Genomic Signature of Mismatch Repair Deficiency in Areca Nut-Related Oral Cancer

Areca nut (AN) chewing contributes to an increase of oral squamous cell carcinoma (OSCC) cases in South and Southeast Asia; however, genomic events underlying the carcinogenesis process of AN-related OSCC remain unclear. Here, we comprehensively describe the genomic and transcriptome alterations of 113 Chinese OSCC patients (89 AN related and 24 AN negative) by whole-exome sequencing and RNA sequencing, and we compared the genomic differences between AN-related and AN-negative samples by integrating sequencing data of 325 OSCC patients from The Cancer Genome Atlas database and 50 from a published Taiwanese study. We identified 11 significantly mutated genes for OSCC, including 4 novel ones (ATG2A, WEE1, DST, and TSC2), of which WEE1 and ATG2A mutated with significantly higher rates in AN-related samples (P = 0.04 and P = 0.003, respectively). Mutational signature analysis revealed that AN-related OSCCs were specially characterized by the genomic signature of mismatch repair deficiency (dMMR), which could also predict the prognosis status of AN-related OSCC. In addition, an elevated PD-L1 expression was also observed in both AN-related patients (P = 3.71 × 10^-11) and those with a high dMMR level (P = 1.99 × 10^-4). Further differential expression analysis and in vitro experiments confirmed the role of dMMR in the development of OSCC induced by AN exposure. Taken together, this study first revealed the molecular profiles and highlighted the role of dMMR in AN-related OSCC among the Chinese population and identified that AN-related OSCC may represent a potential cohort for effective anti-PD-1/L1 immunotherapy.

Secreted Protein Acidic and Rich in Cysteine (SPARC) Enhances Cell Proliferation, Migration, and Epithelial Mesenchymal Transition, and SPARC Expression is Associated with Tumor Grade in Head and Neck Cancer

Secreted protein acidic and rich in cysteine (SPARC) is a secreted protein which is involved in various biological processes. SPARC expression is associated with tumor metastasis and poor prognosis in several types of cancer. However, the SPARC-induced signaling pathway was not fully understood in head and neck cancer. In this study, our results showed that SPARC treatment promoted cell proliferation and migration in head and neck cancer cell lines FaDu and Detroit 562. In addition, SPARC induced expression of epithelial mesenchymal transition (EMT) regulators, including Slug, Snail, and Twist in Detroit 562. The results of phospho-kinase array analysis showed that SPARC treatment increased phosphorylation of some molecules including protein kinase B (PKB/AKT), ribosomal S6 kinase (RSK), and extracellular signal–regulated kinases (ERK). The expression of SPARC-induced EMT regulator Slug was suppressed by AKT inhibitor, but not ERK and RSK inhibitors. The SPARC expression in grade IV tumor samples is higher when compared to that in grade I–III tumor samples. Our results suggest that SPARC treatment enhances the EMT signaling pathway via activation of AKT, and exogenous SPARC and tumor expressing SPARC might be associated with tumor progression in head and neck cancers.

Management of venous ulcers according to their anatomical relationship with varicose veins

Background

Adequately excising varicose and incompetent perforating veins is necessary for reducing their recurrence rate of venous ulcer.

Method

In total, 66 venous ulcers (C6) in 1083 legs with primary varicose veins were managed through endoscopic-assisted surgery. In an endoscopic operative view, the nonvaricose, varicose, and incompetent perforating veins were clearly visualized and precisely dissected. The varicose and incompetent perforating veins were divided and completely excised.

Result

The varicose veins were traced to the base or periphery of the 55 ulcers. Moreover, 89.4% of the ulcers healed within 14 weeks. Kaplan–Meier analysis revealed a five-year recurrence rate of 0.0%, and the satisfaction mean score was 4.6.

Conclusion

Endoscopic-assisted surgery can be used to radically excise varicose veins complicated with venous ulcers; the surgery yields low recurrence and high satisfaction rates.

Microautologous Fat Transplantation for Primary Augmentation Rhinoplasty: Long-Term Monitoring of 198 Asian Patients

Background

Numerous techniques and materials are available for increasing the dorsal height and length of the nose. Microautologous fat transplantation (MAFT) may be an appropriate strategy for augmentation rhinoplasty.

Objectives

The authors sought to determine the long-term results of MAFT with the so-called one-third maneuver in Asian patients who underwent augmentation rhinoplasty.

Methods

A total of 198 patients who underwent primary augmentation rhinoplasty with MAFT were evaluated in a retrospective study. Fat was harvested by liposuction and was processed and refined by centrifugation. Minute parcels of purified fat were transplanted to the nasal dorsum with a MAFT-Gun. Patient satisfaction was scored with a 5-point Likert scale, and aesthetic outcomes were validated with pre- and postoperative photographs.

Results

The mean age of the patients was 45.5 years. The mean operating time for MAFT was 25 minutes, and patients underwent 1-3 MAFT sessions. The mean volume of fat delivered per session was 3.4 mL (range, 2.0-5.5 mL). Patients received follow-up for an average of 19 months (range, 6-42 months). Overall, 125 of 198 patients (63.1%) indicated that they were satisfied with the results of 1-3 sessions of MAFT. There were no major complications.

Conclusions

The results of this study support MAFT as an appropriate fat-transfer strategy for Asian patients undergoing primary augmentation rhinoplasty.

Level of Evidence: 4

Therapeutic

Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma

OBJECTIVES

We determine the diagnostic performance of emergent orbital computed tomography (CT) scans for assessing globe rupture in patients with blunt facial trauma.

METHODS

We performed a retrospective cohort study based on prospectively collected trauma registry and acute care surveillance data in a tertiary-care hospital. Patients aged at least 18 years who underwent isolated orbital CT scanning for assessing potential ocular trauma were examined. Analyses were performed to evaluate the magnitude of agreement between diagnosis by CT scanning and ophthalmic assessment, including globe rupture.

RESULTS

Our study cohort comprised 136 patients, 30% of whom (41 patients) sustained orbital wall fractures. Concordance for orbital CT diagnosis and the ophthalmic assessment of globe rupture was substantial (k=0.708). The relative risk of globe rupture was 0.692 (95% confidence interval (CI): 0.054-8.849) for superior wall fractures, 0.459 (95% CI: 0.152-1.389) for inferior wall fractures, 2.286 (95% CI: 1.062-4.919) for lateral wall fractures, and 0.637 (95% CI: 0.215-1.886) for medial wall fractures. According to multivariate analysis, lateral wall fractures were an independent risk factor for globe ruptures (adjusted odds ratio (OR)=12.01, P=0.011), and medial or inferior wall fracture was a protective factor (adjusted OR=0.14, P=0.012). In the stratified analysis of diagnostic performance of CT scan, specificity was highest among patients with orbital wall fractures (97.2%), followed by negative predictive volume (NPV, 97%), and accuracy (95.1%).

CONCLUSION

Among patients with blunt facial trauma who underwent isolated orbital CT scanning as part of ocular trauma assessment, the diagnostic performance of CT in detecting globe rupture is more accurate in patients with orbital wall fractures. Nevertheless, isolated orbital CT alone does not have a sufficiently high diagnostic performance to be reliable to rule out all globe ruptures. Lateral orbital wall fractures in blunt facial trauma patients, in particular, should prompt thorough evaluation by an ophthalmologist.

Autologous adipose-derived stem cells attenuate muscular atrophy and protect spinal cord ventral horn motor neurons in an animal model of burn injury

BACKGROUND AIMS

Burn injuries might increase muscle mass loss, but the mechanisms are still unclear. In this study, we demonstrated that burn injury induced spinal cord ventral horn motor neuron (VHMN) apoptosis and subsequently caused muscle atrophy and revealed the potential protection of autologous adipose-derived stem cells (ASCs) transplantation on spinal cord VHMNs and muscle against burn injury.

METHODS

Third-degree hind-paw burns were established by contact with a 75°C metal surface for 10 seconds. Adipose tissues were harvested from the groin fat pad, expanded in culture and labeled with chloromethyl-benzamido/1,1'-dioctadecyl-3,3,3',3'- tetramethyl indocarbocyanine perchlorate. The ASCs were transplanted into the injured hind paw at 4 weeks after burn injury. The lumbar spinal cord, sciatic nerve, gastrocnemius muscle and hind-paw skin were processed for immunofluorescent staining at 4 weeks after transplantation, including terminal deoxynucleotidyl transferase (TUNEL) assay, caspase-3, caspase-9, CD 90 and S100, and the gastrocnemius muscle was evaluated through the use of hematoxylin and eosin staining.

RESULTS

Caspase-3-positive, caspase-9-positive and TUNEL-positive cells were significantly increased in the corresponding dermatome spinal cord VHMNs after burn injury. Moreover, the decrease of Schwann cells in sciatic nerve and the increase of denervation atrophy in gastrocnemius muscle were observed. Furthermore, ASCs transplantation significantly attenuated apoptotic death of VHMNs and the area of muscle denervation atrophy in the gastrocnemius muscle fibers.

CONCLUSIONS

The animal model of third-degree burns in the hind paw showed significant apoptosis in the corresponding spinal cord VHMNs, which suggests that neuroprotection might be the potentially therapeutic target in burn-induced muscle atrophy. ASCs have potential neuroprotection against burn injuries through its anti-apoptotic effects.

Alleviation of neuropathic scar pain using autologous fat grafting

Traumatic wounds inflict small- and large-fiber sensory nerve damage, causing neuropathic pain in scar tissue, thus impairing patients' quality of life and leading to the development of psychological disorders. Autologous fat grafting has been clinically shown to improve scar quality, but few studies have explored the effects of this technique on pain. The purpose of this study was to assess the effect of fat grafting on treating neuropathic scar pain. From February 2008 to January 2013, 13 patients who were identified using the Douleur Neuropathique 4 Questions (scores>4/10) were enrolled in this study. The Visual Analog Scale (VAS) and Neuropathic Pain Symptom Inventory (NPSI) were used to evaluate pain preoperatively and 1 week, 4 weeks, and 24 weeks postoperatively. The mechanism of trauma, scar location and size, duration of allodynia, fat graft volume, pharmacologic therapy duration, and total follow-up time were recorded. Thirteen patients experiencing neuropathic pain were enrolled in this study. The mean±SD age was 33.08±16.35 years. The mean duration of pain was 4.29±2.85 months. The mean VAS score before treatment was 7.54±1.05. The mean VAS scores decreased by 4.38±1.66 after 1 week of treatment (P=0.009), 5.38±2.06 after 4 weeks of treatment, and 5.62±2.18 after 24 weeks of treatment. The mean NPSI scores were 49.38±13.25 before treatment, 25±14.4 after 1 week of treatment (P=0.004), 21±17.78 after 4 weeks of treatment, and 14.62±16.88 after 24 weeks of treatment. The 13 patients followed a mean of 24 weeks; 10 (77%) of the patients had improvement of 5 or greater on the VAS score. The mean follow-up period was 19.3±12.26 months (range, 6-38 months). No surgical complications were noted in this series. In our study, both VAS and NPSI scores decreased significantly, revealing that the autologous fat grafting can alleviate neuropathic scar pain 1 week after operation and in the long term.

Fat Grafting in Burn Scar Alleviates Neuropathic Pain via Anti-Inflammation Effect in Scar and Spinal Cord

Burn-induced neuropathic pain is complex, and fat grafting has reportedly improved neuropathic pain. However, the mechanism of fat grafting in improving neuropathic pain is unclear. Previous investigations have found that neuroinflammation causes neuropathic pain, and anti-inflammatory targeting may provide potential therapeutic opportunities in neuropathic pain. We hypothesized that fat grafting in burn scars improves the neuropathic pain through anti-inflammation. Burn-induced scar pain was confirmed using a mechanical response test 4 weeks after burn injuries, and autologous fat grafting in the scar area was performed simultaneously. After 4 weeks, the animals were sacrificed, and specimens were collected for the inflammation test, including COX-2, iNOS, and nNOS in the injured skin and spinal cord dorsal horns through immunohistochemistry and Western assays. Furthermore, pro-inflammatory cytokines (IL-1 β and TNF-α) in the spinal cord were collected. Double immunofluorescent staining images for measuring p-IκB, p-NFκB, p-JNK, and TUNEL as well as Western blots of AKT, Bax/Bcl-2 for the inflammatory process, and apoptosis were analyzed. Fat grafting significantly reduced COX2, nNOS, and iNOS in the skin and spinal cord dorsal horns, as well as IL-1β and TNF-α, compared with the burn group. Moreover, regarding the anti-inflammatory effect, the apoptosis cells in the spinal cord significantly decreased after the fat grafting in the burn injury group. Fat grafting was effective in treating burn-induced neuropathic pain through the alleviation of neuroinflammation and ameliorated spinal neuronal apoptosis.

Health care utilization and expenditures of persons with diabetes comorbid with anxiety disorder: a national population-based cohort study

OBJECTIVE

The aim of this study was to investigate and compare health care utilization and expenditures between persons with diabetes comorbid with and without anxiety disorder in Taiwan.

METHODS

Health care utilization and expenditures among persons with diabetes with and without comorbid anxiety disorder in the period 2000-2004 were examined using the Taiwan's National Health Insurance claims data. Health care utilization included outpatient visits and use of hospital inpatient services, while expenditures included outpatient, inpatient and total medical expenditures. General estimation equation (GEE) models were used to analyze the factors associated with outpatient visits and expenditures, and multiple logistic regression analysis was applied to identify factors associated with hospitalization.

RESULTS

In the study period, the average number of annual outpatient visits was 43.11-50.37 and 29.82-31.42 for persons with diabetes comorbid with anxiety disorder and for those without anxiety disorder, respectively. The average annual total expenditure was NT$74,875-92,781 and NT$63,764-81,667, respectively. Controlling for covariates, the GEE models revealed that age and time were associated with outpatient visits. Income and time factor were associated with total expenditure.

CONCLUSIONS

Health care utilization and expenditures for persons with diabetes with comorbid anxiety disorder are significantly higher than those without anxiety disorder. The factors associated with health care utilization and expenditures are age, income and time.

Tamai zone I fingertip replantation: is external bleeding obligatory for survival of artery anastomosis-only replanted digits?

BACKGROUND

Distal fingertip replantation is associated with good functional and aesthetic results. Venous anastomosis is the most challenging procedure. For replantation with an artery anastomosis-only procedure (no venous anastomosis), some protocols have been designed to relieve venous congestion involve anticoagulation and the creation of wounds for persistent bleeding. This report presents the authors' experience of fingertip survival after artery anastomosis-only replantation with no persistent external bleeding.

METHODS

Twelve Tamai zone I fingertip total amputation patients who underwent artery anastomosis-only replantations were recruited from February 2009 to June 2012. Nerve repair was performed if identified. The patients were not subjected to conventional external bleeding methods. Both the blood color on pinprick and fingertip temperature difference between the replanted and uninjured digits were used as indicators of deteriorated venous congestion.

RESULTS

The replanted digits of 11 patients survived. The only failed replant exhibited an average temperature difference of more than 6°C compared with the uninjured digits and consistently exhibited darker blood during the pinprick test. All other replants exhibited average temperature differences of less than 6°C.

CONCLUSIONS

In these Tamai zone I artery anastomosis-only replantations, fingertips survived without the use of external bleeding method, indicating that external bleeding is probably not obligatory for survival of artery anastomosis-only replanted digits distal to Tamai zone I. An increasing temperature difference between the replanted and uninjured digits and darker blood on pinprick may be used as indicators of deteriorating congestion signs.

Thermal response of a dental tissue induced by femtosecond laser pulses

This paper reports a theoretical and experimental study for thermal transport in a thin slice of human tooth induced by a 120 fs, 800 nm pulse laser at a repetition rate of 1 kHz. The surface reflectivity of enamel and the convection heat transfer coefficient were determined using an inverse heat transfer analysis. Instead of a fully three-dimensional modeling, two simplified two-dimensional (2D) planar and axisymmetric heat conduction models were proposed to simulate the temperature fields. The temperature responses obtained from the 2D planar and axisymmetric model agree well with the experimental measurements. On the other hand, the one-dimensional (1D) result significantly differs from the 2D axisymmetric one, suggesting that care should be taken when a 1D thermal model is considered for estimating temperature response.

Continuous intra-arterial chemotherapy for downstaging locally advanced oral commissure carcinoma

BACKGROUND

The purpose of this study was to assess the usefulness, safety, and efficacy of intra-arterial (IA) infusion chemotherapy for patients with locally advanced oral commissure cancer.

METHODS

Twenty-one patients with stages III and IV squamous cell carcinoma involving the mouth angle were recruited. Methotrexate (MTX; 50 mg/day) was continuously infused into the external carotid artery for a mean period of 8 days, followed by weekly IA bolus of 25 mg MTX for a mean period of 10 weeks.

RESULTS

Thirteen patients (62%) achieved a complete response (CR) and 7 patients (33%) had a partial response (PR). At a median follow-up of 69 months, the estimated 1-year, 3-year, and 5-year survival rates of the patients with CR versus PR were 100% versus 57%, 92% versus 43%, and 80% versus 43%, respectively.

CONCLUSION

Our data demonstrate that continuous IA chemotherapy could achieve a competitive acceptable survival rate and improved locoregional control of advanced oral commissure cancer.

17β-Estradiol attenuates secondary injury through activation of Akt signaling via estrogen receptor alpha in rat brain following subarachnoid hemorrhage

BACKGROUND

Apoptosis is implicated in vasospasm and the long-term sequelae of subarachnoid hemorrhage (SAH). This study tested the hypothesis that attenuation of SAH-induced apoptosis after 17β-estradiol (E2) treatment is associated with an increase in phosphorylation of Akt via estrogen receptor-α (ER-α) in rats.

MATERIALS AND METHODS

We examined the expression of phospho-Akt, ERα and ERβ, and apoptosis in cerebral cortex, hippocampus, and dentate gyrus in a two-hemorrhage SAH model in rats. We subcutaneously implanted other rats with a silicone rubber tube containing E2; they received daily injections of nonselective estrogen receptor antagonist (ICI 182,780), selective ERα-selective antagonist (methyl-piperidino-pyrazole), or ERβ-selective antagonist (R,R-tetrahydrochrysene) after the first hemorrhage.

RESULTS

At 7 d after the first SAH, protein levels of phospho-Akt and ERα were significantly decreased and caspase-3 was significantly increased in the dentate gyrus. The cell death assay revealed that DNA fragmentation was significantly increased in the dentate gyrus. Those actions were reversed by E2 and blocked by ICI 182,780 and methyl-piperidino-pyrazole, but not R,R-tetrahydrochrysene. However, there were no significant changes in the expression of the protein levels of phospho-Akt, ERα, ERβ, and caspase-3, and DNA fragmentation after SAH.

CONCLUSIONS

The present study shows that a beneficial effect of E2 in attenuating SAH-induced apoptosis is associated with activation of the expression of phospho-Akt and ERα, and alteration in caspase-3 protein expression via an ERα-dependent mechanism in the dentate gyrus. These data support further the investigation of E2 in the treatment of SAH in humans.

Micro-RNA profiling as biomarkers in flap ischemia-reperfusion injury

BACKGROUND

Ischemia-reperfusion injury (IRI) is usually the key and often plays an irreversible role to induce flap compromise in microvascular tissue transfers. This article aims to profile the expression of micro-RNAs (miRs) in free flap surgeries following IRI.

METHODS

The miRs expression profiling was initially surveyed in rat epigastric flap vessels using Agilent 350-Microarrayed miRs after IRI, and then quantified by real-time reverse transcription polymerase chain reaction in flap vessels and tissues (n = 5) at three intervals: before induction of ischemia (normoxia without IRI, sham), 2 and 72 hours after reperfusion following 2 hours of ischemia. Furthermore, for seven patients with free anterolateral thigh flap reconstruction, the miRs expression patterns in these flaps before induction of ischemia (normoxia), at 2 and 72 hours after reperfusion following an ischemic interval were investigated.

RESULTS

Four miRs (miR-96, miR-193-3p, miR-210, and miR-21) of 350 tested rat miRs were found to be positively significant. In rat flap vessels, the upregulation of these miRs at 72-hour reperfusion was statistically significant. These patterns were not noted in rat flap tissues, except for miR-96. However, there seemed to be no significant difference in human flap vessels between normoxia and 2-hour reperfusion following ischemia. In human flap tissue, significant upregulation of miR-193-3p, miR-210, and miR-21 was detected at 72-hour perfusion.

CONCLUSIONS

Our findings show some changes of four upregulated miRs in our model of IRI. We suggest that further investigation is needed to determine the role of miRs in IRI of microsurgical reconstruction.

Salvage for pectoralis major myocutaneous flap failure in head and neck reconstruction by microvascular flap

The pectoralis major myocutaneous pedicled flap (PMMPF) - the "workhorse" for head and neck reconstruction - is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) flaps were applied for tongue and mouth floor defects, while three anterolateral thigh (ALT) flaps were used for mouth floor, buccal, and cheek defects. All flaps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases.

Free flap reconstruction in patients with advanced oral squamous cell carcinoma: analysis of patient survival and cancer recurrence

BACKGROUND

The purpose of this study was to compare the initial conditions and treatment outcomes of patients with advanced stage IV oral squamous cell carcinoma (OSCC) treated with or without free flap reconstruction following ablative tumor resection.

METHODS

Two hundred forty-two pathological stage IV OSCC patients (without distant metastasis) treated by tumor ablation with free flap reconstruction (Group 1; n = 93) or without free flap reconstruction (Group 2; n = 149 treated with split-thickness skin grafts, primary closure of defects, secondary granulation of defects, and local or regional flaps) were recruited. We compared patient survival and cancer recurrence rates between these two groups.

RESULTS

Group 1 had significantly more advanced tumor stage than group 2. Despite the unfavorably expected prognosis in group 1, both positive margin rate (17.2% in Group 1 versus 23.5% in Group 2, P = 0.213) and cancer recurrence rate (36.6% in Group 1 versus 38.3% in Group 2; P = 0.792) were not significantly different between the two groups. The 5-year disease-specific survival were also the same (51.4% in Group 1 versus 52.6% in Group 2; P = 0.493).

CONCLUSIONS

Although cancer stages were more advanced in patients requiring free flap reconstruction, patient survival, and cancer recurrence in the patients with free flap reconstruction were maintained as patients without free flap.

Two-year quality of life after free flap reconstruction in tumor-site discrepancy among Taiwanese with moderately advanced oral squamous cell carcinoma

Background

This study describes 2-year impact on quality of life (QOL) in relation to the anatomical discrepancy among T4a oral cancer patients after free flap reconstruction in Taiwan.

Methods

Thirty-two patients who underwent tumor ablation with simultaneous microvascular free flap transfer at 2-year follow-up were recruited. They were divided into six subgroups, according to the resected area, consisting of: (1) buccal/retromolar trigone; (2) cheek; (3) commissure; (4) lip; (5) mandible; and (6) tongue. Functional disturbances and daily activity were analyzed using the Version-1 UW QOL Questionnaire with one more specific category: ‘Drooling’. Kruskal-Wallis rank sums analysis was used to test differences in average QOL scores between these subgroups. Post-hoc analysis was applied to assess influence of dominant categories between subgroups.

Results

The category ‘Pain’ revealed the highest average score and reached significant statistical difference (P = 0.019) among all the categories, however, the category ‘Employment’ averaged the lowest score. Regarding ‘Pain’, there existed a statistical significance (P = 0.0032) between the commissure- and cheek-involved groups, which described the former showed poorer pain quality of life.

Conclusions

The commissure-involved group had the lowest average score, which might imply the worst QOL in our study, especially for the categories ‘Pain’ and ‘Drooling’. This present study of T4a patients was the first carried out in Taiwan implementing the QOL questionnaire, and its results may serve for future reference.

Prevalence and incidence of diagnosed depression disorders in patients with diabetes: a national population-based cohort study

OBJECTIVE

This study aimed to investigate the prevalence and incidence of diagnosed depression disorders among patients with diabetes in Taiwan.

METHODS

Study subjects were identified by at least one service claim for ambulatory or inpatient care with a principal diagnosis of depression disorder, and at least two service claims for ambulatory care or one service claim for inpatient care with a principal diagnosis of diabetes from 2000 to 2004, as found in the National Health Insurance database.

RESULTS

The 1-year prevalence of diagnosed depression disorders in the general population was 11.22 per 1000 in 2000, while the 5-year cumulative diagnosed prevalence increased to 40.76 per 1000 in 2004. The 1-year prevalence rate of diagnosed depression disorders among patients with diabetes was 33.95 per 1000 in 2000, and the 5-year cumulative prevalence increased to 92.17 per 1000 in 2004. Patients with diabetes had a higher 5-year cumulative prevalence and annual incidence than the general population throughout the observation period. A higher diagnosed prevalence was associated with a monthly income <US*$640 using multiple logistic regression analysis. Cox regression analysis revealed that a lower incidence was associated with male gender.

CONCLUSIONS

The prevalence and annual incidence density of diagnosed depression disorders in patients with diabetes were significantly higher than those in the general population. The prevalence of diagnosed depression disorder among patients with diabetes in Taiwan was lower than the rate in Western countries.

Analysis of medical litigation among patients with medical disputes in cosmetic surgery in Taiwan

BACKGROUND

This study aimed to investigate the key factors in medical disputes (arguments) among female patients after cosmetic surgery in Taiwan and to explore the correlates of medical litigation.

METHODS

A total of 6,888 patients (3,210 patients from two hospitals and 3,678 patients from two clinics) received cosmetic surgery from January 2001 to December 2009. The inclusion criteria specified female patients with a medical dispute. Chi-square testing and multiple logistic regression analysis were used to analyze the data.

RESULTS

Of the 43 patients who had a medical dispute (hospitals, 0.53%; clinics, 0.73%), 9 plaintiffs eventually filed suit against their plastic surgeons. Such an outcome exhibited a decreasing annual trend. The hospitals and clinics did not differ significantly in terms of patient profiles. The Chi-square test showed that most patients with a medical dispute (p < 0.05) were older than 30 years, were divorced or married, had received operations under general anesthesia, had no economic stress, had a history of medical litigation, and eventually did not sue the surgeons. The test results also showed that the surgeon's seniority and experience significantly influenced the possibility of medical dispute and nonlitigation. Multiple logistical regression analysis further showed that the patients who did decide to enter into litigation had two main related factors: marital stress (odds ratio [OR], 10.67; 95% confidence interval [CI], 1.20-94.73) and an education level below junior college (OR, 9.33; 95% CI, 1.01-86.36).

CONCLUSION

The study findings suggest that the key characteristics of patients and surgeons should be taken into consideration not only in the search for ways to enhance pre- and postoperative communication but also as useful information for expert testimony in the inquisitorial law system.

Continuous intra-arterial infusion chemotherapy as a palliative treatment for oral squamous cell carcinoma in octogenarian or older patients

We intend to determine the potential benefits and analyze the outcomes of regional intra-arterial infusion chemotherapy (IAIC) for the octogenarian and older patients with oral cancer. Eighteen patients with oral squamous cell carcinoma were included. They were 12 males and six females with ages ranging from 80 to 96 years. An implantable port-catheter system was used for catheterization. Using a portable pump, methotrexate was given continuously through the external carotid artery for a mean period of 5.5 days (range, 4-7 days) followed by weekly bolus of low dose (25mg) of methotrexate until the clinical condition was stabilized. During the first week of IAIC, all tumors began to reduce in size. Of them 11 (61%) had a complete clinical response and 7 (39%) achieved a partial clinical response, after a mean follow-up period of 26 months (range, 8-72 months). The one- and three-year survival rates were 87% and 56%, respectively. There were no catheter-related complications. The side effects were mild and tolerable. IAIC might be specially indicated for oral cancer elderly with co-morbidity since a radical surgery or extensive radiotherapy can be avoided, and offers an acceptable palliative treatment in such patients.

Free flap options for reconstruction of complicated scalp and calvarial defects: report of a series of cases and literature review

OBJECTIVE

The advent of free tissue transfer has offered several options that allow the restoration of both the structural and functional defects of the scalp and calvaria caused by malignant tumors or sequelae after trauma. This study aims to investigate the free flap options for complicated scalp and calvarial reconstructions.

METHODS

There were 12 free tissue transfers used to reconstruct scalp and calvarial defects in this study, with nine acute or subacute wounds resulting from trauma or cranietomy, two congenital hydrocephalus post ventriculo-peritoneal shunting and one primary cancer. They consisted of five fasciocutaneous flaps (four anterolateral thigh fasciocutaneous flaps and one deep inferior epigastric perforator flap) and seven myocutaenosu flaps (five anterolateral thigh myocutaneous flaps and two rectus abdominis myocutaneous flaps).

RESULTS

The overall flap success rate was 100%. There were no major complications except for one where wound dehiscence was caused by hematoma accumulation and was healed by local debridement. All donor sites underwent primary closure except for three receiving split-thickness skin grafting after bulky anterolateral thigh flap harvest. No major donor-site morbidity was observed except for one patient with some graft loss.

CONCLUSIONS

With its evident structural and functional advantages, fasciocutaneous flaps were suitable for larger scalp defect only and myocutaneous flaps can be considered as an excellent reconstructive option for complicated scalp and calvarial defects, especially where dead space coexists.

Attenuation of subarachnoid hemorrhage-induced apoptotic cell death with 17 beta-estradiol. Laboratory investigation

OBJECT

Apoptosis is implicated in vasospasm and long-term sequelae of subarachnoid hemorrhage (SAH). The authors observed that 17beta-estradiol (E2) can attenuate cerebral vasospasm, lower endothelin-1 production, and preserve normal endothelial nitric oxide synthase expression by reduction of inducible NO synthase expression in experimental SAH. The authors investigated the potential antiapoptotic effects of E2 in an experimental rat model of SAH.

METHODS

The authors examined the antiapoptotic effects of E2 in a double-hemorrhage SAH model in male Sprague-Dawley rats. The rats underwent subcutaneous implantation of a Silastic tube containing corn oil either with or without E2, and some E2-treated animals also received ICI 182,780 (a nonselective estrogen receptor [ER] antagonist) for 7 days after SAH. The degree of vasospasm was determined by averaging the cross-sectional areas of the basilar artery 7 days after SAH. The expression of apoptotic indicators, including TNF-alpha, caspase 3, Bcl-2, Bax, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL), and cell death assays were used for detection of apoptosis.

RESULTS

Treatment with E2 significantly attenuated SAH-induced vasospasm. Seven days after the induction of SAH, positive TUNEL-staining was seen, and DNA fragmentation was increased in the dentate gyrus. Increased TNF-alpha and cleaved caspase-3 protein expression and decreased Bcl-2 protein expression in the dentate gyrus were also observed. These changes were reversed with E2-treatment but not in the presence of ICI 182,780. However, the expression of Bax did not change after SAH either with or without E2 treatment.

CONCLUSIONS

The authors found that E2 appears to confer an antiapoptotic effect that reduces secondary brain injury after SAH via estrogen receptor-dependent mechanisms. This finding provides support for possible future applications of E2 treatment for the reduction of secondary injury after SAH in patients.

Attenuation of cerebral vasospasm and secondary injury by 17beta-estradiol following experimental subarachnoid hemorrhage

OBJECT

Cerebral vasospasm remains a major complication in patients who have suffered a subarachnoid hemorrhage (SAH). Previous studies have shown that 17beta-estradiol (E2) attenuates experimental SAH-induced cerebral vasospasm. Moreover, E2 has been shown to reduce neuronal apoptosis and secondary injury following cerebral ischemia. Adenosine A1 receptor (AR-A1) expression is increased following ischemia and may represent an endogenous neuroprotective effect. This study was designed to evaluate the efficacy of E2 in preventing cerebral vasospasm and reducing secondary injury, as evidenced by DNA fragmentation and AR-A1 expression, following SAH.

METHODS

A double-hemorrhage model of SAH in rats was used, and the degree of vasospasm was determined by averaging the cross-sectional areas of the basilar artery 7 days after the first SAH. A cell death assay was used to detect apoptosis. Changes in the protein expression of AR-A1 in the cerebral cortex, hippocampus, and dentate gyrus were compared with levels in normal controls and E2-treated groups (subcutaneous E2, 0.3 mg/ml).

RESULTS

The administration of E2 prevented vasospasm (p < 0.05). Seven days after the first SAH, DNA fragmentation and protein levels of AR-A1 were significantly increased in the dentate gyrus. The E2 treatment decreased DNA fragmentation and prevented the increase in AR-A1 expression in the dentate gyrus. There were no significant changes in DNA fragmentation and the expression of AR-A1 after SAH in the cerebral cortex and hippocampus in the animals in the control and E2-treated groups.

CONCLUSIONS

The E2 was effective in attenuating SAH-induced cerebral vasospasm, decreasing apoptosis in the dentate gyrus, and reducing the expression of AR-A1 in the dentate gyrus after SAH. Interestingly, E2 appears to effectively prevent cerebral vasospasm subsequent to SAH as well as attenuate secondary injury by reducing both apoptosis and a compensatory increase in AR-A1 expression in the dentate gyrus.

Contour refinements of free flaps for optimal outcome in oral reconstruction: combination of modified liposuction technique and w-plasty in one-stage procedure

BACKGROUND

Bulkiness and unsightly scarring are the major complaints after oral cancer reconstruction with free flap transfer. Some debulking procedures, such as blunt-tipped cannula liposuction or staged excision, can result in some improvement, but these methods do not provide a one-stage procedure for flap thinning and scar revision due to the concern of flap ischemic change. All suction lipectomy methods were applied on flap resurfacing cases; no through-and-through defect case was used. The author used a nonstandard open-tip cannula for liposuction and w-plasty for scar revision in a one-stage operation in oral through-and-through defect cases. This method achieved excellent aesthetic results without complications.

MATERIAL AND METHODS

From January of 2004 to October of 2006, secondary debulking procedures were performed on 22 patients who had undergone reconstruction with free anterolateral thigh flaps. All flaps were on the cheek for oral cancer through-and-through defect reconstruction. Suction lipectomy with nonstandard open-tip cannula and w-plasty were performed.

RESULTS

All flaps survived well without any partial skin necrosis. Over 85% of patients were satisfied with the outcome.

CONCLUSIONS

This method can provide a one-stage debulking procedure for the cheek through-and-through defect after free flap reconstruction, and it achieves good aesthetic outcomes.

A new trend for the treatment of blepharoptosis: frontalis-orbicularis oculi muscle flap shortening technique

Operation techniques for blepharoptosis have been a great challenge for plastic surgeons. Complications and recurrence in conventional operations of eyelid ptosis cannot be neglected. The finding of the close linkage between the longitudinal-oriented frontalis muscle (FM) and the horizontal-orientated orbicularis oculi (OOM) muscle convinced us of the efficacy to develop the dynamic and powerful Frontalis-Orbicularis Oculi Muscle (FOOM) flap-shortening technique which corrects blepharoptosis with good biomechanics in place of the traditional frontalis muscle sling. From January 2003 to September 2007, the FOOM flap shortening technique was applied on 35 ptotic eyelids of 31 patients, age ranging from 18 year to 77 years. All FOOM flaps were harvested and adjusted depending on the severity of the blepharoptosis. The follow up period ranged from 5 to 55 months. Thirty eyelids had good results, with the degree of ptosis less than 2mm. There were only five recurrent ptotic eyelids due to technical undercorrection. The estimation of resected length is measured when the FOOM flap is fully stretched and the length is approximately 22.0-23.0 mm for mild cases, 23.0-24.0 mm for moderate cases, and 25.0-26.0 mm for severe blepharoptosis. The FOOM flap-shortening technique was developed and corrected blepharoptosis with good results compared to conventional operation techniques. It achieves antagonistic equilibrium with ideal biomechanics by debilitating eye-closing power and enhancing eye-opening power.

17Beta-estradiol activates adenosine A(2a) receptor after subarachnoid hemorrhage

BACKGROUND

Our previous study showed that 17beta-estradiol (E2) and an adenosine A(2A) receptor (AR-A(2A)) agonist could attenuate subarachnoid hemorrhage (SAH)-induced cerebral vasospasm via preventing the augmentation of iNOS expression and preserving the normal eNOS expression. This study tests the hypothesis that E2 attenuates SAH-induced vasospasm and apoptosis by activating adenosine AR-A(2A) and extracellular signal-regulated kinase 1 and 2 (ERK1/2), and by altering antiapoptotic and proapoptotic protein expression (Bcl-2 and Bax, respectively).

MATERIALS AND METHODS

The two-hemorrhage SAH model in rat was used. Animals were treated with E2 with or without a nonselective estrogen receptor (ER) antagonist (ICI182,780). The cross sectional areas of the basilar artery and terminal dUTP nick-end labeling (TUNEL) were used to determine the degree of vasospasm and apoptosis, respectively. The expressions of Bcl-2, Bax, AR-A(2A), and ERK1/2 in the cerebral cortex, hippocampus, and dentate gyrus were investigated.

RESULTS

E2 significantly attenuated vasospasm. Seven days after the first SAH, TUNEL scores were significantly increased, and protein levels of AR-A(2A), ERK1/2, and Bcl-2 were significantly decreased in the dentate gyrus only but not in the cortex and hippocampus. These changes were reversed by E2 while ICI182,780 abrogated the antiapoptotic and anti-spastic effects of E2. The expression of Bax did not change in the dentate gyrus after SAH with or without treatment.

CONCLUSIONS

The down-regulated AR-A(2A) and ERK may play a role in vasospasm and apoptosis after SAH. The beneficial effect of E2 in the attenuating SAH-induced vasospasm and apoptosis may be due to an increased expression of AR-A(2A) and ERK via ER-dependent mechanisms. These data may support further investigation of E2 in the treatment of SAH in humans.

Cell biology of host-parasite membrane interactions in leishmaniasis

Molecular interactions at the host-parasite interface are crucial for the outcome of microbial infection, particularly in infection by intracellular parasites, such as Leishmania donovani and Leishmania mexicana, whose natural transmission begins with the delivery of the promastigote stage by the sandfly vector into the susceptible host. The ensuing event is intracellular parasitism of macrophages in the host by the amastigote stage. The establishment of this event in leishmaniasis must follow the sequence: (1) Leishmania-macrophage attachment; (2) entry of Leishmania species into macrophages; (3) intra-macrophage survival and differentiation of Leishmania species; and (4) intracellular multiplication of Leishmania species. This sequence precedes all clinical symptoms and pathological consequences in different forms of the disease. Study of these cellular events in Leishmania-macrophage systems in vitro indicates that host-parasite membrane interactions dictate many of the cellular events. Some morphological and functional changes of macrophages in response to leishmanial infection are related to their membrane activities, i.e. endocytosis and exocytosis. Leishmania parasites undergo profound plasma membrane-related changes, on entry into macrophages, at the morphological, antigenic and molecular levels. Most of these changes probably reflect necessary steps for the transition of Leishmania species from an extracellular to an intracellular life. The remarkable ability of Leishmania species subsequently to live in the secondary lysosome of the macrophage may also be due to certain intrinsic structures and dynamic properties of the parasite plasma membrane. Further analysis of leishmanial surface molecules and their interactions with macrophages is essential in any attempt to understand the pathogenic mechanism in leishmaniasis.

Clinical experience of a microvascular venous coupler device in free tissue transfers

Most free flap failures result from technical problems in performing vascular anastomoses, such as endothelial intima lacerations, distortion of the vessels, and unequal intersuture distances. These incorrect practices can lead to thrombosis formation and, ultimately, flap failure. Solving this problem is a challenging issue for all micro-reconstructive surgeons. In the last decade, a vascular anastomotic coupler instrument was developed and reported on. We review our recent experiences of free tissue transfer using this vascular coupler device, and discuss how venous problems can be overcome with its aid. We believe the excellent patency rate of the coupler may minimize the well-described problems of venous thrombosis in the challenging field of free tissue reconstructions.

Management of poisonous snake bites in southern Taiwan

Snake bite envenomation is not uncommon in Taiwan. This study focuses on the pattern of poisonous snake bites and their management in southern Taiwan over a 5-year period. The case histories of 37 patients with poisonous snake bites admitted to the Kaohsiung Medical University Hospital between June 2001 and July 2005 were analyzed retrospectively. Three patients, bitten by unknown species of venomous snakes, were excluded from this study. The frequency of snakebites from each species of snake, the local and systemic manifestations of snake bite, treatment of complications and final outcomes were analyzed. Of the remaining 34 patients, 11 (32.4%) were bitten by bamboo vipers, 10 (29.4%) by Russell's pit vipers, 8 (23.5%) by Taiwan cobras and 5 (14.7%) by Taiwan Habu. The majority of snake bites (28) occurred between May and November. Those affected were mainly outdoor hikers (14) and workers (9). The antivenin requirements for treatment in the emergency room were in accordance with standard procedures. No mortality was noted among those envenomed by poisonous snakes. Although poisonous snake bite is not a common life-threatening emergency in the study area, we observed both an environmental risk and a seasonal incidence of snake bite. Keeping the varied clinical manifestations of snake bite in mind is important for effective management. Ready availability and appropriate use of antivenin, close monitoring of patients, institution of ventilatory support and early referral to a larger hospital when required, all help reduce mortality.

Skin Grafting on the Gastric Wall Following Gastric Pull-Up Reconstruction: A Case Report

A simple, rapid, reliable technique to close an anterior neck defect is presented. This technique involves skin grafting directly onto the de-serosalized stomach wall following gastric pull-up reconstruction for a hypopharyngeal cancer.

Use of single saphenous interposition vein graft for primary arterial circuit and secondary recipient site in head and neck reconstruction: A case report

BACKGROUND

Autologous vein grafts are a valuable tool in microsurgical free tissue transfer. Interposition vein grafts offer the surgeon greater freedom when placing the free flap and choosing the recipient vessels, providing valuable options in case recipient vessels are not available for those patients with large wounds. Free flaps transferred to head and neck regions carry a higher risk of failure, which may be expected to increase more with the use of vein grafts.

METHODS

We present our case with the double use of a single vein graft for both primary arterial conduit in end-to-end fashion and secondary end-to-side recipient site in the microsurgical reconstruction of a complicated head and neck defect.

RESULTS

All these anastomoses and flaps survived perfectly, and the patient was discharged 14 days after the transfer of the second flap.

CONCLUSION

Although the anastomosis of 2 flaps to a single vein graft was successful in our case, it represents a higher risk option than different recipient vessels. We provide this alternative procedure in selected patients, as there is no other receipt vessel or recipient blood flow strong enough to supply more than 1 flap.

Peripheral Sympathectomy for Raynaud's Phenomenon: A Salvage Procedure

We retrospectively reviewed the effectiveness of peripheral sympathectomy for severe Raynaud's phenomenon. In this study, a total of 14 digits from six patients with chronic digital ischemic change were included. All patients had pain, ulcer, or gangrenous change in the affected digits and were unresponsive to pharmacologic or other nonsurgical therapies. In all cases, angiography showed multifocal arterial lesions, so microvascular reconstruction was unfeasible. Peripheral sympathectomy was performed as a salvage procedure to prevent digit amputation. The results were analyzed according to reduction of pain, healing of ulcers, and prevention of amputation. In 12 of the 14 digits, the ulcers healed and amputation was avoided. In the other two digits, the ulcers improved and progressive gangrene was limited. As a salvage procedure for Raynaud's phenomenon recalcitrant to conservative treatment, peripheral sympathectomy improves perfusion to ischemic digits and enables amputation to be avoided.