Palliative Free Flap Surgery for Plantar Sarcoma: A Case Report and Literature Review

We report a case of palliative surgery in a 73-year-old patient with metastatic plantar sarcoma. The patient underwent resection and irradiation of an undifferentiated spindle cell sarcoma in the right plantar region. The wound was not closed and systemic metastases were observed. The chief complaint of the patient on his first visit to our department was difficulty walking due to pain in the right plantar region. Since we were unsuccessful in relieving the pain with conservative treatment, we decided to perform a palliative free tissue transfer to the right plantar. The surgery was successful, the skin ulcer healed, and the pain was relieved after the surgery. When performing palliative surgery, more detailed preoperative management and planning are necessary to achieve a successful outcome. The selection of the flaps according to the local lesion and metastatic lesions and changes in the local hemodynamics should be considered when planning.

Changes in nutritional status by recovery phase interventions would be a powerful determinant of cardiovascular prognosis in heart failure patients

Background

Adequate nutrition has been proposed for better cardiovascular prognosis as well as fitness, although the impact of the “changes” in nutrition and fitness at recovery phase on the future prognosis has been unclear.

Purpose

We aimed to examine whether the change in nutritional level as a result of dietary intervention combined with exercise would determine patients' cardiovascular prognosis.

Methods

This study involved 398 consecutive patients who participated in phase II comprehensive cardiac rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion periods of CCR. Individual dietary guidance was periodically performed with exercise. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided in two groups according to the baseline GNRI and the change in GNRI (ΔGNRI) by the median, respectively, to compare their prognosis between groups. Then they were classified into four categories according to the median values of the changes in GNRI (ΔGNRI) and PVO2 (ΔPVO2) during CCR: “Both improved”, “Only GNRI improved”, “Only PVO2 improved” and “Both NOT improved”, to compare MACCE-free rate between categories.

Results

The rate of MACCE showed significant difference between categories (14%, 18%, 19% and 36%, p<0.001), which was approximately 2 times higher in “Both NOT improved” than the others. Kaplan-Meier analysis showed that according to the level of ΔGNRI, “higher ΔGNRI group” showed significantly higher in MACCE-free survival rate than “lower ΔGNRI group” (log rank p=0.010), whereas there was no significant difference according to the baseline GNRI (see figure). According to the categories divided by ΔGNRI and ΔPVO2, MACCE-free rate was significantly lower in “Both NOT improved” (log rank p<0.001) compared to the other categories. Cox proportional hazard regression analysis revealed that “both NOT improved” was an independent predictor of MACCE (hazard ratio, 2.1, 95% confident interval, 1.344–3.175, p<0.001).

Conclusion

Changes in nutritional level would determine patients' cardiovascular prognosis rather than the baseline nutritional level. Non-responders who showed no improvement in nutritional or fitness by interventions may result in a poor cardiovascular outcome.

Funding Acknowledgement

Type of funding source: None

Value of remote ischaemic preconditioning in rat dorsal skin flaps and clamping time

OBJECTIVE

According to previous reports, remote ischaemic preconditioning (RIPC) is a "delay" procedure that is highly likely to be useful for preventing skin flap necrosis. Differences in the extent of necrosis in rat dorsal skin flaps when different clamping times were used in RIPC were compared among the four groups described below.

METHODS

Group A was a control group in which no prior ischaemic area was created, and both back legs were devascularised for 15 min in Group B, 30 min in Group C, and 60 min in Group D. The experiments were performed on 10 rats in each group, and the surviving area was measured. One-way analysis of variance (ANOVA) and Tukey's multiple comparison test were used for analysis, with p < 0.05 regarded as significant.

RESULTS

The surviving area of the skin flap was 15.4 ± 1.8 cm(2) in Group A, 15.4 ± 2.0 cm(2) in Group B, 17.9 ± 2.0 cm(2) in Group C, and 19.2 ± 3.4 cm(2) in Group D, with significant differences between Groups A and D and between Groups B and D.

CONCLUSIONS

RIPC consisting of 60 min of ischaemic preconditioning may be clinically useful as a method of preventing skin flap necrosis.

The finite element analysis of brain oedema associated with intracranial meningiomas

The mathematical model of vasogenic brain oedema, which was presented at the previous meeting in 1987, was applied to the analysis of peritumoural brain oedema associated with meningiomas. Magnetic resonance images of 90 patients with intracranial meningiomas were reviewed to analyze the spatial extension of peritumoural brain oedema. It is assumed that the heterogeneous pattern of distribution of peritumoural oedema reflects the variability of the compact density of the fibers in the white matter. A two dimensional finite element model was constructed with 786 triangular elements from a horizontal section of the human brain. The development of oedema, the change of interstitial pressure, the deformation of the brain and the absorption of oedema fluid could be simulated by the finite element method. The result of computer simulation represented interactive behaviour of the brain tissue, extracellular fluid, and cerebrospinal fluid in the clinical situation. The finite element method (FEM) may provide a new experimental tool to analyze the pathophysiology of vasogenic brain oedema.

[Continuous subcutaneous infusion of GnRH agonist: effective dosage in the treatment of endometriosis and its influence on the ovarian response to human menopausal gonadotropin]

This study was designed to compare the clinical and hormonal efficacy of the treatment for endometriosis using continuous infusion of three different doses of GnRH agonist (A). In addition, we examined the ovarian responsiveness to human menopausal gonadotropin (hMG) administration during GnRH-A treatment. Thirteen endometriosis patients were divided into 3 groups and given different doses. GnRH-A (Buserelin) was infused continuously through the subcutaneous route at rates of 200 micrograms (Group I; n = 5), 100 micrograms (Group II, n = 4) and 10 micrograms (Group III; n = 4) per day for 24 weeks. After the start of treatment, serum estradiol (E2) was suppressed to the menopausal range within 2 weeks and thereafter maintained this range until 24 weeks in each group. The LH and FSH response to a GnRH Challenge test was completely abolished within 2 weeks in 3 groups. Although serum FSH decreased to below the pretreatment value within a week, the FSH level was significantly lower in groups I and II than in group III until 8 weeks. No difference in the LH level during the treatment was seen among the 3 groups. After completion of the 24 weeks' treatment, FSH increased rapidly, and ovulation returned within 4 to 6 weeks in each group. Pregnancy was achieved in two patients in group I, one patient in group II and one patient in group III during cycles 2 and 5. Serum E2 increased to 200-300 pg/ml in 3 out of 7 patients treated with hMG during GnRH-A infusion, whereas no increase in E2 was seen in the remaining 4 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Successful treatment of endometriosis in women with continuous subcutaneous infusion of gonadotropin-releasing hormone agonist (GnRH-A)]

The clinical and hormonal effectiveness of continuous infusion of GnRH-agonist (A) for the treatment of endometriosis was investigated. Five women with endometriosis (stage II-IV) were treated with continuous subcutaneous infusion of 200 micrograms of GnRH-A (Buserelin) per day for 24 weeks. Serum LH and FSH levels increased initially and then FSH levels declined markedly below pretreatment values within a week, followed by a gradual decrease to the normal range of LH levels within 4 weeks. Serum estradiol decreased below early follicular phase levels within 1 to 3 weeks and thereafter continued to decrease to near castrate levels. The LH and FSH responses to 100 micrograms GnRH challenge test were almost completely abolished within 2 weeks. The pulsatile secretion of LH and FSH were also abolished, when assessed at 16 weeks. The tendency toward the slight but significant elevation in FSH levels without an increase in estradiol was noted from about 12 weeks. No vaginal bleeding or spotting was observed in four of the five patients during the course of the treatment. After completion of the 24 weeks of treatment, FSH increased rapidly to the early follicular phase range, and ovulation returned within 4 weeks. Two of the five patients became pregnant during cycles 2 and 5. From these results, we conclude that continuous sc infusion of GnRH-A is highly effective for complete suppression of the pituitary-ovarian function in patients with endometriosis. Further, this treatment appears to be safe and acceptable, because of its rapid reversibility and its lack of side effects.

[Pulsatile secretion of prolactin during the human menstrual cycle]

Recent investigations have demonstrated the pulsatile nature of prolactin (PRL) secretion and the synchronous relationship between PRL and LH pulses in normal and hypogonadal women. The present study was designed to confirm this synchrony and to investigate the characteristics of PRL pulses at different stages of the menstrual cycle. Blood samples were obtained at 10-min intervals beginning at 1000 h for a duration of 4-7 h in women during the follicular (n = 11), preovulatory LH surge (n = 2) and luteal phases (n = 10). Detectable pulses in plasma PRL concentrations were present in almost all subjects during the each phase of the cycle. During the total 121 h-blood sampling throughout the three phases, 62 PRL pulses and 74 LH pulses were detected and about 80% of these PRL pulses were observed to coincide with LH pulses. The mean (+/- SD) pulse frequency of PRL was significantly lower during the luteal phase (0.28 +/- 0.17 pulses/h) than during the follicular (0.64 +/- 0.25 pulses/h) and preovulatory phases (0.72 +/- 0.16 pulses/h). The mean pulse amplitude of PRL was significantly greater during the luteal phase (6.8 +/- 2.3 ng/ml) than during the follicular (3.6 +/- 1.2 ng/ml) and preovulatory phases (4.8 +/- 1.4 ng/ml). These changes in pulse frequency and amplitude were also observed in LH pulses between the follicular and luteal phases, except during the LH surge when LH pulse amplitude increased markedly, whereas that of PRL did not alter. Further, a positive linear correlation between the pulse frequency of PRL and LH (r = 0.74; p less than 0.001) was found throughout the three phases of the cycle.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulsatile secretion of prolactin and luteinizing hormone and their synchronous relationship during the human menstrual cycle

Recent investigations have demonstrated the pulsatile nature of prolactin (PRL) secretion and the synchronous relationship between PRL and LH pulses in normal and hypogonadal women. The present study was designed to confirm this synchrony and to investigate the characteristics of PRL pulses at different stages of the menstrual cycle. Blood samples were obtained at 10-minute intervals, beginning at 10.00 hours, for a duration of 4-7 hours, from women during the follicular (n = 11), preovulatory (n = 2) and luteal (n = 10) phases. Detectable pulses in plasma PRL concentrations were present in almost all subjects during each phase of the cycle. During the total 121-hour blood sampling throughout the 3 phases, 62 PRL pulses and 74 LH pulses were detected and about 80% of the PRL pulses were observed to coincide with LH pulses. The mean (+/- SD) pulse frequency of PRL was significantly lower during the luteal phase (0.28 +/- 0.17 pulses/hour) than during the follicular (0.64 +/- 0.25 pulses/hour) and preovulatory (0.72 +/- 0.16 pulses/hour) phases, while the mean pulse amplitude of PRL was significantly greater during the luteal phase (6.8 +/- 2.3 ng/ml) than during the follicular (3.6 +/- 1.2 ng/ml) and preovulatory (4.1 +/- 1.0 ng/ml) phases. These changes in pulse frequency and amplitude were also observed in LH pulses between the follicular and luteal phases, except at the LH surge, when LH pulse amplitude increased markedly, but that of PRL did not alter. Furthermore, a positive linear correlation between the pulse frequency of PRL and LH (r = 0.74, p less than 0.001) was found throughout the 3 phases of the cycle. These results demonstrate that a marked degree of synchrony between PRL and LH pulses is observed during the menstrual cycle and suggest that the frequency and amplitude of PRL pulses vary from the follicular to luteal phases, except at the LH surge, almost in parallel with those of LH pulses.

[Indication and effect of bromocriptine in euprolactinemic amenorrhea--comparison with clomiphene]

Effect of bromocriptine on induction of ovulation and occurrence of pregnancy was examined in patients with normoprolactinemic ovulatory disturbances. The patients under study (53 in number) were divided into two groups, A and B, depending on the effect clomiphene had on the ovulatory responses and the occurrence of pregnancy. Of the group A, patients (21 in number), who had failed to show any ovulatory response to clomiphene, 8 patients ovulated on bromocriptine alone. Three out of 13 patients who complained of sterility became pregnant. Three out of 8 patients who had not ovulated on bromocriptine therapy alone ovulated on a combination of bromocriptine and clomiphene, and 2 out of these 3 cases became pregnant. Of the group B patients (31 in number), who had failed to become pregnant in spite of ovulatory responses to previous clomiphene therapies, 7 out of 23 became pregnant, who complained of sterility when on bromocriptine alone. Out of 12 cases who had failed to get pregnant on the bromocriptine alone, 2 patients became pregnant on the combination of bromocriptine and clomiphene. These data may indicate that the bromocriptine or the combined therapy of bromocriptine and clomiphene is useful for the treatment of patients with ovulatory disturbances or sterility who do not respond to the clomiphene therapy.

Neuroendocrine regulation of LHRH and gonadotropin

Analysis of gonadotropin secretion patterns throughout the menstrual cycle revealed a complex rhythm. Especially at 1-3 hour intervals this was seen, with a frequency that was dependent on the phase of the menstrual cycle. There is little information available concerning the role of plasma luteinizing hormone-releasing hormone (LHRH) in the regulation of donadotropin secretion in amenorrheic and postmenopausal women. In this paper, the authors present the results of a detailed investigation into the secretory pattern of LH, follicle stimulating hormone, and LHRH in normal women with a normal menstrual cycle, amenorrheic women, and postmenopausal women.

[Endocrine evaluation of induction of ovulation with pulsatile and continuous administration of human menopausal gonadotropin (hMG) in anovulatory women]

To evaluate the endocrine profiles during induction of ovulation with pulsatile and continuous administration of hMG (Pergonal), 3 patients with polycystic ovarian disease (PCO) and 4 patients with hypothalamic amenorrhea were selected as the subjects. The total dose of hMG per day was 150 IU in each patient. hMG pulse was administered intravenously via a portable infusion pump every 90 min in 4 patients including 3 PCO cases (9.375 IU/pulse) and every 18 min in one patient (1.875 IU/pulse). The remaining 2 patients received continuous subcutaneous infusion of hMG (150 IU/day). Following hMG treatment, 8,000 to 10,000 IU of hCG was used to induce ovulation. All 7 patients ovulated and 4 of them conceived. Pregnancy resulted in 2 patients following pulsatile (every 90 min) administration and in 2 patients after continuous infusion. The duration of hMG treatment needed to induce ovulation was similar among the three modes of administration and within the range of 7 to 10 days. A sustained elevation of circulating FSH levels was observed in all patients and serum estradiol increased more than 3,000 pg/ml in 6 of 7 patients during the course of treatment. Mean (+/- SE) midluteal progesterone level was 107.1 +/- 20.9 ng/ml. Moderate to severe ovarian hyperstimulation occurred in all patients. These results indicate that both pulsatile and continuous administration of hMG are similarly effective in inducing ovulation. They also appear to indicate that the hMG-induced follicular development is profoundly affected by the maintenance of high levels of FSH in the circulation rather than by the mode of administering hMG, whether pulsatile or continuous.

[Restoration of pituitary-ovarian function by pulsatile administration of GnRH during the early puerperium]

In general, the hypogonadotropic hypogonadism seen during early puerperium is thought to be due to long-term deprivation of endogenous GnRH during the course of pregnancy. Recently, based on the pulsatile nature of hypothalamic GnRH section, it has been demonstrated that pulsatile administration of this decapeptide is effective in activation of the pituitary-ovarian function and induction of ovulation in patients with endogenous GnRH deficiency. Thus, we investigated whether this physiological replacement of GnRH can bring about the rapid restoration of the pituitary-ovarian function in early puerperal women. Fourteen postpartum women who had undergone cesarean section for obstetric reasons at 37-41 weeks of gestation volunteered for this study. Six of them received 10 micrograms (one subject received 5 micrograms) of GnRH in every 90 min from day 0-5 postpartum for 7-17 days duration by a portable auto-infusion pump. The remaining 8 subjects without treatment served as controls. On day 14 postpartum, serum baseline values of LH and FSH were significantly higher and their responses to the 100 micrograms GnRH challenge test were significantly greater in GnRH-treated subjects than those in the control subjects, respectively. Serum estradiol levels increased day by day, reaching more than 500 pg/ml at the end of the treatment in the 6 subjects. One of them ovulated within 3 weeks postpartum following GnRH treatment and subsequent hCG administration. These results demonstrate that the physiological replacement of pulsatile GnRH can restore the pituitary-ovarian function even within the first 2 weeks postpartum and in the presence of puerperal hyperprolactinemia. They also suggest that a deficiency of endogenous GnRH secretion may account for, at least in part, the pathophysiology of the hypogonadotropic hypogonadism during early puerperium.

[Induction of ovulation with pulsatile LHRH in anovulatory women]

Nine anovulatory patients were treated by administering pulsatile LHRH (2-20 micrograms, i.v. at 90 min intervals) for 15-58 days. These patients consisted of 4 women with hypothalamic amenorrhea, one women with oligomenorrhea, 2 women with polycystic ovarian disease (PCOD) and 2 women with hyperprolactinemic amenorrhea. Four of them were involuntarily infertile. The pulsatile LHRH therapy induced follicular maturation and ovulation, as evidenced by increased plasma estradiol levels followed by a midcycle LH surge and subsequent rise in plasma progesterone (P) levels, in 8 of the 9 patients. One patient with PCOD failed to ovulate. All of 11 treatment cycles were ovulatory in the 8 patients. A maximal P level of below 10 ng/ml was seen in 3 of the 11 induced ovulatory cycles, indicating corpus luteum insufficiency. Luteolysis occurred soon after discontinuing the pulsatile LHRH administration at the mid to late luteal phase in 3 ovulatory cycles. One of the 4 infertile women became pregnant. The results indicate that chronic pulsatile administration of LHRH is useful in inducing ovulation not only in hypothalamic amenorrhea, but also in PCOD and hyperprolactinemic amenorrhea. They also suggest that although a possible augmentation of the hypothalamic LHRH release at the preovulatory phase cannot be denied, a series of endocrine events during the human menstrual cycle may be regulated by the feedback action of the ovarian signals on the pituitary under a fixed input of the hypothalamic LHRH.

[Plasma prolactin response to suckling stimulation in puerperal women]

Plasma PRL response to suckling was studied during the 1st week, between the 1st and 2nd weeks and between the 4th and 5th weeks postpartum. During the 1st week, mean (+/-SE) basal PRL significantly rose from 201.9 +/- 27.5 ng/ml to 294.7 +/- 25.6 ng/ml at 15 min and 300.9 +/- 25.9 ng/ml at 30 min after suckling had begun. Between the 1st and 2nd weeks, mean basal levels and the responses to suckling were not significantly different from those during the 1st week. Between the 4th and 5th weeks, mean basal values were considerably lower and the responses to suckling were significantly greater [51.8 +/- 6.9 ng/ml at 0 min; 212.9 +/- 14.8 ng/ml at 15 min and 239.3 +/- 21.4 ng/ml at 30 min] than those within the 2nd week. Assessment of intersubject variations within the 5th week revealed that a significant inverse correlation existed between the basal levels and the suckling-induced maximum increments in PRL (r = -0.538, p less than 0.001). The effects of the oral administration of two serotonin antagonist (cyproheptadine and metergoline) and the dopamine infusion on plasma PRL levels and the response to suckling were investigated during the 1st week postpartum. Metergoline and dopamine suppressed basal PRL levels and abolished the response to suckling, whereas cyproheptadine suppressed the response less effectively without modifying the basal levels. These data suggest that in the early puerperal period an inverse relationship exists between the basal level and the response to suckling in plasma PRL. The suckling-induced PRL release may be mediated via a serotonergic as well as a dopaminergic pathway.

[Effect of a histamine H2-receptor antagonist, cimetidine, on prolactin secretion in women]

The effect of acute intravenous injection of 400mg cimetidine, a histamine H2-receptor antagonist, on prolactin (PRL) secretion was investigated in women with normal menstrual cycles (n = 12) and normoprolactinemic secondary amenorrhea (n = 10). In addition, the PRL response to cimetidine was also examined in women with puerperal (n = 10) and idiopathic (n = 10) hyperprolactinemia. The administration of cimetidine provoked a rapid rise in plasma PRL in both normal and amenorrheic women, with peak values occurring at 10-15 minutes, followed by a return toward the baseline by 2 hours. The PRL response was significantly greater (p less than 0.001) in normal women [mean (+/- SE) basal vs. peak values: 15.3 +/- 1.5 vs. 124.6 +/- 10.3 ng/ml (p less than 0.001)] than in amenorrheic women [13.5 +/- 1.3 vs. 71.7 +/- 7.2 ng/ml (p less than 0.001)]. There were no significant changes in plasma LH or FSH levels in any group. The cimetidine injection caused a remarkable increase in plasma PRL in women with puerperal hyperprolactinemia [110.8 +/- 31.1 vs. 288.8 +/- 39.6 ng/ml (p less than 0.001)], while the PRL response was diminished or absent in women with idiopathic hyperprolactinemia [103.3 +/- 19.3 vs. 122.9 +/- 14.6 ng/ml (p greater than 0.1)]. The mean incremental PRL response was 1.6 times greater than that observed in normal women. These results suggest that histamine may exert an inhibitory effect on PRL secretion through H2-receptors and that an altered central histaminergic tone may be involved in amenorrheic or pathological hyperprolactinemic state.

[Suppression of puerperal lactation by metergoline]

Suppression of puerperal lactation by a potent serotonin antagonist, metergoline was studied in 33 puerperal women, i.e., abortion after sixteen weeks of gestation 6, premature labor 13, labor at term 13, and hydatiform mole 1. The drug was administered orally at a dose of 4 mg bid for 5 days to 26 subjects, starting within one week from delivery (group A). The remaining 7 subjects received 4 mg of metergoline bid for 7 days after more than 2 weeks from delivery (group B). Lactation was either rapidly suppressed or prevented in 22 out of the 26 subjects in group A and in all subjects in group B. After the therapy was stopped, rebound phenomena were observed in 4 subjects in group A and in 2 subjects in group B, but a further 5-7 days' treatment with metergoline produced satisfactory results. The mean plasma prolactin levels, studied in 10 subjects in group A at hourly intervals after the first metergoline dose, decreased significantly one hour later (p less than 0.05) and reached the nadir level, 19.9 +/- 2.6% of the mean basal value, 4 hours later. The daily plasma prolactin levels in 9 subjects were significantly lower than those of the control group during metergoline treatment (p less than 0.001). No side effects of metergoline medication were observed. Metergoline for a short course of administration is very effective in the suppression of puerperal lactation. In case of the suppression of lactation after the second week of puerperium, 10-14 days of metergoline treatment is recommended to avoid the rebound phenomena.

[Effects of bromocriptine and dopamine on pituitary hormone secretion in women]

The present study was designed to examine whether a dopamine agonist, bromocriptine (Brc) exerts similar effects as dopamine (DA) on the pituitary hormones secretion and also to investigate the interaction of these dopaminergic agents and a dopamine receptor antagonist, metoclopramide (MCP) on the DA receptors in the hypothalamic-pituitary axis. Thirty normal cycling women in the midfollicular phase volunteered for this study. Following the administration of Brc (2.5mg, orally) to 13 subjects, a partially significant fall in LH levels, but not in FSH levels, during 4h was observed. DA, infused at a rate of 5 micrograms/kg/min for 4h, induced a significant fall in LH levels between 1 and 4h, but in FSH levels only at 2.5h after the start of infusion in 9 subjects. The amplitude of the spontaneous pulsations of LH secretion which was observed in 8 control subjects, was diminished by DA, while the amplitude seemed to be augmented by Brc. The administration of MCP (10mg, i.v.) to all subjects at 3h during the 4h experimental period caused no observable change in LH and FSH levels. A significant and progressive decline in PRL levels was observed in both Brc-and DA-treated groups of subjects, and this PRL-lowering effect was markedly counteracted by MCP administration in DA-treated group, but not in Brc-treated group. Brc induced a widely varying but significant rise in GH levels, with which MCP did not appear to interfere, whereas DA failed to cause any significant changes in GH levels. These data suggest that Brc, in contrast with DA, seems to be able to increase the pulse amplitude, but not the basal level, of LH and to stimulate GH secretion. Brc is also regarded to be a potent and unique PRL inhibitor, because its PRL-lowering effect cannot be easily antagonized by MCP.