Reconstruction of palatomaxillary defects following cancer ablation with temporalis muscle flap in medically compromised patients: a 15-year single institutional experience

Objectives

Successful reconstruction of palatomaxillary defects following cancer ablation represents a formidable challenge for surgeons to achieve consistently favorable outcomes. The purpose of this article is to present our experience in oncologic palatomaxillary repair with temporalis muscle flap (TMF) for medically compromised patients who are not ideal candidates for microvascular reconstruction at a Chinese tertiary referral hospital over a 15-year period (1998–2012).

Method

A retrospective chart review was performed to identify patients with compromised medical conditions who underwent oncologic palatomaxillary reconstruction using TMF. Patients’ demographics, clinicopathological variables, and surgical techniques were presented. Postoperative functional and aesthetic outcomes were assessed by measurements and patients self-evaluations.

Results

Sixty-nine TMFs were successfully harvested and used for immediate oncologic palatomaxillary reconstruction in 67 patients (31 males and 36 females, mean age 60.4 years) with diverse primary malignancies. These patients’ co-morbidities included systemic diseases, preoperative chemotherapy/radiotherapy, and elder over 65 years which precluded the ideal utility of free flaps. Fifty-one patients remained alive without disease, while nine had recurrences/metastases and seven died during the follow-up (0.5–10.4 years, mean 3.7 years). All flaps survived with only partial necroses in four cases. Complications and donor-site morbidities were minimal with five transient facial paralysis and four mild diplopia and enophthalmos. Unrestricted diet and mouth opening, intelligible speech, and satisfactory temporal aesthetics were obtained in most patients.

Conclusion

The TMF is a reliable, versatile, and alternative option for oncologic palatomaxillary reconstruction with satisfactory functional and aesthetic outcomes and minimal complications, especially when appropriately selected for those medically compromised patients.     

High-resolution photoacoustic tomography of resting-state functional connectivity in the mouse brain

The increasing use of mouse models for human brain disease studies presents an emerging need for a new functional imaging modality. Using optical excitation and acoustic detection, we developed a functional connectivity photoacoustic tomography system, which allows noninvasive imaging of resting-state functional connectivity in the mouse brain, with a large field of view and a high spatial resolution. Bilateral correlations were observed in eight functional regions, including the olfactory bulb, limbic, parietal, somatosensory, retrosplenial, visual, motor, and temporal regions, as well as in several subregions. The borders and locations of these regions agreed well with the Paxinos mouse brain atlas. By subjecting the mouse to alternating hyperoxic and hypoxic conditions, strong and weak functional connectivities were observed, respectively. In addition to connectivity images, vascular images were simultaneously acquired. These studies show that functional connectivity photoacoustic tomography is a promising, noninvasive technique for functional imaging of the mouse brain.Resting-state functional connectivity (RSFC) is an emerging neuroimaging approach that aims to identify low-frequency, spontaneous cerebral hemodynamic fluctuations and their associated functional connections (1, 2). Recent research suggests that these fluctuations are highly correlated with local neuronal activity (3, 4). The spontaneous fluctuations relate to activity that is intrinsically generated by the brain, instead of activity attributable to specific tasks or stimuli (2). A hallmark of functional organization in the cortex is the striking bilateral symmetry of corresponding functional regions in the left and right hemispheres (5). This symmetry also exists in spontaneous resting-state hemodynamics, where strong correlations are found interhemispherically between bilaterally homologous regions as well as intrahemispherically within the same functional regions (3). Clinical studies have demonstrated that RSFC is altered in brain disorders such as stroke, Alzheimer’s disease, schizophrenia, multiple sclerosis, autism, and epilepsy (6–12). These diseases disrupt the healthy functional network patterns, most often reducing correlations between functional regions. Due to its task-free nature, RSFC imaging requires neither stimulation of the subject nor performance of a task during imaging (13). Thus, it can be performed on patients under anesthesia (14), on patients unable to perform cognitive tasks (15, 16), and even on patients with brain injury (17, 18).RSFC imaging is also an appealing technique for studying brain diseases in animal models, in particular the mouse, a species that holds the largest variety of neurological disease models (3, 13, 19, 20). Compared with clinical studies, imaging genetically modified mice allows exploration of molecular pathways underlying the pathogenesis of neurological disorders (21). The connection between RSFC maps and neurological disorders permits testing and validation of new therapeutic approaches. However, conventional neuroimaging modalities cannot easily be applied to mice. For instance, in functional connectivity magnetic resonance imaging (fcMRI) (22), the resting-state brain activity is determined via the blood-oxygen-level–dependent (BOLD) signal contrast, which originates mainly from deoxy-hemoglobin (23). The correlation analysis central to functional connectivity requires a high signal-to-noise ratio (SNR). However, achieving a sufficient SNR is made challenging by the high magnetic fields and small voxel size needed for imaging the mouse brain, as well as the complexity of compensating for field inhomogeneities caused by tissue–bone or tissue–air boundaries (24). Functional connectivity mapping with optical intrinsic signal imaging (fcOIS) was recently introduced as an alternative method to image functional connectivity in mice (3, 20). In fcOIS, changes in hemoglobin concentrations are determined based on changes in the reflected light intensity from the surface of the brain (3, 25). Therefore, neuronal activity can be measured through the neurovascular response, similar to the method used in fcMRI. However, due to the diffusion of light in tissue, the spatial resolution of fcOIS is limited, and experiments have thus far been performed using an exposed skull preparation, which increases the complexity for longitudinal imaging.Photoacoustic imaging of the brain is based on the acoustic detection of optical absorption from tissue chromophores, such as oxy-hemoglobin (HbO₂) and deoxy-hemoglobin (Hb) (26, 27). This imaging modality can simultaneously provide high-resolution images of the brain vasculature and hemodynamics with intact scalp (28, 29). In this article, we perform functional connectivity photoacoustic tomography (fcPAT) to study RSFC in live mice under either hyperoxic or hypoxic conditions, as well as in dead mice. Our experiments show that fcPAT is able to detect connectivities between different functional regions and even between subregions, promising a powerful functional imaging modality for future brain research.     

Computer-assisted surgery in orthopedic oncology: Technique,indications, and a descriptive study of 130 cases

Background and purpose —

In orthopedic oncology, computer-assisted surgery (CAS) can be considered an alternative to fluoroscopy and direct measurement for orientation, planning, and margin control. However, only small case series reporting specific applications have been published. We therefore describe possible applications of CAS and report preliminary results in 130 procedures.

Patients and methods —

We conducted a retrospective cohort study of all oncological CAS procedures in a single institution from November 2006 to March 2013. Mean follow-up time was 32 months. We categorized and analyzed 130 procedures for clinical parameters. The categories were image-based intralesional treatment, image-based resection, image-based resection and reconstruction, and imageless resection and reconstruction.

Results —

Application to intralesional treatment showed 1 inadequate curettage and 1 (other) recurrence in 63 cases. Image-based resections in 42 cases showed 40 R0 margins; 16 in 17 pelvic resections. Image-based reconstruction facilitated graft creation with a mean reconstruction accuracy of 0.9 mm in one case. Imageless CAS was helpful in resection planning and length- and joint line reconstruction for tumor prostheses.

Interpretation —

CAS is a promising new development. Preliminary results show a high number of R0 resections and low short-term recurrence rates for curettage.Oncological surgical treatment can be considered to be a trade-off between margins and function, with margins being the most important factor to consider. Accuracy is needed to achieve an efficient but oncologically safe result. To assist in this, most procedures in bone tumor surgery require intraoperative imaging with fluoroscopy and/or measurements with rulers for anatomical orientation and margin control. The best examples of this are pelvic resections. Cartiaux et al. (2008) demonstrated that 4 experienced surgeons could achieve a 10-mm resection margin, with 5-mm tolerance, on pelvic sawbones in only half of the resections. The supportive imaging and measuring modalities have, however, remained more or less unchanged for many years. In a 2-dimensional (2D) workflow such as fluoroscopy, there is still the requirement for an accurate frame of reference based on anatomical landmarks for adequate 3-dimensional (3D) margin control.In recent years, the use of computer-assisted surgery (CAS) in orthopedic surgery has become more common as an alternative for intraoperative imaging and measurements, providing the necessary precision in bone tumor surgery. The technique that is mostly used in orthopedic oncology is image-based navigation. The patient’s own anatomy (MRI and/or CT) is entered into the system and used during surgery. This provides real-time, continuous, 3D imaging feedback and may lead to more precise margin control, better tissue preservation, and new approaches to reconstruction while remaining oncologically safe. Several publications have supported CAS as being a safe navigation platform for planning and performing resections (Wong et al. 2007, So et al. 2010, Cho et al. 2012). A recent publication describes lessons in the technological approach and offers comments on CAS workflow (Wong 2010). However, to date the largest case series have involved only 20 and 31 cases (Cheong and Letson 2011, Jeys et al. 2013). The reported use has mostly been limited to complex tumor resections (e.g. pelvic), and due to the novelty of the technique, applications, approaches, and set-up times differ greatly (Saidi 2012). Here we describe possible applications of CAS in bone tumor surgery (also outside of complex resections), consider their usefulness, and report preliminary results from 130 CAS procedures performed at a single institution.     

颅脑外科手术中无菌冲洗盐水给水方式的效果探讨

目的:通过对颅脑外科手术中所用开放式与密闭式无菌生理盐水的污染程度的监测,分析原因,进行对比。方法:随机将72例颅脑外科择期无菌手术分为开放式给水和密闭式给水各36例。在不同时间点,两种无菌生理盐水同时取样,并进行细菌培养监测。结果:密闭组手术中使用的无菌生理盐水未检出细菌。开放组随手术时间和无菌生理盐水开放的时间延长,冲洗水中细菌的检查数量逐渐增加,两组比较有显著差异(P<0.05)。结论:使用密闭式无菌生理盐水冲洗可以有效控制细菌污染,降低手术感染率,减少院内感染,减轻患者痛苦和负担。     

Market, hospital, and nursing unit characteristics as predictors of nursing unit skill mix: a contextual analysis

The objective was to examine the relative contributions of market, hospital, and nursing unit characteristics to the prediction of nursing unit skill mix. The strongest predictors of nursing skill mix were found to be the technological sophistication of the hospital, the volume of services offered, and the percentage of patients covered by managed care payors. The results suggest that skill mix on nursing units is buffered from market forces but is highly sensitive to hospital characteristics. These factors need to be taken into account when decisions are made about the allocation of personnel resources. In this article, the terms "nursing skill mix" and "nurse staffing" are used interchangeably.     

Persistent elevation of paraoxonase-1 specific enzyme activity after weight reduction in obese non-diabetic men with metabolic syndrome

BackgroundParaoxonase-1 (PON1) is an esterase associated with the high-density lipoprotein (HDL) in serum. To date, there have been few reports about circulating PON1 protein concentration and specific activity in subjects with metabolic syndrome (MetS). More importantly, it is unknown whether weight loss could alter PON1 protein expression or specific activity in obese non-diabetic men with MetS.MethodsWe prospectively enrolled a total of 40 obese non-diabetic men with MetS. Among them, 22 subjects finished the 3-month course of weight loss program and complied for longer follow-ups post-weight loss at the 3rd, 12th, and 18th month from the beginning of the program. Twenty-six healthy volunteers served as controls. Serum circulating PON1 concentration was measured by an enzyme linked immunosorbent kit (ELISA) and PON1 activity was measured by an automated PON1 activity assay.ResultsObese non-diabetic men with MetS (n = 40) had a higher PON1 protein concentration (31.0 ± 11.3 vs. 24.8 ± 9.7 μg/ml, p = 0.025) but lower specific enzyme activity (7.5 ± 4.0 vs. 11.2 ± 7.2 mU/μg, p = 0.023) than those of the controls. Multivariate regression analysis of baseline PON1 specific activity revealed that adiponectin was a significant positive predictor (p = 0.044) while monocyte chemotactic protein-1 (MCP-1) was a negative predictor (p = 0.031). After a 3-month weight loss program, obese MetS men (n = 22) had a significant weight reduction (95.8 ± 9.0 to 86.3 ± 10.4 kg, with a 9.9 ± 5.4% decrease, p < 0.001). PON1 protein decreased significantly after weight loss and kept declining through the 3rd month till the 18th month follow-up. PON1 specific enzyme activity (baseline 7.5 ± 2.6 mU/μg) increased significantly after weight loss and kept increasing through the 12th month till the 18th month follow-ups (11.8 ± 6.4 mU/μg, p = 0.001 vs. baseline).ConclusionsWeight loss by a 3-month diet and exercise program time-sequentially increased PON1 specific enzyme activity in obese non-diabetic men with MetS.     

老龄急性缺血性脑卒中后多器官功能障碍综合征模型大鼠的免疫功能变化

目的：观察老龄大鼠急性缺血性脑卒中后多器官功能障碍综合征（multiple organ dysfunction syndrome in the elderly，MODSE）后免疫功能的变化。 方法：实验于2005—10／12在解放军兰州军区总医院动物实验室进行。取46只健康老龄Wistar大鼠中，鼠龄24个月，随机抽出6只作为对照组，不干预，其余40只实施双侧颈动脉夹闭30min再灌注，建立老龄大鼠急性缺血性脑卒中后多器官功能障碍综合征模型。在术后1，3，5d时相点用流式细胞仪分析实验大鼠胸腺、脾脏、外周血中T淋巴细胞、B淋巴细胞、自然杀伤细胞数量变化，以及胸腺、脾脏中淋巴细胞的凋亡数量变化。 结果：①40只实施双侧颈动脉夹闭的老龄大鼠，术后1d死亡6只，在34只存活大鼠中，根据血气及生化指标检测结果，发生多器官功能障碍综合征有19只（MODSE组），未发生者15只（无MODSE组）。②外周血和脾脏、胸腺内免疫细胞的变化：术后1d，无MODSE组和MODSE组大鼠的免疫细胞数量均低于对照组（P〈0．05，0.01）；MODSE组大鼠T，B，自然杀伤细胞数量在外周血较对照组低3～5倍，脾脏内低两三倍。③脾脏、胸腺内凋亡细胞变化：术后1d，无MODSE组和MODSE组老龄大鼠免疫细胞凋亡比例增加，均高于对照组（P〈0.05，0．01），MODSE组高于无MODSE组（P〈0.01）。 结论：老龄大鼠急性缺血性脑卒中后，免疫细胞的凋亡增加，外周和中枢免疫器官内免疫细胞数量明显下降，导致细胞免疫和体液免疫功能的下降，发生多器官功能障碍综合征者变化更明显。这提示急性缺血性脑卒中后多器官功能障碍综合征的发生与免疫功能的下降有密切关系。     

Posterior Fibular Groove Deepening Procedure With Low-Profile Screw Fixation of Fibrocartilaginous Flap for Chronic Peroneal Tendon Dislocation

Chronic peroneal tendon dislocation is an uncommon disorder that frequently presents with concomitant pathology. Posterior fibular groove deepening and retinaculum repair have been increasing in popularity for treatment of peroneal tendon dislocations. The purpose of the present study was to introduce a posterior fibular groove deepening procedure using low-profile snap-off screws to securely and simply fix the fibrocartilaginous flap to facilitate faster rehabilitation and to assess the clinical outcomes of patients with chronic peroneal tendon dislocation and associated pathologic features. In the present retrospective case series, 34 ankles in 34 patients underwent the fibular groove deepening procedure using low-profile screws with superior peroneal retinaculum repair. The clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and patient subjective satisfaction rate. The time of return to recreational and sports activities was also assessed. Weightbearing ankle radiographs were evaluated to assess the stability of the flap by checking the screws. The mean follow-up period was 47.96 (range 12 to 142) months. The mean AOFAS scale score for all patients improved from 69.96?±?13.14 to 87.72?±?10.13 at the last follow-up examination (p?<?.001). Overall, 85.3% of patients subjectively rated their operative outcomes as excellent or good. The 18 (52.9%) patients with an isolated peroneal tendon dislocation had a faster return to recreational or sports activities than the 16 (47.1%) patients with concomitant pathologic features (2.95?±?0.19 versus 4.14?±?1.34 months; p?=?.002). No patient experienced residual dislocation, screw loosening, or irritation from the screws. The fibular groove deepening procedure using low-profile screws is be a simple procedure that offers rigid fixation. This leads to relatively fast rehabilitation and resumption of recreational or sports activities.     

The Feasibility of Extracorporeal Membrane Oxygenation in the Variant Airway Problems

Introduction: Extracorporeal membrane oxygenation (ECMO) is widely used to treat respiratory distress during cardiac or respiratory arrest; moreover, its use is being extended to a wide variety of clinical fields. In this study we assess the utility of ECMO in the management of airway obstruction.Patients and Methods: 15 patients underwent ECMO for airway obstruction. We retrospectively analyzed and evaluated the feasibility of ECMO in the treatment of airway problems.Results: Seven patients received ECMO to facilitate respiration and promote stability during trachea surgery. In six cases ECMO ceased immediately following the operation; in the remaining case ECMO cessation was delayed due to post-operative ARDS. In three cases emergency ECMO was used in response to respiratory arrest; two patients died. In five cases ECMO was emergently inserted to prevent death, following airway blockade by massive hemoptysis. One patient was not discharged from the intensive care unit. Another patient was transferred to a general ward but died from other causes.Conclusion: ECMO is useful during anesthesia in patients at high risk of airway blockade, for example due to endobronchial bleeding, and during complex thoracic surgery. ECMO confers a safer environment during airway surgery, and its complication rate is acceptable.