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Background Percutaneous endoscopic surgery is a popular surgery to treat lumbar spinal disorders. However, seizure after percutaneous endoscopic surgery is an unpredictable complication. The only prodromal sign for seizure currently known is neck pain. We reviewed the incidence of, and risk factors for, seizure during percutaneous endoscopic surgery and present the cases of 3 patients with seizure and our management. Case Description From October 2006 to March 2019, 3 of 816 patients (0.34%) with thoracic lumbar disorders who had undergone percutaneous endoscopic surgery experienced a seizure episode. The cases of those 3 patients were carefully reviewed. Studies of the risk factors for seizure after spinal procedures reported before June 13, 2019 were identified through a PubMed search. We found that infusion fluid containing cefazolin, the infusion rate, a prolonged operative time, the occurrence of a dural tear, and sevoflurane anesthesia might be associated with seizure, both described in the reported data and found in our experience. Three patients who experienced a seizure episode had had general anesthesia with sevoflurane, and the surgical approach used was interlaminar for a herniated disc in L5-S1. We noted a “red flag sign,” namely an uncontrollable hypertension episode combined with a decreasing pulse rate, in all 3 patients who had experienced a seizure, which was not observed in the other patients. All 3 patients had received antihypertensive medication (labetalol) ≥3 times without response. Conclusion Seizure after percutaneous endoscopic surgery is rare, but lethal. Although its cause remains unknown, all risk factors for seizure should be checked and corrected immediately when a red flag sign, uncontrolled hypertension, appears.

The correct differential diagnosis of dementia has an important impact on patient treatment and follow-up care strategies. Tc-99m-ECD SPECT imaging, which is low cost and accessible in general clinics, is used to identify the two common types of dementia, Alzheimer’s disease (AD) and Lewy body dementia (LBD). Two-stage transfer learning technology and reducing model complexity based on the ResNet-50 model were performed using the ImageNet data set and ADNI database. To improve training accuracy, the three-dimensional image was reorganized into three sets of two-dimensional images for data augmentation and ensemble learning, then the performance of various deep learning models for Tc-99m-ECD SPECT images to distinguish AD/normal cognition (NC), LBD/NC, and AD/LBD were investigated. In the AD/NC, LBD/NC, and AD/LBD tasks, the AUC values were around 0.94, 0.95, and 0.74, regardless of training models, with an accuracy of 90%, 87%, and 71%, and F1 scores of 89%, 86%, and 76% in the best cases. The use of transfer learning and a modified model resulted in better prediction results, increasing the accuracy by 32% for AD/NC. The proposed method is practical and could rapidly utilize a deep learning model to automatically extract image features based on a small number of SPECT brain perfusion images in general clinics to objectively distinguish AD and LBD.

BACKGROUND Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites. METHODS Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared. RESULTS One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group. CONCLUSION Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Background. The pedicle screw is one of the main tools used in spinal deformity correction surgery. Robotic and navigated surgeries are usually used, and they provide superior accuracy in pedicle screw placement than free-hand and fluoroscopy-guided techniques. However, their high cost and space limitation are problematic. We provide a new solution using 3D printing technology to facilitate spinal deformity surgery. Methods. A workflow was developed to assist spinal deformity surgery using 3D printing technology. The trajectory and profile of pedicle screws were determined on the image system by the surgical team. The engineering team designed drill templates based on the bony surface anatomy and the trajectory of pedicle screws. Their effectiveness and safety were evaluated during a preoperative simulation surgery. The surgery consisted in making a pilot hole through the drill template on a computed tomography- (CT-) based, full-scale 3D spine model for every planned segment. Somatosensory evoke potential (SSEP) and motor evoke potential (MEP) were used for intraoperative neurophysiological monitoring. Postoperative CT was obtained 6 months after the correction surgery to confirm the screw accuracy. Results. From July 2015 to November 2016, we performed 10 spinal deformity surgeries with 3D printing technology assistance. In total, 173 pedicle screws were implanted using drill templates. No notable change in SSEP and MEP or neurologic deficit was noted. Based on postoperative CT scans, the acceptable rate was 97.1% (168/173). We recorded twelve pedicle screws with medial breach, six with lateral breach, and five with inferior breach. Medial breach (12/23) was the main type of penetration. Lateral breach occurred mostly in the concave side (5/6). Most penetrations occurred above the T8 level (69.6%, 16/23). Conclusion. 3D printing technology provides an effective alternative for spinal deformity surgery when expensive medical equipment, such as intraoperative navigation and robotic systems, is unavailable.

Return to activity (RTA) and return to school (RTS) are important issues in pediatric concussion management. This study aims to update CanChild’s 2015 RTA and RTS protocols, on the basis of empirical data and feedback collected from our recently completed prospective cohort study, focusing on concussed children and their caregivers; systematic review of evidence published since 2015; and consultation with concussion management experts. The new protocols highlight differences from the earlier versions, mainly, (1) symptom strata to allow quicker progression for those who recover most quickly; (2) a shortened rest period (24-48 hours) accompanied by symptom-guided activity; (3) the recommendation that children progress through the stages before they are symptom free, if symptoms have decreased and do not worsen with activity; (4) specific activity suggestions at each stage of the RTA protocol; (5) recommendations for the amount of time to spend per stage; and (6) integration of RTS and RTA.

Lymphovenous anastomosis is technically challenging and can be successfully performed with an advanced operating microscope, supermicrosurgical instruments, and indocyanine green lymphography. This study compared the outcomes between side-to-end and end-to-end lymphovenous anastomosis configurations for unilateral extremity lymphedema.Between April of 2013 and June of 2017, lymphovenous anastomosis was indicated for 58 patients who preoperatively had patent lymphatic ducts by indocyanine green lymphography, including 20 patients with upper limb lymphedema and 38 patients with lower limb lymphedema. Either an end-to-end or a side-to-end lymphovenous anastomosis was used to anastomose the subdermal venule to the lymphatic duct. The circumferential difference and episodes of cellulitis were used as outcome measurements.Twenty-three patients underwent an end-to-end lymphovenous anastomosis and 35 patients underwent side-to-end lymphovenous anastomosis. All patients had an immediate patency evaluated by indocyanine green lymphography and patent blue assessments. All patients returned to their daily routine without the use of any compression garments. At an average follow-up of 16.5 months (range, 13.4 to 19.6 months), the improvement of circumferential difference (3.2 percent; range, 1.8 to 4.6 percent) in the side-to-end group was statistically greater than that in the end-to-end group (2.2 percent; range, 1 to 3.4 percent; p = 0.04). The overall episodes of cellulitis were significantly reduced from 1.7 times/year (range, 1.3 to 2.1 times/year) to 0.7 times/year (range, 0.3 to 1.1 times/year; p0.001), but no difference was observed between the two groups.Both side-to-end and end-to-end lymphovenous anastomosis configurations were effective surgical approaches for improving early-grade extremity lymphedema. Side-to-end lymphovenous anastomosis has the advantages of having greater efficacy for lymph drainage, requiring only one anastomosis and eliminating the need to use compression garments.Therapeutic, III.

Solar fuel generation using seawater as the proton source is fascinating but challenging due to the detrimental chlorochemistry, the lack of active and stable oxygen evolution catalysts operating at seawater pH (∼8) and high turnover conditions. In the present study, iron phosphate modified calcium iron oxide (CaFeOx|FePO4) modified FTO electrodes were prepared, and their electrocatalytic properties towards the oxygen evolution reaction in both synthetic and natural seawater solutions were investigated. CaFeOx|FePO4 was prepared by electrodepositing FePO4 onto CaFeOx, prepared by spin-coating and a follow-up annealing process, under a constant applied current for different durations. Mg2+-induced fouling significantly reduces the activity of CaFeOx and slows down the activation process of CaFeOx, but can be mitigated by surface-modification of CaFeOx with FePO4. In addition, the presence of additional electrodeposited iron phosphate on the surface of CaFeOx attenuates the production of corrosive hypochlorite from chloride oxidation. With these unique properties of FePO4, the activated CaFeOx|FePO4 electrode shows high activity and stability under high turnover conditions, reaching 10 mA cm-2 at an overpotential of ∼710 mV, with a moderate increase in η (∼70 mV), mainly due to the change in solution pH, over 10 h of electrolysis in phosphate-buffered (0.5 M, pH 7) seawater solution.

The pathophysiology of Horner's syndrome arises due to compression or destruction of the oculosympathetic nerve pathway. Traumatic Horner's syndrome may indicate lethal neurovascular injury, such as brain stem lesion, cervical spine injury, or carotid artery dissection. The middle-third is the most common type of clavicle fracture. However, the association of the isolated middle-third clavicle fracture and Horner's syndrome is rare. We report the case of a 47 year-old woman who presented to our emergency department with acute trauma. Severe tenderness and limited mobility were observed in her left shoulder. On radiographic examination, a middle-third clavicle fracture was diagnosed. Ptosis and myosis were also noticed on further examination, and she was subsequently diagnosed with Horner's syndrome. A survey of the brain, cervical spine, carotid artery, and lung revealed no pathological findings. Surgery for the clavicle fracture was performed 2 days after the accident. The patient recovered from Horner's syndrome gradually over the 2 months following the surgery, and the syndrome completely resolved by the third month. To the best of our knowledge, this is the first report of traumatic Horner's syndrome caused by an isolated middle-third clavicle fracture. The improved outcome may be attributed to the surgical intervention for middle-third clavicle fracture, which may help release ganglion or neuronal compression.

Neurological disorders (NDs) are diseases of the central and peripheral nervous system that affected the hundreds of millions of people worldwide. Temporal lobe epilepsy (TLE) is a common NDs with hallucinations and disturbance of consciousness that cause the abnormal neurological activity in any part of brain. Neuroinflammation (NI) has been identified in epilepsy-related tissue from both experimental and clinical evidence and suspected to participate in the formation of neuronal cell death, reactive gliosis and neuroplastic changes in the hippocampus, may contribute to epileptogenesis. The NI is tightly regulated by microglia, but it is thought that excessive or chronic microglial activation can contribute to neurodegenerative processes. Therefore, the modulation of microglia responses may provide a therapeutic target for the treatment of severe or chronic NI conditions. Although the condition responds well to antiepileptic drugs (AEDs), there are still unresponsive to AEDs in about 1/3 of cases. Neural stem cells are the origin of various types of neural cells during embryonic development. Currently, many results of stem cell therapies in the animal experiments and clinical trials were demonstrated the efficacious therapeutic effects in the attenuated symptoms of ND. Therefore, the combined application therapies of stem cells and drugs may be a promising candidate for the therapeutic strategies of NDs, especially TLE.

In patients with diabetes mellitus (DM), incident cardiovascular (CV) events are associated with poor long-term outcomes. Serum high-sensitivity troponin I (hs-TnI) is widely used to diagnose and predict outcomes in patients with acute coronary syndrome, however, few studies have investigated the accuracy of urine hs-TnI as a predictor for incident CV events in patients with DM. The enrolled participants included patients with DM. Fresh urine hs-TnI levels were measured. Medical records of enrolled patients were used to determine the number of incident CV events prospectively for 3 months. The study cohort comprised 378 participants. We observed significantly higher levels of urine hs-TnI in those with than without subsequent incident CV events. The multivariate logistic regression analysis using different models consistently showed that urine hs-TnI &gt, 4.10 pg/mL was an independent factor predictive of incident CV events. The ROC-AUC analysis revealed that the optimal cutoff value for urine hs-TnI for predicting incident CV events was 1.55 pg/mL and the area was 0.611 (p = 0.027). A single measurement of urinary hs-TnI, collected easily and non-invasively, may be an acceptable biomarker for predicting subsequent incident CV events in patients with DM.

Background and Objectives: The proximity of the popliteal vessels in the distal femur may increase the risk of iatrogenic vascular injury during cerclage wiring. In this study, the closest location and distance of the popliteal vessels to the femur was examined using magnetic resonance imaging (MRI). The associations between anthropometric factors and the distance that would guide the placement of wires safely during surgery were also identified. Materials and Methods: We reviewed adult knee magnetic resonance images and recorded: (1) the relation and the shortest horizontal distance (d-H) from the femoral cortex to the popliteal vessels in axial images and (2) the vertical distance (d-V) from the adductor tubercle to the axial level of the d-H values in coronal images. The effects of anthropometric factors (sex, age, body height, body weight, body mass index, thigh circumference, femoral length and femoral width) on these distances were analysed. Results: Analysis of 206 knee magnetic resonance images revealed that the closet locations of popliteal vessels were at the posteromedial aspect of the femur. The d-H and d-V were 7.38 &plusmn, 3.22 mm and 57.01 &plusmn, 11.14 mm, respectively, and were both shorter in women than in men (p &lt, 0.001). Multivariate analysis identified thigh circumference and femoral length as the most influential factors for the d-H and d-V, respectively (p &lt, 0.001). Linear regression demonstrated a strong positive linear correlation between the thigh circumference and the d-H and between the femoral length and the d-V (Pearson&rsquo, s r = 0.891 and 0.806, respectively (p &lt, 0.001)). Conclusions: The closet location and distance of the popliteal vessels to the femur provide useful information for wire placement during distal femoral fracture surgery while minimising the risk of vascular injury. Given that patients with a smaller thigh circumference and a shorter femoral length are more likely to have a smaller d-H and a shorter d-V, respectively, cautious measures should be taken in such cases.

Medical institutions usually ensure the quality of medications by reviewing manufacturing documents and examining the appearance of the drugs. However, these mechanisms may not be robust enough to confirm the quality of the medications used. To evaluate the quality of medicines used at a medical center in Taiwan, a total of 190 new or formulary drugs were analyzed in a period from April 2004 to June 2010. For each medication, at least one test in the pharmacopeia or pharmaceutical manufacturers' specifications was chosen according to the dosage form or clinical requirement. A total of 437 tests were conducted. The overall failure rate was 5.8% (11/190) among all the drug products tested. Higher failure rates were seen in drugs with special dosage forms (12.5%) or dubious quality (7.7%). Although the failure rates of domestic brand-name drugs (9.1%, 2/22) and imported generic drugs (16.7%, 1/6) appeared to be higher than those of imported brand-name drugs (0%, 0/29) and domestic generic drugs (6.0%. 8/ 133), there was no significant difference among the various groups by Fisher's exact test due to the small sample size. Nevertheless, this study shows that there are still some substandard medicines in the market. The quality of imported brand-name drugs was shown to be unquestionable. The quality of domestic generic drugs was found to be equivalent to that of domestic brand-name or imported generic drugs. In-house laboratory analysis is an effective method that can be used together with the review of manufacturing documents to ensure the quality of drugs used at health-care institutions.

Nephrotoxic serum (NTS) nephritis occurs in three stages: inflammation, early kidney damage, and severe kidney damage. We quantified the temporal changes in the enantiomers of lactate (LA) and 3-hydroxybutyrate (3HB) in serum and urine during the progression of autoimmune kidney damage in mice with NTS nephritis. Two-dimensional and three-dimensional HPLC were used to quantify the enantiomers. The serum and urinary levels of LA and 3HB enantiomers significantly changed during the progression of NTS nephritis. Specifically, d-LA was significantly higher in the serum (131.8 ± 30.6, 123.7 ± 27.2, 109.3 ± 15.6 vs. 51.2 ± 7.5 μM; p 0.05) and urine (222.2 ± 34.8, 197.4 ± 53.9, 214.8 ± 68.9 vs. 100.8 ± 37.7 μmol/g creatinine; p 0.05) of the week 0 (W0), week 1 (W1), and week 2 (W2) groups than the normal group. The l-3HB/d-3HB ratio was significantly lower in the W0, W1, and W2 groups than the normal group in serum (0.0362 ± 0.0082, 0.0346 ± 0.0065, 0.0323 ± 0.0033 vs. 0.0602 ± 0.0214; p 0.05) and urine (0.0591 ± 0.0304, 0.1524 ± 0.0365, 0.1232 ± 0.1066 vs. 0.3273 ± 0.1394; p 0.05). The changes in serum and urinary d-LA and l-3HB/d-3HB ratios were stable before severe kidney damage. In conclusion, we successfully determined the levels of LA and 3HB enantiomers in NTS nephritis by HPLC. Serum and urinary d-LA contents and l-3HB/d-3HB ratios may have potential as biomarkers of early autoimmune kidney injury.

Aims Emergency department (ED) visits for decompensated heart failure (HF) are frequent and associated with poor long‐term outcomes in patients with HF. Serum N‐terminal pro b‐type natriuretic peptide (NT‐proBNP) is widely used to assist diagnosis and predict clinical outcomes in HF patients. Few studies have investigated the use of urine NT‐proBNP as an HF biomarker. This study aims to assess the value of urine NT‐proBNP for predicting ED visits for decompensated HF as compared with that of serum NT‐proBNP. Methods and results This study included 122 HF patients with reduced left ventricular ejection fraction (

BACKGROUND This study was to investigate the lymphoscintigraphy findings for the diagnosis and severity in unilateral gynecological cancer-related lymphedema (GCRL) and to correlate lymphoscintigraphy stages with the clinical findings. METHODS Patients with unilateral GCRL who underwent lymphoscintigraphy were staged using the presence of ileo-inguinal lymph nodes, distal-lymphatic ducts, and dermal backflow findings. Taiwan Lymphoscintigraphy Staging (TLS) was divided into three patterns and seven stages: normal drainage (L-0); partial obstruction (P-1, P-2, and P-3); and total obstruction (T4, T-5, and T-6). Correlations between clinical lymphedema severity and TLS were evaluated using analysis of variance and multivariable linear regression analyses. RESULTS A total of 141 patients with unilateral GCRL were divided as follows: 6 (4.3%) in normal drainage, 56 (39.7%) in partial-obstruction, and 79 (56%) in total obstruction. Cellulitis episodes, circumferential difference, and computed tomography (CT) volumetric difference were shown to be statistically different between TLS stages (P

Ruellia tuberosa L. (RTL) exhibits phytochemical activities and has been used as a folk medicine for curing diabetes mellitus in East Asia for decades. This study investigated the effect of RTL aqueous and ethanolic extracts on nonalcoholic fatty liver disease (NAFLD) and hepatic lipid accumulation in high‐fat diet (HFD) and streptozotocin (STZ)‐induced type 2 diabetes mellitus (T2DM) rats. Administration of RTL aqueous extract (RTLW) or ethanolic extract (RTLE) at dosage of 100 or 400 mg/kg body weight for 4 weeks was carried out in HFD/STZ‐induced T2DM rats. Liver weight, adipose (epididymal and perirenal adipose tissues) weight, hepatic triglyceride level, and de novo lipogenesis (DNL)‐associated protein expression were monitored after scarification. The results revealed that RTLW and RTLE reduced relative liver weight and relative fat weights in HFD/STZ‐induced T2DM rats. RTLW and RTLE also ameliorated NAFLD and hepatic triglyceride (TG) accumulation in diabetic rats. Moreover, hepatic DNL‐regulated enzymes such as sterol regulatory element‐binding protein‐1 (SREBP1) and fatty acid synthase (FAS) expression were significantly suppressed by RTLE (100 and 400 mg/kg body weight) in diabetic rats. The evidences of this study suggest that RTL possesses potential on alleviating NAFLD and lipid accumulation via regulating DNL in the liver of HFD/STZ‐induced T2DM rats., This study investigated the effect of RTL aqueous and ethanolic extracts on nonalcoholic fatty liver disease (NAFLD) and hepatic lipid accumulation in high‐fat diet (HFD) and streptozotocin (STZ)‐induced type 2 diabetes mellitus (T2DM) rats. Liver weight, adipose (epididymal and perirenal adipose tissues) weight, hepatic triglyceride level, and de novo lipogenesis (DNL)‐associated protein expression were monitored after scarification. The evidences of this study suggest that RTL possesses potential on alleviating NAFLD and lipid accumulation via regulating DNL in the liver of HFD/STZ‐induced T2DM rats.

This study investigated the outcome of lymphedema microsurgery with or without microsurgical breast reconstruction for breast cancer-related lymphedema (BCRL).Complete decongestive therapy, lymphovenous anastomosis, and vascularized lymph node flap transfer are the 3 major treatment modalities for BCRL. Releasing axillary contracture and transferring a free flap may potentially improve the BCRL.Between 2004 and 2015, 124 patients with BCRL who underwent 3 treatment modalities without or with microsurgical breast reconstruction were included in this study as groups I and II, respectively. Patients were offered the lymphedema microsurgery depending on the availability of patent lymphatic ducts on indocyanine green lymphography if they failed to complete decongestive therapy. The circumferential difference, reduction rate, and episodes of cellulitis were used to evaluate the outcome of treatments.Improvements in the circumferential difference (12.8 ± 4.2% vs 11.5 ± 5.3%), the reduction rate (20.4 ± 5.1% vs 14.7 ± 6%), and episodes of cellulitis (1.7 ± 1.1 vs 2.1 ± 2.4 times/yr) did not significantly differ between groups I and II (P = 0.06, 0.07, and 0.06, respectively). In both groups, vascularized lymph node flap transfer was significantly superior to lymphovenous anastomosis or complete decongestive therapy in terms of improvements in the circumferential difference, reduction rate and episodes of cellulitis (P = 0.04, 0.04, and 0.06, respectively).Microsurgical breast reconstruction did not improve the outcome of BCRL. Improvements in BCRL were better for lymphatic microsurgery than complete decongestive therapy. Moreover, vascularized lymph node flap transfer provided greater improvements in the BCRL than lymphovenous anastomosis.

Purpose To evaluate the feasibility of cutaneous and subcutaneous limb tissue elasticity measurement in participants with limb lymphedema by using acoustic radiation force impulse (ARFI) elastography. Materials and Methods From July 2015 to June 2017, ARFI elastography was performed in 64 participants with lymphedema (seven men and 57 women; age range, 23-85 years) by using a US system. Tissue stiffness quantification with shear-wave velocity (SWV) was obtained in the cutaneous and subcutaneous limb tissues. Lymphoscintigraphy was the reference standard. Results SWV was significantly higher in limbs with lymphatic obstruction than in unaffected limbs (cutaneous tissue: 2.75 m/sec vs 1.74 m/sec, respectively; subcutaneous tissue: 1.90 m/sec vs 1.35 m/sec, respectively; P < .001). SWV was significantly different among limbs without lymphatic drainage obstruction, with partial obstruction, and with total obstruction (cutaneous tissue: 1.74 m/sec vs 2.75 m/sec vs 2.77 m/sec; subcutaneous tissue: 1.35 m/sec vs 1.90 m/sec vs 1.90 m/sec, respectively; P < .001). By using a cut-off value of 2.10 m/sec and 1.43 m/sec for cutaneous and subcutaneous tissue, respectively, sensitivity was 83.1% (59 of 71) and 80.3% (57 of 71), and specificity was 86.0% (49 of 57) and 70.2% (40 of 57) for manifestation of lymphatic obstruction. The corresponding areas under the receiver operating characteristic curve were 0.91 and 0.83, respectively. Conclusion Acoustic radiation force impulse elastography showed that cutaneous and subcutaneous tissues are stiffer in lymphedematous limbs than in unaffected limbs. Acoustic radiation force impulse elastography is a feasible imaging modality for noninvasive tissue stiffness quantification in limb lymphedema. © RSNA, 2018 Online supplemental material is available for this article.

Pao-Hsien Huang,1 Chih-Hua Tseng,1 Chia-Yu Lin,2 Chiang-Wen Lee,3–5 Feng-Lin Yen2,6 1School of Pharmacy, 2Department of Fragrance and Cosmetic Science, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, 3Research Center for Industry of Human Ecology, Chang Gung University of Science and Technology, Kweishan, Taoyuan, 4Department of Nursing, Division of Basic Medical Sciences, 5Chronic Diseases and Health Promotion Research Center, Chang Gung University of Science and Technology, Chia-Yi, 6Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan, Republic of China Background: 7,3´,4´-Trihydroxyisoflavone (734THI), a secondary metabolite derived from daidzein in soybean, possesses several biological activities, including antioxidant, skin whitening and anti-atopic dermatitis properties, but the poor aqueous solubility of 734THI has limited its application in medicine and cosmetic industry.Methods: The aim of the present study was to improve the physicochemical properties of 734THI using planetary ball mill preparation under a solvent-free process to improve its solubility and anti-pollutant activity. Results: 734THI nanoparticle powder (734THIN) was successfully prepared by the planetary ball mill technique using polyvinylpyrrolidone K30 as the excipient. 734THIN effectively increased the aqueous solubility and cellular uptake of 734THI by improving its physicochemical properties, including particle size reduction, crystalline–amorphous transformation and intermolecular hydrogen bonding with polyvinylpyrrolidone K30. In addition, 734THIN inhibited the overexpression of COX-2 and MMP-9 by downregulating MAPK pathway signaling in particulate matter-exposed HaCaT keratinocytes, while raw 734THI in PBS with low aqueous solubility did not show any anti-inflammatory or antiaging activity.Conclusion: 734THIN may be used as an additive in anti-pollutant skin care products for preventing particulate matter-induced inflammation and aging in skin. Keywords: 7,3´,4´-trihydroxyisoflavone, nanoparticle, planetary ball mill, particulate matter, inflammation

Introduction Objective sleep duration has been suggested to be a novel biomarker in the phenotyping of insomnia (Vgontzas & Fernandez-Mendoza, 2013). It was hypothesized that insomnia phenotype with PSG-defined short sleep duration (< 6 hours) is associated with physiological hyperarousal, while the phenotype with normal sleep duration (≥ 6 hours), is associated with anxious-ruminative psychological profile and poor resources for coping with stress. The aim of this study was to assess whether these two insomnia phenotypes differ in terms of self-reported psychological and physiological features. Methods A total 45 (mean age=36.6, female=76%) insomnia patients underwent a polysomnographic evaluation, completed several self-rating scales (include ISI, BAI, BDI, FIRST, DBAS, and PSAS), and were split into two groups base on their objective sleep duration (cut-off 6 hours). Results When compared to the short sleep group using independent sample t-test, the normal sleep group showed a significant higher mean score on FIRST (t= -2.13; p< .05). The short sleep group showed non-significant trends to have higher mean scores on BDI and BAI. The scores on the other scales showed no significant differences between the two groups. The FIRST score correlated positively with the score of DBAS (r= 0.32; p< .05) and the total (r= 0.36; p< .05) and cognitive-subscale scores (r= 0.41; p< .01) on PSAS. The BAI score correlated positively with the score of the total (r= 0.53; p< .001) and somatic subscale (r= 0.59; p< .001) on PSAS. Conclusion These results support the hypotheses that the normal sleep phenotype tends to be more vulnerable to the impact of stress, especially on sleep, due to pre-sleep cognitive hyperarousal. Since the BAI scale contains more items regarding physiological symptoms of anxiety disorders, the tendency of higher BAI score in short sleep group may indicate that the short sleep phenotype has higher physiological arousal, which supports the phenotyping model proposed by Vgontzas and Fernandez-Mandoza. Support (if any)

Greater provider volume is associated with better outcomes. There is, however, a paucity of evidence on volume-outcome associations for surgical complications and 30-day all-cause rehospitalization after free tissue transfer or free flap surgery. Surgical complications and frequent rehospitalization are important quality indicators that substantially hinder appropriate health care spending. The authors hypothesized that increased provider volume and surgeon experience are associated with lower complication and hospital readmission rates.The authors conducted a retrospective cohort study of adults aged 18 to 64 years who underwent free tissue transfer. They examined 100 percent of all free tissue transfers between 2001 and 2012 using Taiwan's national data, and used regression modeling to examine associations between volume and outcome. All models were adjusted for patient, surgeon, and hospital characteristics.Seventeen percent of free tissue transfer operations (4201 of 25,327) had complications. Infection was the most prevalent after free tissue transfer (70 percent), and the 30-day rehospitalization rate was approximately 20 percent. Hospital volume was associated with a small decrease in complications (OR, 0.99; 95 percent CI, 0.99 to 0.99; p0.01). For surgeons, years of experience and not annual case volume decreased surgical complications (OR, 0.98; 95 percent CI, 0.97 to 0.99; p = 0.01). The authors did not find any association between hospital or surgeon volume, or surgeon's years of experience and 30-day rehospitalization.Higher-volume hospitals and more experienced surgeons were shown to have a lower likelihood of postsurgery complications. Hospital process and structure affect outcomes and reduce surgical complications. Reducing 30-day rehospitalization may require payment reform, as it demands coordinated care before and after hospital discharge.Therapeutic, III.

INTRODUCTION The vascularized submental lymph node (VSLN) flap has become a popular choice for the treatment of lymphedema. Despite its favorable characteristics, anatomic variability exists, making the harvest of this flap challenging. Knowledge and characterization of anatomic variability can aid the surgeon in safe and effective flap harvest. METHODS A prospective analysis of all patients who underwent VSLN flap transfer for lymphedema was performed. Demographics, operative details, and post-operative recovery were analyzed for included patients. Intraoperative videography and detailed anatomic drawings of each case were reviewed to accurately account for anatomic variability and details. RESULTS Forty-two patients were identified during the study period. Arteriovenous anatomic variability (A1-A2 and V1-V4) existed, with most patients having the artery and vein present superior to the submandibular gland (A1V1; 31%), with other combinations occurring less frequently. Flap harvest time was found to be significantly increased with an intraglandular arterial course (P

Background and Objectives Due to its consistent vascular and lymphatic anatomy, the vascularized submental lymph node flap is a reliable option for lymphedema treatment. Despite these advantages, flap harvest requires resection of platysma, which may cause a marginal mandibular nerve pseudo-paralysis. The aim of this study was to investigate the donor site morbidity of an innovative platysma-sparing vascularized submental lymph node flap transfer for treating extremity lymphedema. Methods Ten patients undergoing platysma sparing submental lymph-node flap harvest were prospectively enrolled in the study and compared with a control group of 10 patients who underwent standard submental lymph-node flap harvest. Photogrammetry analysis was used to assess donor site morbidity with regards to marginal mandibular nerve pseudo-paralysis. Results All flaps survived. No necrosis of the skin paddle was observed in both groups. There were no marginal mandibular nerve palsies in both group. There were no cases of marginal mandibular nerve pseudo-paralysis in the platysma sparing group. Conclusions The platysma sparing submental flap, while offering comparable functional improvement for extremity lymphedema, has the advantages of maximizing nerve and muscular preservation, significantly reducing donor site morbidity. J. Surg. Oncol. © 2016 Wiley Periodicals, Inc.

Ultraviolet (UV) light has been developed for surface decontamination. However, UV light has some limitations at harmful effects for human and animals

Background Vascularized submental lymph node (VSLN) transfer is an emerging approach for extremity lymphedema. This study investigated the long-term outcome and venous complications of VSLN for unilateral lower extremity lymphedema. Methods Between 2010 and 2018, patients who underwent VSLN for unilateral lower extremity lymphedema were retrospectively evaluated. Patient demographics, operative records, complications, circumferential improvement, and episodes of cellulitis were analyzed. Further comparisons were performed between different types, numbers, and techniques of venous anastomoses. Results A total of 75 VSLNs in 70 patients survived, giving a 100% success rate. Six flaps (8%) had venous complications (VC group) and 69 flaps (92%) did not (No-VC group). There were no statistical differences in types, numbers, and techniques of anastomoses between two groups (P = .65, 1, and .56, respectively). At a mean follow-up of 32.0 ± 23.0 months, mean circumferential improvement and episodes of cellulitis between two groups did not statistically differ significantly (P = .31 and .09, respectively). Conclusions VSLN is an effective treatment for lower extremity lymphedema. The types, numbers of veins, and techniques of venous anastomoses did not statistically affect the venous complication rates. Functional outcomes of the VSLNs were not compromised if venous complications were salvaged promptly.

OBJECTIVES This study aimed to identify the cognitive factors associated with the professional healthcare advice (PHCA) seeking behavior in breast cancer-related lymphedema (BCRL). METHODS From January 2018 to December 2018, patients with BCRL were prospectively enrolled for a cross-sectional survey of lymphedema-related perceived risks, lymphedema quality of life (LYMQoL), knowledge scale of lymphedema, and PHCA behavior at first clinical visit, 3 and 6 months postbaseline. RESULTS A total of 180 patients including 100 (55.6%) patients underwent a vascularized lymph node transfer (VLNT) and 80 (44.4%) patients received compressive decongestive therapy (CDT) were enrolled. At 6 months of follow-up, mean episodes of cellulitis (from 2.2 to 0.2 times/year), mean circumferential difference (7.8 ± 3.9%), wearing compression garments (from 29% to 0 %) in the VLNT group were statistically reduced than those in the CDT group (p = .01

Introduction Patients with pre-existing lymphedema who undergo total knee arthroplasty (TKA) for osteoarthritis (OA) are at high risk for periprosthetic joint infection. This complication usually requires removal of the implant. This study aimed to investigate whether surgical treatment of lymphedema reduces the rate of prosthesis removal in such patients. Materials and methods We retrospectively reviewed our prospective database of patient information collected between January 2009 and December 2018. A total of 348 cases of lower extremity lymphedema were reviewed, and those who underwent total knee TKA for OA of the knee were included. Patient demographics, clinical data, lymphedema surgical history, and TKA surgical history including any episodes of removal were collected and analyzed. Results There were nine of 15 lymphedema patients with knee OA who subsequently underwent TKA. The mean patient age was 70.4 ± 7.1 years. A total of 18 TKAs were performed in nine patients. The knee prosthesis removal rate was 66.7% (12/18). The prosthesis removal rate was 40% (2/5) in patients who underwent lymphedema microsurgery vs 76.9% (10/13) for those who did not (P = .03). Conclusions Pre-existing lymphedema is associated with a high rate of knee prosthesis removal. Lymphedema microsurgery reduced the removal rate of knee prostheses. We recommend that lymphedema microsurgery be considered for patients who require TKA as a treatment for of the knee.

Background Vascularized lymph node transfer (VLNT) has become one of the effective surgical treatments for extremity lymphedema. This study was to evaluate the re-exploration and total complication rates of VLNT for lower extremity lymphedema between two different flap inset techniques. Methods Sixty-nine patients who underwent 74 submental VLNT transfers between 2008 and 2018 were retrospectively studied. Fifty-six flaps were inset using a new delayed primary retention suture (DPRS) technique and other 18 flaps using conventional interrupted sutures as the non-DPRS group. Results The overall flap success rate was 100%. The DPRS group was released at a mean of 1.7 ± 0.7 times and took a mean of 10.3 ± 3.3 days for wound closure. There were no statistical differences in demographics, mean symptom duration, and mean Cheng's Lymphedema Grading between two groups. Mean frequency of cellulitis of 2.5 ± 1.5 times/year in non-DPRS group was significantly greater than 1.4 ± 1.6 times/year in DPRS group (P = .01). The re-exploration and total complication rates were 5.4% and 7.1% in DPRS group, and 27.8% and 33.3% in non-DPRS group, respectively (P = .02 and .02, respectively). Conclusions The DPRS technique is a safe, simple, and reliable method for insetting the submental VLNT, which statistically decreased the re-exploration and total complication rates.

Background:. Circumferential difference of lymphedematous limbs at designated anatomic distances has been the primary mode for measuring lymphedematous extremities. Computed tomography (CT) imaging produces accurate, consistent, hygienic volume measurements and a direct limb representation. This study compares these 2 main modalities and assesses their correlation. Methods:. CT and circumferential difference measurements, costs, and correlation of patient limbs that received vascularized lymph node transfer were compared. Results:. Mean circumferential difference by tape measurement pre- and postoperatively was 31.4% ± 19.1% and 17.4% ± 8.8% for upper limbs and 43.2% ± 16.1% and 22.4% ± 12% for the lower limbs, respectively. Mean CT volumetric difference pre- and postoperatively were 36.1 ± 4.1% and 27.2 ± 2.8% for the upper limb and 46.2 ± 3.2% and 33.2 ± 2.1% for the lower limbs, respectively. CT volume measurements significantly correlated with their respective circumferential difference with Pearson correlation coefficient of r = +0.7, which was statistically significant (P = 0.03), indicating a strong positive correlation between circumferential difference and actual limb volume changes as determined by CT imaging. Circumferential differences are more cost effective than CT volume assessments in the domains of measurement frequency (P = 0.03), fee (P < 0.01), time (P = 0.03), total cost per year (P < 0.01), and cost/minute (P = 0.03). Conclusions:. Standardized circumferential differences that are currently used are comparable to unbiased CT volumetric measurements and can be used as a reliable, reproducible, minimally invasive, low cost, and accurate method of measuring the lymphedematous limbs.

Background The profunda feomris artery perforator (PAP) flap was recently revisited and gains popularity as an alternative method of autologous breast reconstruction. The purpose of this article is to demonstrate that PAP flap can be used reliably for reconstruction of various soft tissue defects. Methods A total of 55 free PAP flaps and 16 pedicle PAP flaps were transferred in 63 patients. Each case was reviewed to verify a PAP flap was performed identifying defect location, flap size, flap design, and postoperative complications. Results Seven flaps in five patients underwent breast reconstructions, 48 patients underwent head and neck reconstructions using free PAP flaps. The mean perforator number was 1.9, and the average pedicles length was 9.7 cm. The majority of perforators were musculocutaneous, and the others were septocutaneous. The mean ischemia time was 121.4 min. Minor complications included wound poor healing, flap partial necrosis, and pedicle vessels problems. Sixteen pedicle PAP flaps were transferred in 10 patients for vulvar reconstruction. Minor complications included urinary tract infection, poor wound healing, wound infection, hematoma. Conclusions The anatomy and number of perforators of PAP flap are reliable with adequate pedicle length. This flap can be an excellent option for reconstruction of most soft tissue defects. J. Surg. Oncol. 2016;114:193–201. © 2016 Wiley Periodicals, Inc.

To investigate the pump mechanism and pathway of lymph transit in vascularized lymph node flaps.Microsurgical treatment of lymphedema with vascularized lymph node transfer can improve signs and symptoms of disease, but the pathways and mechanisms of these flaps warrant further exploration.(Animal model) 72 flaps were raised in 18 rats: 36 groin flaps contained lymph nodes (LN), 36 deep inferior epigastric artery perforator flaps did not (non-LN). Indocyanine green (ICG) was added into normal saline (NS), 1%, 3%, 5%, 7% and 10% albumin. Three rats were assigned to each group. LN and non-LN flaps were submerged in solution and surveyed for venous fluorescence. In the 7% albumin and NS groups, volumetric change of solution was measured. (Human model) A similar experiment was performed in humans using five submental LN flaps.(Animal model) Fluorescence was detected in the venous pedicle of LN flaps submerged in 5%, 7% and 10% albumin, and half of flaps submerged in 3% albumin. Fluorescence was not detected in LN node flaps submerged in ICG-containing NS or 1% albumin solution. Fluorescence was not detected in non-LN flaps. There was greater volume reduction with LN flaps than non-LN flaps (p0.001). (Human model) Fluorescence was detected in the venous pedicle of all flaps immersed in lymph.ICG fluorescence was detected in the venous pedicle of rat and human LN flaps submerged in lymph or albumin when the concentration was greater than 3%. Based on these results, a pathway for lymphatic uptake is presented.

The relationship between methylglyoxal (MGO) and D-lactate during saikosaponin C (SSC) treatment of mice with accelerated nephrotoxic serum (NTS) nephritis was investigated. NTS nephritis was induced by administration of anti-basement membrane antibodies to C57BL/6 mice and three dosages of SSC were administered for 14 days. Proteinuria, blood urea nitrogen, serum creatinine, renal histology, urinary MGO and d-lactate changes were examined. Compared to the NTS control group, the middle dosage (10 mg/kg/day) of SSC significantly alleviated the development of nephritis based on urine protein measurements (34.40 ± 6.85 vs. 17.33 ± 4.79 mg/day, p

Background:. Primary lymphedema is a debilitating disease. This study was to investigate the outcomes between vascularized lymph node transfer (VLNT) and lymphovenous anastomosis (LVA) for treating primary lymphedema. Methods:. Between January 2010 and December 2016, 17 patients with mean age of 31.5 ± 15.5 (ranged, 2–57) years diagnosed with 19 primary limb lymphedema were recruited. Patients with patent lymphatic ducts on indocyanine green lymphography were indicated for LVA, whereas those without patent lymphatic ducts were indicated for VLNT. Circumferential limb measurements, body weight, episodes of cellulitis and Lymphedema Quality-of-Life (LYMQoL) questionnaire were compared between preoperatively and postoperatively. Results:. Fifteen lymphedematous limbs underwent VLNT (79%) and 4 underwent LVA (21%). All VLNT flaps survived. At a mean follow-up of 19.7 ± 8.5 months, mean reduction of limb circumference, body weight, and episodes of cellulitis were 3.7 ± 2.9 cm and 1.9 ± 2.9 cm (P = 0.2); 6.6 ± 5.9 kg and 1.7 ± 0.6 kg (P < 0.05); 5.1 ± 2.8 times/y and 4.2 ± 0.5 times/y in VLNT and LVA groups, respectively (P = 0.7). Improvements in overall score (from 3.9 ± 1.2 to 6.4 ± 1.1, P < 0.05) of the LYMQoL in VLNT group had statistical significant difference than that (from 3.0 ± 1.4 to 5.0 ± 2.4, P = 0.07) in LVA group. Conclusions:. Both VLNT and LVA can effectively treat primary lymphedema patients. The reduction of above-knee circumference, body weight, episodes of cellulitis, and the improvement of LYMQoL was significantly greater in LVNT compared with LVA.

Objective The need to have a pediatric-specific concussion management protocol on Return to School (RTS) and Return to Activity (RTA) after concussion has been recognized internationally. The first step to evaluate the protocol effectiveness is to establish whether children and youth are adhering to these recommendations. The objective of this study was to explore the prevalence and predictors of adherence to RTS and RTA concussion management protocols for children/youth. Design A prospective cohort of children/youth with concussion. Setting Childhood Disability Research Centre. Participants One hundred thirty-nine children/youth aged 5 to 18 years, diagnosed with concussion and symptomatic upon enrollment, were followed for up to 6 months. Primary recruitment occurred from a Children's Hospital Emergency Department. Intervention Provision of RTS/RTA guidelines. Main outcome measures Measurement of adherence came from multiple sources, including the child's and parent's knowledge of protocols, research personnel evaluations, and self-reported stages of RTS/RTA and Post-Concussion Symptom Scale (PCSS) scores. Results Spearman correlations and logistic regression were used, investigating the relationship between PCSS and progression of protocols and determining predictors of adherence. Significant negative associations between total PCSS score and stage of RTS/RTA protocols were found. Fifty-three percent and 56% of the participants adhered to the RTS and RTA protocols, respectively. Conclusions Children's knowledge of protocols and total PCSS scores significantly predicted adherence to RTS/RTA and may be the most important factors in predicting adherence during recovery from concussion.

Objective: The aim was to validate the new Taiwan Lymphoscintigraphy Staging, correlate it with Cheng Lymphedema Grading (CLG) and evaluate the treatment outcomes of unilateral extremity lymphedema. Background: No consensus has been reached for diagnosis and staging for patients with lymphedema among medical specialties. Methods: We included 285 patients with unilateral extremity lymphedema using lymphoscintigraphy. Lymphoscintigraphy was correlated to clinical symptoms and signs, and classified into normal lymphatic drainage, partial obstruction, and total obstruction. Inter- and intraobserver reliability of Taiwan Lymphoscintigraphy Staging, correlation between Taiwan Lymphoscintigraphy Staging and clinical findings were conducted. Patients were categorized in surgical (n = 154) or nonsurgical (n = 131) groups for outcome evaluation. Results: Lymphoscintigraphy found 11 patients (3.9%) with normal lymphatic drainage, 128 (44.9%) with partial obstruction, and 146 (51.2%) with total obstruction. Taiwan Lymphoscintigraphy Staging showed high interobserver agreement [intraclass correlation coefficient: 0.89 (95% confidence interval, 0.82-0.94)], and significantly correlated to computed tomography volumetric difference (r = 0.66, P < 0.001) and CLG [intraclass correlation coefficient: 0.79 (95% confidence interval 0.72-0.84)]. At a mean follow-up of 31.22.9 months, significant improvement in the circumferential difference (from 23.9%+/- 17.6% to 14.6%+/- 11.1%; P = 0.03) with a mean circumferential reduction rate of 40.4%+/- 4.5% was found in surgical group. At a mean follow-up of 26.6 +/- 8.7 months, the nonsurgical group had increase of mean circumferential difference from 24.0%+/- 17.2% to 25.3%+/- 19.0% (P = 0.09), with a mean circumferential reduction rate was -1.9%+/- 13.0%. Conclusions: The Taiwan Lymphoscintigraphy Staging is a reliable diagnostic tool, correlated with clinical findings and CLG, aiding in the selection of the appropriate treatment to achieve favorable long-term outcomes in unilateral extremity lymphedema.

Purpose This study was to investigate intraoperative assessment of side-to-end lymphovenous anastomosis (LVA) with indocyanine green (ICG) and the correlation between its patency and surgical outcome. Methods LVA was applied to five patients with early-stage lower extremity lymphedema. Side-to-end anastomosis and then end-to-end anastomosis were created as a second alternative. Immediately after the anastomosis, ICG was used to confirm its patency. Results The mean number of anastomoses was 2.0 ± 0.7, and the types of anastomoses were primarily side-to-end and secondarily end-to-end. The mean reduction rate was 63.8 ± 20.2% after LVA at 10 ± 6.4 months of follow-up. In all cases, the affected extremities became soft immediately after surgery, and no cellulitis episodes were observed. Conclusion Side-to-end LVA can be an effective treatment for early-stage lower extremity lymphedema. ICG lymphodynamic assessment is useful not only in the preoperative identification of functional lymphatics but also in the intraoperative visualization of new drainage routes in LVA surgery. © 2015 Wiley Periodicals, Inc. Microsurgery 36:310–315, 2016.

Background/PurposeAcanthamoeba keratitis is difficult to treat because Acanthamoeba cysts are resistant to the majority of antimicrobial agents. Despite the efficacy of 0.02% chlorhexidine in treating Acanthamoeba keratitis, a lack of data in the literature regarding the formulation's stability limits its clinical use. The objective of this study was to develop an optimal extemporaneous 0.02% chlorhexidine digluconate ophthalmic formulation for patients in need.MethodsWith available active pharmaceutical ingredients, 0.02% chlorhexidine digluconate sample solutions were prepared by diluting with BSS Plus Solution or acetate buffer. Influences of the buffer, type of container, and temperature under daily-open condition were assessed based on the changes of pH values and chlorhexidine concentrations of the test samples weekly. To determine the beyond-use date, the optimal samples were stored at 2–8°C or room temperature, and analyzed at time 0 and at Week 1, Week 2, Week 3, Week 4, Week 5, Week 8, Week 12, and Week 24.ResultsDespite chlorhexidine exhibiting better stability in acetate buffer than in BSS solution, its shelf-life was

Supplemental Digital Content is available in the text., Background: We examined the associations of surgeon and hospital volume with total cost, length of stay (LOS), and cost per day for free tissue transfer (FTT) surgeries. Evidence demonstrates a higher likelihood of success for FTT in higher volume hospitals. Little, however, is known about volume-outcome associations for surgical costs and LOS. We hypothesized that higher provider volume is associated with lower cost and shorter LOS. Methods: Using Taiwan’s national data (2001–2012), we conducted a retrospective cohort study of all adults 18–64 years of age who underwent FTT during the study period. We used hierarchical regression modeling for our analyses. Our 3 outcome variables were total cost of FTT surgery, LOS in hospital, and cost per day. Results: Except for functional muscle flap, in which LOS was 12 days shorter in high-volume compared with low-volume hospitals (P = 0.017), no association between hospital volume and LOS was found. Contrary to our hypothesis, our results for all FTT cases demonstrate positive associations of medium-volume hospitals (OR = 1.31; CI, 1.11–1.55) and high-volume surgeons (OR = 1.16; CI,1.03–1.32) with total cost and cost per day, respectively. The interactions of hospital volume and surgeon volume show that in medium- and high-volume hospitals, surgeons with the highest volume had the lowest predicted cost per day among hospitals in that category; but all differences in cost were small. Conclusions: There were no substantial variations based on different hospital or surgeon volume in LOS, total cost, or cost per day for FTT operations performed in Taiwan.

Oxidative stress has been implicated in the etiology of pancreatic β-cell dysfunction and diabetes. Studies have shown that chlorella could be important in health promotion or disease prevention through its antioxidant capacity. However, whether chlorella has a cytoprotective effect in pancreatic β-cells remains to be elucidated. We investigated the protective effects of chlorella on H2O2-induced oxidative damage in INS-1 (832/13) cells. Chlorella partially restored cell viability after H2O2 toxicity. To further investigate the effects of chlorella on mitochondria function and cellular oxidative stress, we analyzed mitochondria membrane potential, ATP concentrations, and cellular levels of reactive oxygen species (ROS). Chlorella prevented mitochondria disruption and maintained cellular ATP levels after H2O2 toxicity. It also normalized intracellular levels of ROS to that of control in the presence of H2O2. Chlorella protected cells from apoptosis as indicated by less p-Histone and caspase 3 activation. In addition, chlorella not only enhanced glucose-stimulated insulin secretion (GSIS), but also partially restored the reduced GSIS after H2O2 toxicity. Our results suggest that chlorella is effective in amelioration of cellular oxidative stress and destruction, and therefore protects INS-1 (832/13) cells from H2O2-induced apoptosis and increases insulin secretion. Chlorella should be studied for use in the prevention or treatment of diabetes.

Background Nonanatomic (distal) placement of vascularized lymph node (VLN) transfers have shown efficacy in the treatment of extremity lymphedema, but the mechanism by which these flaps provide relief of lymphedema remains unclear. Intrinsic lymphovenous connections have been previously shown to exist in the transferred flap. But, the long-term interaction of the VLN flap and surrounding lymphedematous extremity has not been previously investigated. Patients and Methods A retrospective review of a prospective maintained database of patients who underwent VLN transfer was evaluated. Patients who underwent distal VLN transfer and had more than 1-year follow-up were identified. Lymphodynamic evaluation was performed using 0.3 to 0.6 mL indocyanine green (ICG) injection at 5 cm proximal to the flap edge on identified patients. Migration direction of dye and latency period was evaluated. Results In total, 20 patients were identified who met inclusion criteria. Average long-term follow-up was 27.3 months. The average circumference reduction of the affected extremity was 40.5%. ICG appearance within the VLN flap was found in all patients occurring on average in 178.3 seconds. In all cases, flow occurred in the distal direction (toward the flap) with proximal placement of dye. Latency period was found to inversely correlate with circumference reduction (p Conclusions Distal, nonanatomic placement of VLN flaps provide sustained limb circumference reduction in extremity lymphedema patients following a minimum of 1-year postoperatively. Flap integration with the recipient site reliably occurs as witnessed with consistent ICG drainage, and occurs in the gravity-dependent direction. Faster clearance of ICG will result in improved clinical limb circumference reduction.

Objective To compare symptoms of obstructive sleep apnea (OSA) and polysomnography (PSG) results in children with Down syndrome and typically developing children. Study design A total of 49 children with Down syndrome referred for PSG between 2008 and 2012 were matched with typically developing children of the same sex, age, and OSA severity who had undergone PSG in the same year. A parent completed a sleep symptom questionnaire for each child. Sleep quality and measures of gas exchange were compared between the matched groups. Results The 98 children (46 females, 52 males) had mean age of 6.2 years (range, 0.3-16.9 years). Fourteen children had primary snoring, and 34 had OSA (9 mild, 7 moderate, and 19 severe). Children with Down syndrome had more severe OSA compared with 278 typically developing children referred in 2012. Symptom scores were not different between the matched groups. Those with Down syndrome had a higher average pCO 2 during sleep ( P = .03) and worse McGill oximetry scores. Conclusion Compared with closely matched typically developing children with OSA of comparable severity, children with Down syndrome had a similar symptom profile and slightly worse gas exchange. Referred children with Down syndrome had more severe OSA than referred typically developing children, suggesting a relative reluctance by parents or doctors to investigate symptoms of OSA in children with Down syndrome. These findings highlight the need for formal screening tools for OSA in children with Down syndrome to improve detection of the condition in this high-risk group.

Little is known about the impact of acquired brain injury (ABI) on the long-term quality-of-life (QoL) in children and youth. The objectives of this study were to illustrate the long-term QoL trajectories at 5 years post-ABI.The QoL of children between 5-18 years (n = 94) admitted to McMaster Children's Hospital with ABI were assessed longitudinally for a minimum of 5 years post-injury using the Child Health Questionnaire. Independent t-tests were used to examine differences in QoL between the study cohort and a normative sample at different time points. Mixed-effects models were used to identify predictors for QoL.The QoL of children with ABI was significantly poorer (p0.05) than the normative data on all domains and at all-time points except at baseline. The CHQ physical summary score (PHSS) showed a significant decline immediately after injury and a significant recovery at 8 months post-injury; while the CHQ psychosocial summary score (PSSS) showed a significant immediate decline, which remained over the course of the study. Pre-morbid school record, time post-injury and mechanism of injury significantly predicted the CHQ PSSS.QoL is impacted by ABI regardless of severity. This impact is further affected by time post-injury.