The Value of Preoperative Local Symptoms in Prognosis of Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy: A Retrospective, Multicenter Cohort Study

Purpose

We aimed to evaluate the impact of preoperative local symptoms on prognosis after radical nephroureterectomy in patients with upper tract urothelial carcinoma (UTUC).

Methods

This retrospective study consisted of 2,662 UTUC patients treated at 15 institutions in Taiwan from 1988 to 2019. Clinicopathological data were retrospectively collected for analysis by the Taiwan UTUC Collaboration Group. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and bladder recurrence-free survival (BRFS). The prognostic value of preoperative local symptoms in OS, CSS, DFS, and BRFS was investigated using Cox proportional hazards models.

Results

The median follow-up was 36.6 months. Among 2,662 patients, 2,130 (80.0%) presented with hematuria and 398 (15.0%) had symptomatic hydronephrosis at diagnosis. Hematuria was associated with less symptomatic hydronephrosis (p <0.001), more dialysis status (p = 0.027), renal pelvic tumors (p <0.001), and early pathological tumor stage (p = 0.001). Symptomatic hydronephrosis was associated with female patients (p <0.001), less dialysis status (p = 0.001), less bladder cancer history (p <0.001), ureteral tumors (p <0.001), open surgery (p = 0.006), advanced pathological tumor stage (p <0.001), and postoperative chemotherapy (p = 0.029). Kaplan-Meier analysis showed that patients with hematuria or without symptomatic hydronephrosis had significantly higher rates of OS, CSS, and DFS (all p <0.001). Multivariate analysis confirmed that presence of hematuria was independently associated with better OS (HR 0.789, 95% CI 0.661-0.942) and CSS (HR 0.772, 95% CI 0.607-0.980), while symptomatic hydronephrosis was a significant prognostic factor for poorer OS (HR 1.387, 95% CI 1.142-1.683), CSS (HR 1.587, 95% CI 1.229-2.050), and DFS (HR 1.378, 95% CI 1.122-1.693).

Conclusions

Preoperative local symptoms were significantly associated with oncological outcomes, whereas symptomatic hydronephrosis and hematuria had opposite prognostic effects. Preoperative symptoms may provide additional information on risk stratification and perioperative treatment selection for patients with UTUC.

Perineural Invasion is a Powerful Prognostic Factor for Upper Tract Urothelial Carcinoma Following Radical Nephroureterectomy

BACKGROUND

Taiwan has the highest incidence of upper tract urothelial carcinoma (UTUC) worldwide. Although many pathological factors can predict the prognosis of UTUC, previous studies have rarely discussed perineural invasion (PNI). Therefore, we aimed to investigate the effect of PNI on a well-established cohort of patients with UTUC.

METHODS

This retrospective study included 803 patients with non-metastatic UTUC who underwent radical nephroureterectomy between June 2000 and August 2019. Demographic and clinicopathological parameters, including PNI, were collected for analysis. Using the Kaplan-Meier method and Cox proportional hazards model, we evaluated the significance of PNI with respect to progression-free survival (PFS), cancer-specific survival (CSS), and overall survival (OS).

RESULTS

The median follow-up was 30.9 months, and there were 83 cases of PNI (10.3%). PNI-positive patients had unfavorable pathological features, including high pT stage, positive lymph node involvement, high tumor grade, and more lymphovascular invasion (all p < 0.001). Kaplan-Meier analysis showed that PNI was significantly associated with PFS, CSS, and OS (all p < 0.00001), and when combined with lymphovascular invasion, patients could be divided into groups with distinct survival rates (all p < 0.00001). In multivariate analysis, PNI was an independent factor leading to worse PFS (hazard ratio [HR] 1.72, 95% confidence interval [CI] 1.19-2.50; p = 0.004), CSS (HR 2.54, 95% CI 1.58-4.10; p = 0.0001), and OS (HR 1.78, 95% CI 1.19-2.65; p = 0.005).

CONCLUSIONS

We demonstrated an association between PNI and the prognosis of UTUC. Routine assessment of PNI in UTUC with standardized protocols may help achieve better risk stratification and subject selection for perioperative treatment.

Association between exposure to perfluoroalkyl substances and metabolic syndrome and related outcomes among older residents living near a Science Park in Taiwan

Perfluoroalkyl substances (PFASs) are an emerging class of artificial environmental chemicals that have multiple potentially harmful effects on health. The largest Science Park in Taiwan discharges wastewater containing PFASs into the Keya River, and a high concentration of PFASs has been found in this river and its aquatic creatures. We conducted a cross-sectional study from 2016 to 2017 of 397 subjects aged 55-75 years living near the river and evaluated the association of PFASs with metabolic syndrome and related outcomes. The results indicated that perfluorooctane sulfonate (PFOS) levels were positively associated with serum low-density lipoprotein (LDL) levels (P for trend = 0.03) and that perfluorononanoic acid (PFNA) and PFOS levels were positively correlated with uric acid levels (P for trend = 0.03 and 0.03). Perfluorodecanoic acid (PFDA) and perfluoroundecanoic acid (PFUnDA) levels were negatively associated with serum triglyceride levels (P for trend = 0.014 and < 0.01). After excluding lipid-lowering drug users, the association between certain PFAS levels and the LDL level was significantly enhanced, but the downward trends of serum triglyceride levels were weakened. When stratified by sex, PFNA (P for trend <0.01), perfluorohexanesulfonate (PFHxS) (P for trend <0.01), and PFOS (P for trend <0.01) showed positive associations with the uric acid level only among males. In conclusion, our results showed that associations were consistently null between PFASs and metabolic syndrome. PFAS levels were associated with serum lipids, and lipid-lowering drugs may interfere with this relationship. Certain PFASs were found to be positively associated with uric acid levels, especially in males. Further studies are warranted to clarify the causal relationships.

Different enzyme activities of sialyltransferases in gynecological cancer cell lines

PURPOSE

Due to rarity of a relationship between sialyltransferase enzyme activities and gynecological cancers, we arranged the study to evaluate sialyltransferase enzyme activity in the various kinds of gynecological cancer cell lines.

METHODS

Ten cell lines from various kinds of gynecological cancers and two cell lines from normal tissue were enrolled in this study. The activities of each subtype of sialyltransferases were detected using Gal beta1,3GalNAc-acetyl-lactosamine)-Obz1 (acceptor for ST2,3Gal I), Gal beta1,3GlcNAc beta1,3Gal beta1,4GlcNAc (acceptor for ST2,3Gal III), Gal beta1,4GlcNAc (acceptor for ST2,3Gal IV), asialo-bovine submaxillary mucin (acceptor for ST2,6GalNAc I), asialo-fetuin (acceptor for STalpha2,6GalNAc II), and fetuin (acceptor for ST2,6GalNAc III), respectively. The amounts of sialic acids were measured using fluorescein-conjugated Sambucus nigra agglutinin (SNA) specific for alpha2,6-sialic acids and fluorescein-conjugated Maackia Amurensis agglutinin (MAA) specific for alpha2,3-sialic acids.

RESULTS

The activities of two sialyltransferase subtypes, ST3Gal I & ST6GalNAc II, were significantly higher in nearly all cell lines. More specifically, cervical cancer cell line-ME 180, ovarian cancer cell line-ES-2, and choriocarcinoma cell line-BeWo showed high levels of ST3Gal I enzyme activity; all gynecological cancer cell lines except endometrial cancer cell line-RL95-2 had high levels of ST6GalNAc II enzyme activity when compared with a normal control cell line--fibroblast cell line (CCD-966Sk). Cell lines tested in this study have diverse levels of surface alpha2,6-sialic acid sugar chains (enhanced SNA binding) when compared with alpha2,3-sialic acid sugar chains (enhanced MAA binding) but we found that some cell lines such as Ca Ski (cervical cancer cell line), CC7T (cervical cancer cell line), PA-I (ovarian cancer cell line), and BeWo showed significantly altered cell surface alpha2,6-sialic acid sugar chains.

CONCLUSION

Increasing enzyme activity of ST3Gal I and ST6GalNAc II might be important in various kinds of gynecological cancers. More specifically, enhanced activity of sialyltransferases involving alpha2,6-sialic acid sugar chains might be more important in cancer development. Future studies will investigate whether the enzyme activity of these sialyltransferases can be helpful for clinical practice.

Glucose-insulin infusion for the early treatment of non-oliguric hyperkalemia in extremely-low-birth-weight infants

In order to investigate the status of non-oliguric hyperkalemia and to evaluate glucose-insulin infusion treatment among extremely-low-birth-weight (ELBW) infants, 161 infants weighting less than 1000 gm at birth were enrolled for this study. They were divided into two groups: a hyperkalemic group and a non-hyperkalemic group. Hyperkalemia was defined here as a serum potassium level of greater than 6 mEq/L in a non-hemolyzed arterial blood sample. A glucose-insulin infusion was administered to the patients when hyperkalemia was detected in them during the first few days after birth. The infusion was discontinued when the serum potassium levels had been less than 6 mEq/L and stabilized for 6 hours. The incidence of non-oliguric hyperkalemia among ELBW infants in this study was 58% (93/161). The mean gestational age of neonates was 25.7 +/- 1.8 weeks (hyperkalemic) and 26.6 +/- 1.7 weeks (non-hyperkalemic). The mean rate of increases in serum potassium levels was 0.32 +/- 0.29 mEq/L/hr (hyperkalemic) and 0.13 +/- 0.12 mEq/L/hr (non-hyperkalemic). The incidence of severe intraventricular hemorrhage (IVH) was 19% (18/93) (hyperkalemic) and 4.4% (3/68) (non-hyperkalemic). The incidence of cardiac arrhythmia was 12% (11/93) (hyperkalemic) and 0% (non-hyperkalemic) respectively. Neonates with fewer weeks of gestation at birth and faster increases in serum potassium levels were associated with a more prominent tendency toward hyperkalemia. Hyperkalemia markedly increases the risk of severe IVH and arrhythmia for ELBW infants. A higher glucose infusion rate should be maintained to prevent hypoglycemia following insulin treatment.

Direct and simultaneous determination of copper, chromium, aluminum, and manganese in urine with a multielement graphite furnace atomic absorption spectrometer

A simple method was developed for the direct and simultaneous determination of copper, chromium, aluminum, and manganese in urine using a multielement GFAAS (Perkin-Elmer SIMAA6000). Pd was used as the chemical modifier along with a special purge gas (5% H2 in Ar). A simple calibration curve method can be used (with 1:1 dilution). A standard reference material (Seronorm Trace Elements Urine) was used to find the optimal temperature program and to confirm the accuracy of the technique. The analyzed values were within 90-110% of the certified values. The relative standard deviations were 1.7, 1.5, 1.6, and 1.5% for these four elements and the detection limits were 0.08 microg L(-1) for Cu, 0.05 microg L(-1) for Cr, 0.06 microg L(-1) for Al, and 0.06 microg L(-1) for Mn. The recoveries of Cu, Cr, Al, and Mn from real urine samples were 100 +/- 5%, except for Cu (80%). The found values of Cu, Cr, Al, and Mn in a real urine sample were 14.3, 0.78, 18.9, and 0.06 microg L(-1), respectively. Scanning electron micrographs were used to investigate the physical form of Pd on the surface of the platform in the graphite furnace. Use of 5% H2 in Ar as the purge gas resulted in smaller and more uniformly distributed Pd particles (Pd particle diameters 0.4-0.6 microm using 5% H2 in Ar compared to 0.4-1.2 microm using pure Ar), increasing the effect of the Pd chemical modifier and promoting the efficiency of atomization.

Partial liquid ventilation in normal rabbits: comparison of three kinds of perfluorocarbon

Perfluorocarbon liquids have been used in liquid ventilation studies and considered an effective technique of gas exchange with less barotrauma when compared with gas ventilation. We compared the effects of partial liquid ventilation (PLV) using 3 kinds of perfluorocarbon liquids (Fluorinert FC 43, FC 77 and FC 84) available in Taiwan in normal rabbits. We were able to achieve adequate oxygenation and ventilation during a 2-hour-duration of PLV using FC 43, FC 77 or FC 84. There was no significant difference in hemodynamic status or laboratory findings between control group and PLV groups. There were also no significant differences before LV and after 2 hours of PLV among PLV groups. Histological study of lung tissue revealed intact and well expanded alveoli, and no significant pathological change after 2 hours of PLV. These results show that PLV using FC 43, FC 77 or FC 84 is an effective technique for maintaining adequate pulmonary gas exchange in normal rabbits.

Risk factors of pulmonary hemorrhage in very-low-birth-weight infants: a two-year retrospective study

Pulmonary hemorrhage is a serious complications in very-low-birth-weight (VLBW) infants with respiratory distress syndrome (RDS). We undertook a 2-year retrospective study to investigate the predisposing factors and the incidence of pulmonary hemorrhage in VLBW infants. From January 1997 through December 1998, twenty infants were diagnosed with massive pulmonary hemorrhage (MPH) according to the following criteria: active bleeding from the endotracheal tube, acute drop in hematocrit (> or = 10%), and the development of multilobar infiltration on chest radiograph. The mean gestational age was 26.9 +/- 2.5 weeks, the mean birth weight was 909 +/- 290 g. Twenty historic controls with similar gestational age and birth weight were retrospectively identified during the study period. The incidence of MPH in VLBW infants was 5.9%(20/340). A lack of prenatal corticosteroid administration, surfactant replacement therapy for RDS, and a patent ductus arteriosus (PDA) with cardiovascular dysfunction requiring dopamine support were the significantly predisposing factors of MPH in the acute stage (< or = 7th day of life). To avoid MPH and decrease mortality and morbidity in the acute stage, prenatal corticosteroid administration, evaluation of the necessity of surfactant therapy, and early recognition and aggressive treatment of hemodynamically significant PDA were necessary.

Glass peek composite promotes proliferation and osteocalcin production of human osteoblastic cells

An isoelastic intramedullary implant has been developed using a composite of polyetheretherketone and 10% random, chopped E-glass fibers (GPEEK). The effect of this novel material on human bone cells has not been defined. The objective of this study was to test whether GPEEK supported the proliferation of the human bone cell line MG63, which exhibits osteoblastlike characteristics. Cells (1 x 10(5)/mL) were propagated on GPEEK discs with three different surface roughnesses (3, 6, and 9 microns) and on polystyrene plates, for comparison. The reaction of MG63 osteoblastlike cells to the GPEEK polymer composite was analyzed by determination of cell yield, osteocalcin production, and levels of alkaline phosphatase. The viable cells that were retrieved from the GPEEK discs of all three surface roughness had an approximate sixfold increase in number. Osteoblastic function of the cells, indicated by osteocalcin production, was unimpaired after a 5-day culture on the three surfaces of GPEEK. The highest level of osteocalcin was produced by osteoblastic cells propagated on GPEEK with a 9 microns surface roughness. The levels of alkaline phosphatase of these cells were similarly greater for the different degrees of surface roughness. Overall, this study demonstrates that GPEEK supported proliferation of osteoblastlike cells and provided a favorable environment for the continued production of osteocalcin in vitro.

Facial mutilation after an assault with chemicals: 15 cases and literature review

Facial mutilation after an assault with chemicals is rarely discussed in the literature even though it is a devastating injury that occurs worldwide and is not prohibited or punished by special laws. It is our purpose to describe the devastating outcome of facial mutilation after an assault with chemicals and to draw attention to this injury as a worldwide problem. We studied fifteen patients who sustained facial mutilation with chemicals. The common story was that the patient's spouse was the perpetrator, that sulfuric acid was used, and that the deed occurred after marital or financial discord. All victims were disfigured severely and most became reclusive and rarely left their homes. Six patients (40%) had total bilateral blindness and one suffered partial loss of vision. Lower eyelid ectropion (14), microstomia (12), cervical flexion contracture (10), ear deformity (8), and nostril stenosis (6) were common. Few of the perpetrators were prosecuted. We reviewed the literature and found that the problem has been described all over the world, and that the outcome is similar to that which we described. The problem deserves worldwide recognition and attention.

Acute pulmonary oedema following administration of vasopressin for control of massive GI tract haemorrhage in a major burn patient

A 35-year-old male sustained a full-skin thickness chemical burn involving 60 per cent of TBSA when hydrochloric acid was applied to his face, trunk and extremities by his girlfriend. Debridements and skin graftings were performed smoothly and he was doing well until day 23 after injury, when massive GI tract bleeding caused a drop in blood pressure. Vasopressin was given intravenously to control the bleeding, which stopped, and the blood pressure returned to normal after transfusion. After the vasopressin infusion was tapered off acute pulmonary oedema developed abruptly, which required treatment by intubation and PEEP using a respirator. The lung condition had returned to normal by the following day. A second episode of massive GI tract bleeding recurred 10 days later, again vasopressin was given through a catheter into the inferior mesenteric artery. Again pulmonary oedema developed 38 h after the vasopressin use, the oedema disappeared within 2 days when the vasopressin infusion tapered off. It should be kept in mind that acute pulmonary oedema may develop when high doses of vasopressin are used in the treatment of Curling's ulcer or other GI tract bleeding.

Pelvic abscess induced by a methicillin-resistant Staphylococcus aureus from haematogenous spread via the CVP line in a burn patient

A 38-year-old female patients was found accidentally to have a positive culture of MRSA from a routine CVP catheter tip culture 1 week after she had complete wound closure. She was recovering from a partial skin thickness burn covering 42 per cent TBSA on the trunk and extremities. Fever and hip pain developed abruptly 1 week later when she was ready for discharge from hospital. Magnetic resonance imaging (MRI) of the pelvis disclosed an intramuscular abscess. Open drainage was performed and pus culture yielded a MRSA with the same sensitivity profile as the previous CVP tip culture. Vancomycin 500 mg every 6 h was used for 3 weeks until the drain culture disclosed a negative result, and a follow-up MRI indicated a loss of the abscess space. Follow-up at an outpatient clinic 3 months later showed that the patient remained symptom free. In this patient haematogenous dissemination was the most likely route of pelvic abscess formation. It should be remembered that MRSA infection is not always only a local problem, especially in the immunocompromised condition of burn injury.

An alternative method of skin grafting: the scalp microdermis graft

Although microskin grafting has been used successfully to treat major burns, when the donor skin areas are inadequate, it is still not in popular use because of the difficulties of mincing and floating procedures. Floating is expected to produce more microskin patches with the dermal side upwards than with the epidermal side upwards. Another problem is that many microskin patches will be lost in the container during floating. This problem may be solved by preparing the microskin from the second layer scalp skin. This will be a graft of hair follicle cells, which can be sowed on the wound no matter which side is upwards. Grafting was carried out on well-prepared granulation beds, or on the fat surface after tangential excision, or on the bed after fascial excision of the burn. Allograft and Biobrane were used as cover dressings. The combination of fascial excision and allograft overlay gave an acceptable result. This can be an alternative method of skin grafting for burns with very limited donor skin areas when the scalp skin is not burned.

A new method of microskin mincing

Microskin grafting has been used successfully for major burns when donor skin areas are inadequate to cover the skin defect. The microskin may be made by repeated cutting with scissors or by a specially designed machine. However microskin grafting is still not popular due to the difficulty of the mincing process, which may take hours to do. An easy and quick method of skin mincing using the Tanner-Vandeput Mesh Dermatome has been developed. The mincing process may be done in just a few minutes instead of hours. The skin pieces made with this technique are all of a uniform square shape and size (1.2 mm x 1.2 mm). Microskin grafting using the mincing technique has been carried out on 10 thighs of five patients with a fixed patch size (1.2 mm x 1.2 mm); an expansion ratio of 1:10 is used to ensure that the average interpatch distance would be within 5 mm for a better and quicker healing. All areas healed within 6 weeks without any secondary skin grafting. The resulting 'cobblestone' appearance of the healed skin is not good looking but there is no excess scar formation. The scar is soft and can be pinched up easily. This is an easy way of microskin mincing, it is quick and can be done in any clinic without specially trained personnel or the need to buy a new instrument.

Separation of thoracopagus conjoined twins. A case report

A pair of thoracopagus conjoined twins with a connection at the atrioventricular groove of both hearts and a huge conjoined liver were surgically separated. An aortopulmonary shunt was created for Twin B, a victim of complex congenital heart disease with hypoplastic right heart syndrome, who died 5 hours later. However, Twin A survived after prolonged endotracheal intubation and parenteral nutrition. He survived for 7 months, and went home, but finally died of sepsis. In reviewing 47 pairs of surgically separated thoracopagus conjoined twins, in 30 pairs of type A (Leachman's classification, completely separate hearts), 42 patients survived (70%); in 5 pairs of type B (atrial connection only), one patient survived (10%); in 9 pairs of type C (both atrial and ventricular interconnections), none survived; in 3 pairs of unknown type, 2 survived. Total survival rate of surgically separated thoracopagus conjoined twins was 47.9%. The survival rate was 38.2% in those operated in the neonatal period (n = 34) and 63.6% in those operated over 1 month of age (n = 44) (p = 0.016). In conclusion, thoracopagus conjoined twins are rare. Although its separation carries a high risk, especially in those with cardiac connection, this report confirmed that separation is still feasible under proper preparation and planning.

The algebraic view-point in microskin grafting in burned patients

Microskin grafting has proved to be an effective treatment for major burns when the area of available donor skin is inadequate. In fact, microskin grafting can be comparable to the patch graft of Gabarro. Further mincing procedures cut the skin patches into smaller pieces around 1 mm2. The healing process is completed by the epithelial migration between the micropatches. The possibly longest interpatch distance is related to the expansion ratio and the size of the microskin patch. From the equation L = x.(1.4 square root of Y-1.2) it is clear that the interpatch distance L is directly related to the patch side-length x. This means that when the patch side-length is doubled then the interpatch distance will be doubled. However the expansion ratio Y is related to its square root, so that the influence of the expansion ratio Y is much less important. For improving the healing process, the interpatch distance is better kept within 5 mm. With this understanding, we can calculate the required donor skin surface area for a given wound area according to the different side-length of micropatch, and also the possible maximum patch size for a given wound area for different available donor skin areas. As the area of available skin may be very limited, the maximum patch size may be smaller than the usual size (around 1 mm). Then we have to elongate the interpatch distance, though it would delay the healing. This is a purely theoretical reference. In normal clinical practice, the discussed conditions should be considered.

A technique for simultaneous replantation of multiple amputated digits at Tamai's Zone V

A technique for simultaneously replanting multiple digits amputated at Tamai's Zone V is described. Since these multiple amputated digits are connected together, they should be replanted as a single unit. The technique includes applying the pneumatic tourniquet first, debridement, bone shortening, and fixation of all the amputated digits, including tendon repairs, application of vascular clamps before releasing the tourniquet, followed by vascular anastomosis in one-by-one fashion for each digit. The disadvantage of this technique is the difficulty in keeping the digit cool. The advantages are it is a less time-consuming operation, there is reduced blood loss and contamination, and there is a better axial arrangement of the bony framework.

A simple device for nasal tube fixation in facial burns patients

In acute facial burns, it is sometimes necessary to insert tubes down one or both nostrils. We describe a simple secure method of fixation.

Sequence of a cDNA clone encoding pig heart mitochondrial CoA transferase

We have isolated a full-length cDNA clone encoding the cytoplasmic precursor to pig heart mitochondrial CoA transferase (succinyl-CoA:3-ketoacid coenzyme A transferase (3-oxoacid CoA transferase, EC 2.8.3.5], a key enzyme for ketone body catabolism. The deduced amino acid sequence indicates the presence of a 39-residue mitochondrial signal sequence and a 481-residue mature protein of molecular weight 52,197. CoA transferase is known to be susceptible to proteolytic cleavage to produce a nicked but active enzyme. We have identified the site of proteolysis, and analysis of the sequence in its vicinity suggests that the polypeptide may fold into two domains connected by a highly hydrophilic bridge.

Phosphorylation by cyclic AMP-dependent protein kinase does not affect the association of ATP citrate-lyase with isolated mitochondria

ATP citrate-lyase is known to be a substrate for various protein kinases, but the functional role, if any, of kinase-directed phosphorylation of this enzyme has not been identified. Recently, Strålfors [(1987) J. Biol. Chem. 262, 11486-11489] has suggested that effects on the association of this enzyme with mitochondria may account for the observed ability of isoproteronol or insulin to promote immobilization of ATP citrate-lyase in permeabilized cells. Here we report studies involving phosphorylation of the pure enzyme in vitro using cyclic AMP-dependent protein kinase. We show that phosphorylation has no significant effect on the fraction of the enzyme that may be bound to isolated mitochondria.

Transpositional digital replantation

When a functionally important digit is injured as part of a multiple digit injury, transpositional digital replantation is worth considering to preserve greater hand function and to avoid or minimize the necessity for secondary reconstructive procedures. We present two such cases with transpositional digital replantation. The indications for this technique are: 1) multiple digit injury, 2) severe crush injury, 3) the possibility of preserving more and better joints in some fingers, and 4) injury distal to Tamai's zone V (11). The benefits of this procedure are that function can be better with the more completely preserved digits replanted into the most useful positions and of similar lengths. Difficulties are encountered when there are large discrepancies in size of surviving digits, and problems with soft-tissue coverage, tendon repair, a 'step' at the fracture site after bone fixation, and with vessel anastomosis. Use of this procedure can result in preservation of hand function and fewer secondary reconstructive procedures.

Evaluation of survival in digital replantation with thermometric monitoring

Since January 1981, we have used the Exacon thermometer to monitor skin temperature of 180 completely amputated digits during and after replantation surgery. When skin temperature on the first day after surgery was above 32 degrees, 153 of 154 replanted digits survived. In contrast, when skin temperature was 32 degrees or lower, 22 of 26 replanted digits failed. Data were analyzed by the Probit model, which indicated that skin temperature monitoring with 32 degrees as critical temperature is significant at P = 0.01. Also, critical temperature was tested in the range of 31.0 degrees to 33 degrees at intervals of 0.1 degree. We found the probability of predicting the viability for replanted digits is highest when skin temperature is 32 degrees or higher.