arterial microanastomosis at the level of the web space to take advantage of the larger diameter of the vessels in this area. Cosmetic reconstruction of the distal finger with a partial second toe-to-hand transfer provides a high degree of patient satisfaction, both aesthetically and functionally.

Inhibition of diazepam on morphine-induced hyperactivity, reverse tolerance and postsynaptic dopamine receptor supersensitivity

The effects of diazepam on the development of reverse tolerance and postsynaptic dopamine receptor supersensitivity induced by morphine were examined in mice. A single administration of morphine induced hyperactivity and the morphine-induced hyperactivity was inhibited dose-dependently by the administration of diazepam (1, 2 and 4 mg x kg(-1), i.p.), an agonist for benzodiazepine receptor linked to the GABA(A) receptor. Daily repeated administration of morphine developed reverse tolerance to the hyperactivity of morphine. The concomitant administration of diazepam inhibited the morphine-induced hyperactivity and the diazepam administration prior to and during the chronic administration of morphine in mice inhibited the development of reverse tolerance to the hyperactivity of morphine (10 mg x kg(-1), s.c.). Postsynaptic dopamine receptor supersensitivity was also developed in reverse tolerant mice that had received the same morphine. The development of postsynaptic dopamine receptor supersensitivity was evidenced by the enhanced ambulatory activity of apomorphine (2 mg x kg(-1), s.c.). Diazepam also inhibited the development of postsynaptic dopamine receptor supersensitivity induced by the chronic administration of morphine. These results suggest that the hyperactivity, reverse tolerance and postsynaptic dopamine receptor supersensitivity induced by morphine may be modulated via the activation of the GABA(A) receptor induced by diazepam.

Design and synthesis of a novel class of histone deacetylase inhibitors

Histone deacetylase inhibitors (HDACs) have emerged as a novel class of antiproliferative agents. Utilizing structure-based design, the synthesis of a series of sulfonamide hydroxamic acids is described. Further optimization of this series by substitution of the terminal aromatic ring yielded HDAC inhibitors with good in vitro and in vivo activities.

Tumor necrosis factor-related apoptosis inducing ligand (TRAIL)-induced apoptosis is dependent on activation of cysteine and serine proteases

We examined the role of caspases and serine protease(s) in cell death induced by tumour necrosis factor-related apoptosis-inducing ligand (TRAIL). After incubation of adenocarcinoma cells with TRAIL, caspase-3, -8 were activated and the cleavage of Bid induced the release of cytochrome c, from the mitochondria to the cytosol. Tetrapeptide inhibitors of caspase-1, -2, -3, and -8 suppressed DNA fragmentation and attenuated the release of cytochrome c, whereas inhibitors of caspase-5 did not. Interestingly, the general serine protease(s) inhibitor 4-(2-aminoethyl)benzylsulfonyl fluoride (AEBSF) resulted in the arrest of apoptosis. However, the AEBSF did not prevent the release of mitochondrial cytochrome c during TRAIL-induced apoptosis. From these results, we postulate that serine protease(s) may be involved in post-mitochondrial apoptotic events, that lead to the activation of the initiator, caspase-9.

Microbial energetics and stoichiometry for biodegradation of aromatic compounds involving oxygenation reactions

Oxygenation reactions significantly alter the energy and electron flows and, consequently, the overall stoichiometry for the microbial utilization of aromatic compounds. Oxygenation reactions do not yield a net release of electrons, but require an input of electrons to reduce oxygen molecules. The biodegradation pathway of phenanthrene as a model compound was analyzed to determine the impact of oxygenation reactions on overall stoichiometry using the half-reaction method. For individual oxygenation reactions, the half-reaction method for analyzing the electron and energy flows must be modified, because the reactions do not release electrons for synthesis or energy generation. Coupling the oxygenation reaction to subsequent reaction steps provides a net electron release for the coupled reactions. Modeling results indicate that oxygenation reactions increase the oxygen requirement and reduce the cell yield, compared to the conventional mineralization represented by hydroxylation reactions in place of oxygenations. The computed yields considering oxygenation reactions conform better to empirical yields reported in the literature than do yields computed by the hydroxylation single-step methods. The coupled-reaction model also is consistent with information about the ways in which micro-organisms that degrade aromatics accumulate intermediates, regulate degradation genes, and organize enzyme clusters.

Cdc5 interacts with the Wee1 kinase in budding yeast

Development of a multicellular organism requires that mitosis and morphogenesis be coordinated. These processes must also be synchronized during the growth of unicellular organisms. In the yeast Saccharomyces cerevisiae, mitosis is dependent on the prior growth of a daughter cell in the form of a bud. Overexpression of wild-type Polo-like kinase Cdc5 or a catalytically inactive form resulted in the formation of multinucleate cells in budding yeast. Immunofluorescence analysis of these multinulceate cells showed that mitosis and bud formation were no longer linked. Others have shown that Swe1 is required for coupling mitosis to bud formation during a perturbed cell cycle. When the normal pathway of bud formation is perturbed, Swe1 functions to delay mitosis through negative regulation of Clb/Cdk. In cells lacking Swe1, multinucleate cells are formed in response to delays in bud formation. Affinity purification, two-hybrid analysis, and mutant characterization results suggested that Cdc5 and Swe1 interact. From these results, we conclude that multinucleate formation in response to Cdc5 overexpression is linked to titration of Swe1 function. These results also suggest that Cdc5 may be a negative regulator of Swe1.

Pre-expanded arterialised venous free flaps for burn contracture of the cervicofacial region

Despite the fact that arterialised venous flaps provide thin good-quality tissue to repair defects of the face and neck, their clinical applications have been limited by an unstable postoperative course and variable flap necrosis. In an effort to resolve these problems, a tissue-expansion technique has been applied to the arterialised venous flap before flap transfer. Three pre-expanded arterialised venous free flaps have been used to treat post-burn scar contracture of the cervicofacial region. The donor site was confined to the forearm in each case. A rectangular expander was usually placed over the fascia of the flexor muscles in the proximal two-thirds of the forearm. The mean expansion period, volume and flap size were 44 days, 420 cm(3)and 147 cm(2), respectively. There were no complications caused by insertion and expansion. The cervicofacial region was successfully reconstructed, after excision of the post-burn contractures, with pre-expanded arterialised venous flaps, with no marginal necrosis or postoperative instability. Large thin arterialised venous flaps are well matched with the recipient defect in the cervicofacial area and the colour and texture match obtained with forearm tissue produced an aesthetically favourable result. Pre-expanded arterialised venous flaps are another new option for free flap reconstruction of the face and neck.

Evaluation of the interaction between biodegradation and sorption of phenanthrene in soil-slurry systems

This work develops and utilizes a non-steady-state model for evaluating the interactions between sorption and biodegradation of hydrophobic organic compounds in soil-slurry systems. The model includes sorption/desorption of a target compound, its utilization by microorganisms as a primary substrate existing in the dissolved phase, and/or the sorbed phase in biomass and soil, oxygen transfer, and oxygen utilization as an electron acceptor. Biodegradation tests with phenanthrene were conducted in liquid and soil-slurry systems. The soil-slurry tests were performed with very different mass transfer rates: fast mass transfer in a flask test at 150 rpm, and slow mass transfer in a roller-bottle test at 2 rpm. The results of liquid tests indicate that biodegradation of the soil-soluble organic fraction did not significantly enhance the biodegradation rate. In the slurry tests, phenanthrene was degraded more rapidly than in liquid tests, but at a similar rate in both slurry systems. Modeling analyses with several hypotheses indicate that a model without biodegradation of compound sorbed to the soil was not able to account for the rapid degradation of phenanthrene, particularly in the roller-bottle slurry test. The model with sorbed-phase biodegradation and the same biokinetic parameters, but unique mass transfer coefficients, simulated the experimental data in both slurry tests most successfully. Reduced mass transfer resistance to bacteria attached to the soil is the most likely phenomenon accounting for rapid sorbed-phase biodegradation.

Inhibition of Baclofen on morphine-induced hyperactivity, reverse tolerance and postsynaptic dopamine receptor supersensitivity

The effects of baclofen on the development of reverse tolerance and postsynaptic dopamine receptor supersensitivity induced by morphine were examined in mice. A single administration of morphine induced hyperactivity and the morphine-induced hyperactivity was inhibited dose dependently by the administration of a GABA(B)receptor agonist, baclofen (1.25, 2.5 and 5 mg kg(-1), i.p.). Daily repeated administration of morphine developed reverse tolerance to the hyperactivity of morphine. The concomitant administration of baclofen inhibited the morphine-induced hyperactivity and the baclofen administration prior to and during the chronic administration of morphine in mice inhibited the development of reverse tolerance to the hyperactivity of morphine (10 mg kg(-1), s.c.). Postsynaptic dopamine receptor supersensitivity was also developed in reverse-tolerant mice that had received the same morphine. The development of postsynaptic dopamine receptor supersensitivity was evidenced by the enhanced ambulatory activity of apomorphine (2 mg kg(-1), s.c.). Baclofen also inhibited the development of postsynaptic dopamine receptor supersensitivity induced by the chronic administration of morphine. These results suggest that the hyperactivity, reverse tolerance and postsynaptic dopamine receptor supersensitivity induced by morphine may be modulated via the activation of GABA(B)receptors induced by baclofen.

Bimodal regulation of Na+-Ca2+ exchanger by -adrenergic signaling pathway in shark ventricular myocytes

In shark heart, the Na(+)--Ca(2+) exchanger serves as a major pathway for both Ca(2+) influx and efflux, as there is only rudimentary sarcoplasmic reticulum in these hearts. The modulation of the exchanger by a beta-adrenergic agonist in whole-cell clamped ventricular myocytes was compared with that of the Na(+)--Ca(2+) exchanger blocker KB-R7943. Application of 5 microM isoproterenol and 10 microM KB-R7943 suppressed both the inward and the outward Na(+)--Ca(2+) exchanger current (I(Na--Ca)). The isoproterenol effect was mimicked by 10 microM forskolin. Isoproterenol and forskolin shifted the reversal potential (E(rev)) of I(Na--Ca) by approximately -23 mV and -30 mV, respectively. An equivalent suppression of outward I(Na--Ca) by KB-R7943 to that by isoproterenol produced a significantly smaller shift in E(rev) of about --4 mV. The ratio of inward to outward exchanger currents was also significantly larger in isoproterenol- than in control- and KB-R7943-treated myocytes. Our data suggest that the larger ratio of inward to outward exchanger currents as well as the larger shift in E(rev) with isoproterenol results from the enhanced efficacy of Ca(2+) efflux via the exchanger. The protein kinase A-mediated bimodal regulation of the exchanger in parallel with phosphorylation of the Ca(2+) channel and enhancement of its current may have evolved to satisfy the evolutionary needs for accelerated contraction and relaxation in hearts of animals with vestigial sarcoplasmic Ca(2+) release stores.

Implication of a small GTPase Rac1 in the activation of c-Jun N-terminal kinase and heat shock factor in response to heat shock

Heat shock induces c-Jun N-terminal kinase (JNK) activation as well as heat shock protein (HSP) expression through activation of the heat shock factor (HSF), but its signal pathway is not clearly understood. Since a small GTPase Rac1 has been suggested to participate in the cellular response to stresses, we examined whether Rac1 is involved in the heat shock response. Here we show that moderate heat shock (39-41 degrees C) induces membrane translocation of Rac1 and membrane ruffling in a Rac1-dependent manner. In addition, Rac1N17, a dominant negative mutant of Rac1, significantly inhibited JNK activation by heat shock. Since Rac1V12 was able to activate JNK, it is suggested that heat shock may activate JNK via Rac1. Similar inhibition by Rac1N17 of HSF activation in response to heat shock was observed. However, inhibitory effects of Rac1N17 on heat shock-induced JNK and HSF activation were reduced as the heat shock temperature increased. Rac1N17 also inhibited HSF activation by l-azetidine-2-carboxylic acid, a proline analog, and heavy metals (CdCl)), suggesting that Rac1 may be linked to HSF activation by denaturation of polypeptides in response to various proteotoxic stresses. However, Rac1N17 did not prevent phosphorylation of HSF1 in response to these proteotoxic stresses. Interestingly, a constitutively active mutant Rac1V12 did not activate the HSF. Therefore, Rac1 activation may be necessary, but not sufficient, for heat shock-inducible HSF activation and HSP expression, or otherwise a signal pathway(s) involving Rac1 may be indirectly involved in the HSF activation. In sum, we suggest that Rac1 may play a critical role(s) in several aspects of the heat shock response.

Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers

Severe postburn hand deformities were classified into three major patterns: hyperextension deformity of the metacarpophalangeal joint of the fingers with dorsal contracture of the hand, adduction contracture of the thumb with hyperextension deformity of the interphalangeal joint, and flexion contracture of the palm. Over the past 6 years, 18 cases of severe postburn hand deformities were corrected with extensor tenotomy, joint capsulotomy, and release of volar plate and collateral ligament. The soft-tissue defects were reconstructed with various fasciocutaneous free flaps, including the arterialized venous flap (n = 4), dorsalis pedis flap (n = 3), posterior interosseous flap (n = 3), first web space free flap (n = 3), and radial forearm flap (n = 1). Early active physical therapy was applied. All flaps survived. Functional return of pinch and grip strength was possible in 16 cases. In 11 cases of reconstruction of the dorsum of the hand, the total active range of motion in all joints of the fingers averaged 140 degrees. The mean grip strength was 16.5 kg and key pinch was 3.5 kg. In palm reconstruction, the wider contact area facilitated the grasping of larger objects. In thumb reconstruction, key-pinch increased to 5.5 kg and the angle of the first web space increased to 45 degrees. Jebsen's hand function test was not possible before surgery; postoperatively, it showed more functional recovery in gross motion and in the dominant hand. Aggressive contracture release of the bone,joints, tendons, and soft tissue is required for optimal results in the correction of severe postburn hand deformities. Various fasciocutaneous free flaps used to reconstruct the defect provide early motion, appropriate thinness, and excellent cosmesis of the hand.

Antimalarial, antiproliferative, and antitumor activities of artemisinin-derived, chemically robust, trioxane dimers

Nine C-10 non-acetal derivatives of the natural trioxane artemisinin (1) were prepared as dimers using some novel chemistry. As designed, each dimer was stable chemically. C-10 Olefinic dimers 7 and C-10 saturated dimers 8-13 all showed good to excellent antimalarial and antiproliferative activities in vitro. Dimers 8, 10, and 12 were especially potent and selective at inhibiting growth of some human cancer cell lines in the NCI in vitro 60-cell line assay.

Topoisomerase II inhibition by aporphine alkaloids

The aporphine alkaloids (+)-dicentrine and (+)-bulbocapnine are non-planar molecules lacking features normally associated with DNA binding by intercalation or minor groove binding. Surprisingly, dicentrine showed significant activity as a topoisomerase II (EC 5.99.1.3) inhibitor and also was active in a DNA unwinding assay. The DNA unwinding suggests DNA intercalation, which could explain the inhibition of topoisomerase II. Bulbocapnine, which differs from dicentrine only by the presence of a hydroxyl group at position 11 and the absence of a methoxyl group at position 9, was inactive in all assays. Molecular modeling showed that dicentrine can attain a relatively planar conformation, whereas bulbocapnine cannot, due to steric interaction between the 11-hydroxyl group and an oxygen of the methylenedioxy ring. These observations suggest that dicentrine is an "adaptive" DNA intercalator, which can bind DNA only by adopting a somewhat strained planar conformation. The requirement of a suboptimal conformation to achieve DNA binding appears to make dicentrine a weaker topoisomerase II inhibitor than the very planar oxoaporphine alkaloid liriodenine. These results suggest that it may be possible to modulate DNA binding and biologic activity of drugs by modifications affecting their ability to adopt planar conformations.

Microsurgical reconstruction of partial thumb defects

We have reconstructed thumb defects using microsurgical techniques in 43 patients. The flap survival was 100% and functional improvement with near normal appearance was obtained in the reconstructed thumbs. In order to obtain satisfactory results, donor sites were confined to the great toe and its adjacent structures and adventitia was removed from the vascular pedicle, which was transferred by subcutaneous tunnelling to minimize scar formation in the reconstructed thumb. The width of transferred nail and pulp volume were matched to the defect in the thumb before transfer.

Effects of endothelin-1 on Ca2+ signaling in guinea-pig ventricular myocytes: role of protein kinase C

The effects of ET-1 on contraction, Ca2+ transient and L-type Ca2+ current (ICa.L) were studied in single cells isolated from ventricles of guinea-pig hearts. The aim of our study was to elucidate the mechanism of the positive inotropic effect during endothelin receptor stimulation by focusing on the role of PKC. ET-1 at concentrations of 5 and 10 nM produced a biphasic pattern of inotropism: a first decrease in contraction by 34.4 +/- 2.5% of the control followed by a sustained increase in contraction by 66.6 +/- 8.4% (mean +/- SEM, n = 9). The Ca2+ transient decreased by 13.5 +/- 1.0% during the negative inotropic phase, while it increased by 58.1 +/- 8.4% (n = 10) during the positive inotropic phase. Using the whole-cell voltage-clamp technique with conventional microelectrodes, the application of ET-1 (5 nM) increased the ICa.L by 32.6 +/- 5.1% (n = 10), which was preceded by a short-lived decrease in ICa.L. Incubation of myocytes with pertussis toxin (PTX, at 2 micrograms/ml for > 3 h at 35 degrees C) failed to block the ET-1-induced enhancement of ICa.L. The increases in contraction, Ca2+ transient, and ICa.L by ET-1 were inhibited by pretreatment with 5-N-methyl-N-isobutyl amiloride (MIA; 10 microM), an amiloride analog, and a novel selective Na+/H+ exchange inhibitor HOE694 (10 microM). To determine whether activation of protein kinase C (PKC) is responsible for the enhancement of ICa.L by ET-1, we tested a PKC inhibitor, GF109203X, and found that it does exert an inhibitory effect on the ET-1-induced ICa.L increase. Our study suggests that during ET receptor stimulation an increase in ICa.L due to stimulation of Na+/H+ exchange via PKC activation causes an increase in Ca2+ transients and thereby in the contractile force of the ventricular myocytes.

KR025, a new cytotoxic compound from Myxococcus fulvus

A new bithiazole, KR-025 (1), was isolated from Myxococcus fulvus. Its structure was elucidated by spectroscopic analysis. In addition to 1, the strain produced relatively large quantities of a second, closely related antibiotic, myxothiazol. These compounds demonstrated potent cytotoxicity against human tumor cells.

Classification of the first web space free flap of the foot and its applications in reconstruction of the hand

Owing to its unique anatomic arterial supply and dual nerve innervation, the first web space of the foot can be used to harvest various sizes and shapes of flaps, which the authors have classified into four types according to their usage in hand reconstruction. This in turn depends on the site, shape, and size of the soft-tissue defect in the hand. Web skin flaps (n = 8) were used in prevention of contracture in the first web space and for proximal finger reconstruction. Two-island skin flaps (n = 4) were used to resurface the pulp defect in two adjacent fingers. In severe adduction contracture of the first web space, fill-up web flaps (n = 10) were used to replace the volume defect after a release procedure in the hand. Adjuvant web flaps (n = 9) were used in wrap-around procedures, in dorsalis pedis flap transfer, and in vascularized joint transfer to supplement the main flaps and to restore sensation in the reconstructed area. In the past 10 years up to February of 1998, a total of 31 patients with soft-tissue defects in the hand and fingers were reconstructed using the web space free flap with flap survival rate of 100 percent. The mean static 2-point discrimination was 8.5 (7.2 to 10) mm, and the mean first web angle was 86 degrees. The advantage of the first web space flap from the foot is that it can easily be harvested to match various sizes and shapes of defects in the hand and fingers. In addition, because of the anatomic similarity in contour, thickness, texture, and nerve innervation with the hand, the sensory restoration is excellent with minimal morbidity at the donor site. By classifying the flaps into four types according to various sizes, shapes, and the site from which the flap are harvested, clinical usefulness in various types of hand and finger reconstruction was confirmed.

Role of PKC in the effects of alpha1-adrenergic stimulation on Ca2+ transients, contraction and Ca2+ current in guinea-pig ventricular myocytes

The effects of alpha1-adrenoceptor stimulation on intracellular Ca2+ transients, contractility and L-type Ca2+ current (ICa,L) were studied in single cells isolated from ventricles of guinea-pig hearts. The aim of our study was to elucidate the mechanisms of the positive inotropic effect of alpha1-adrenergic stimulation by focussing on the role of protein kinase C (PKC). Phenylephrine, an alpha1-adrenergic agonist, at concentrations of 50-100 microM elicited a biphasic inotropic response: a transient negative inotropic response (22.9+/-6.0% of control) followed by a sustained positive inotropic response (61.0+/-8.4%, mean+/-SE, n=12). The Ca2+ transient decreased by 10.2+/-3.9% during the negative inotropic phase, while it increased by 67.7+/-10% (n=12) during the positive inotropic phase. These effects were inhibited by prazosin (1 microM), a alpha1-adrenergic antagonist. Phenylephrine increased the ICa,L by 60.8+/-21% (n=5) during the positive inotropic phase. To determine whether activation of PKC is responsible for the increases in Ca2+ transients, contractile amplitude and ICa,L during alpha1-adrenoceptor stimulation, we tested the effects of 4beta-phorbol 12-myristate 13-acetate (PMA), a PKC activator, and of bisindolylmaleimide I (GF109203X) and staurosporine, both of which are PKC inhibitors. PMA mimicked phenylephrine's effects on Ca2+ transients, contractile amplitude and ICa,L. PMA (100 nM) increased the Ca2+ transient, contractile amplitude and ICa,L by 131+/-17%, 137+/-25% (n=8), and 81.1+/-26% (n=5), respectively. Prior exposure to GF109203X (1 microM) or staurosporine (10 nM) prevented the phenylephrine-induced increases in Ca2+ transients, contractile amplitude and ICa,L. Our study suggests that during alpha1-adrenoceptor stimulation increase in ICa,L via PKC causes an increase in Ca2+ transients and thereby in the contractile force of the ventricular myocytes.

Effects of blood flow and venous network on the survival of the arterialized venous flap

The purpose of this study was to evaluate further factors that could explain the survival mechanism in the arterialized venous flap. The authors used 16 canines to investigate the survival rate and pattern of the arterialized venous flap and compared the results with those of the conventional saphenous flap. The number and distribution of draining veins in the arterialized venous flap group were varied to observe their impact on the survival rate and pattern. Gross examination of venous network, blood gas, venogram, blood pressure, and histologic study were also carried out. Although there was no significant difference in final survival rate between conventional flap and arterialized venous flap with two efferent veins (p > 0.01), that of the arterialized venous flap increased significantly as the number of draining veins increased. Blood gas analysis showed that more effective oxygen consumption took place when the number of draining veins increased. By measuring the blood flow and volume at 8 hours after the operation with a laser Doppler flowmeter, it was possible to predict the necrosis of the arterialized venous flap. Attachment to a high pressure arterial blood flow system induced smooth muscle proliferation and neogrowth of elastic fibers in the veins. Furthermore, progressive narrowing of the lumen hastened the development of a collateral circulation, demonstrated on a venogram by the tortuous vessels and neovascularization up to the flap margin. To make it possible to predict and achieve complete survival of the arterialized venous flap, the following criteria must be considered: (a) an arterialized venous flap should be designed to contain most of the venous network in the center, (b) the arterial inflow has to be anastomosed to one afferent vein, (c) two or more efferent veins should drain the arterialized venous flap.