From Case Reports to Molecular Insight: Examining the Outcomes and Underlying Mechanisms of Squamous Cell Carcinoma in Breast Implant Patients-A Systematic Review

There is extensive coverage in the existing literature on implant-associated lymphomas like anaplastic large-cell lymphoma, but breast implant-associated squamous cell carcinoma (BIA-SCC) has received limited scholarly attention since its first case in 1992. Thus, this study aims to conduct a qualitative synthesis focused on the underexplored association between breast implants and BIA-SCC. A systematic review was conducted utilizing the PubMed, Web of Science, and Cochrane databases to identify all currently reported cases of BIA-SCC. Additionally, a literature review was performed to identify potential biochemical mechanisms that could lead to BIA-SCC. Studies were vetted for quality using the NIH quality assessment tool. From an initial pool of 246 papers, 11 met the quality criteria for inclusion, examining a total of 14 patients aged between 40 and 81 years. BIA-SCC was found in a diverse range of implants, including those with smooth and textured surfaces, as well as those filled with saline and silicone. The condition notably manifested a proclivity for aggressive clinical progression, as evidenced by a mortality rate approximating 21.4% within a post-diagnostic interval of six months. Our literature review reveals that chronic inflammation, driven by various external factors such as pathogens and implants, can initiate carcinogenesis through epigenetic modifications and immune system alterations. This includes effects from exosomes and macrophage polarization, showcasing potential pathways for the pathogenesis of BIA-SCC. The study highlights the pressing need for further investigation into BIA-SCC, a subject hitherto inadequately addressed in the academic sphere. This necessitates the urgency for early screening and intervention to improve postoperative outcomes. While the review is confined by its reliance on case reports and series, it serves as a valuable reference for future research endeavors.

Microsurgical replantation after forehead avulsion - success or failure? A case report

In this article we would like to present, to our best knowledge, the very first published replantation of a forehead/part of a forehead as a single unit. The patient is a 57-year-old male smoker who sustained an avulsion forehead injury after a dog bite. Replantation was performed using microanastomosis of the supratrochlear vessels with restoration of good blood circulation after the procedure. Unfortunately, 5 days after the surgery, ischemia of the flap occurred followed by successful acute revision surgery. Nevertheless, the day after the ischemia reoccurred due to the time that passed, circumstances and unfavorable conditions affecting the sutured vessels, no further revision surgery was indicated. Observation continued and eventual wound necrosis after demarcation was left to be treated with skin grafting or per secundam intentionem. Only partial necrosis of the flap occurred, approximately 50%, which was subsequently treated with a full-thickness skin graft with very good results leading to the satisfaction of the patient.

No drains in reduction mammaplasty - a systematic review

Breast reduction mammaplasty is the only effective therapeutic intervention for patients with symptomatic breast hypertrophy. In this procedure, closed suction drains have become a standard of care, while the literature supporting use of drains is lacking. In fact, with emerging data we found out that drains might not be so necessary. This review aimed to systematically compare the number of complications in drained and undrained breasts and to evaluate the safety of omitting drains in reduction mammaplasty in clinical practice. A systematic review of literature was conducted identifying all studies on drainage in reduction mammaplasty. The analysed databases revealed 13 eligible studies to be included in this review. There were 308 drained breasts and 859 undrained breasts in total in patients from 16 to 73 years of age. The resected tissue weight per side fluctuated from 108 to 1,296 grams. In total, there was only 2.4% incidence of haematoma complications in undrained breasts and 3.9% in drained breasts. Closed suction drains are still being routinely used in reduction mammaplasty, although aborting drain use is proven to be not only safe, but advantageous. The clear benefit is increased patient comfort, shortened hospital stay, decreased cost of the procedure and nurse care, and decreased rate of complications.

Aircraft noise exposure induces pro-inflammatory vascular conditioning and amplifies vascular dysfunction and impairment of cardiac function after myocardial infarction

AIMS

Traffic noise may play an important role in the development and deterioration of ischemic heart disease. Thus, we sought to determine the mechanisms of cardiovascular dysfunction and inflammation induced by aircraft noise in a mouse model of myocardial infarction (MI) and in humans with incident MI.

METHODS AND RESULTS

C57BL/6J mice were exposed to noise alone (average sound pressure level 72 dB; peak level 85 dB) up to 4d, resulting in pro-inflammatory aortic gene expression in the myeloid cell adhesion/diapedesis pathways. Noise alone promoted adhesion and infiltration of inflammatory myeloid cells in vascular/cardiac tissue, paralleled by an increased percentage of leukocytes with a pro-inflammatory, reactive oxygen species (ROS)-producing phenotype and augmented expression of Nox-2/phospho-NFκB in peripheral blood. Ligation of the LAD resulted in worsening of cardiac function, pronounced cardiac infiltration of CD11b+ myeloid cells and Ly6Chigh monocytes and induction of interleukin (IL) 6, IL-1β, CCL-2 and Nox-2, being aggravated by noise exposure prior to MI. MI induced stronger endothelial dysfunction and more pronounced increases in vascular ROS in animals preconditioned with noise. Participants of the population-based Gutenberg Health Cohort Study (median follow-up:11.4y) with incident MI revealed elevated CRP at baseline and worse LVEF after MI in case of a history of noise exposure and subsequent annoyance development.

CONCLUSION

Aircraft noise exposure before MI substantially amplifies subsequent cardiovascular inflammation and aggravates ischemic heart failure, facilitated by a pro-inflammatory vascular conditioning. Our translational results suggest, that measures to reduce environmental noise exposure will be helpful in improving clinical outcome of subjects with MI.

Telomere shortening in hypertensive heart disease depends on NOX2-mediated loss of PRDX1 and oxidative DNA damage

Background

Heart failure (HF) coincides with cardiomyocyte telomere shortening. Arterial hypertension is the most prominent risk factor for HF. Both HF and arterial hypertension are associated with dysregulation of the neurohormonal axis and increased ROS. However, how neurohormonal activation is linked to telomere shortening in the pathogenesis of HF is incompletely understood. Further, recent findings suggest that peroxiredoxin 1 (PRDX1) can act as a telomere specific antioxidant.

Methods

To induce hypertensive HF, male C57BL/6J mice were subjected to AngII-infusion, uninephrectomy and high-salt (AngII++) for 5 weeks. Cardiac function was assessed by ultrasound. Mouse adult cardiomocytes (CMs) isolated from C57BL/6J mice and mice lacking the NADPH-oxidase (NOX) 2/gp91phox as well as rat ventricular CM-derived cells (H9C2) were stimulated with AngII. Telomere length was quantified by Q-FISH after staining with a C-rich telomere probe (TelC). DNA/RNA-damage was evaluated after staining for Oxo-8-Gua (8-oxo-7,8-dihydroguanine) and Oxo-8-G (8-oxo-7,8-dihydroguanosine). Superoxide (O2-) was quantified by 2-hydroxyethidium (2-HE) using HPLC analysis. Colocalization of Oxo-8-Gua and TelC was quantified by automated image analysis. (Sub)cellular and tissue expression of gp91phox/Nox2 and PRDX1 was evaluated by ICC/IHC. All image quantification was conducted semiautomatically.

Results

In mice subjected to hypertensive HF, CM telomere shortening correlated significantly with both left ventricular (LV) dilatation and impairment of LV systolic function, paralleled by a significant loss of myocardial PRDX1 and significantly increased myocardial DNA/RNA-damage. Similarly, CMs stimulated with AngII exhibited significant telomere shortening, significant loss of PRDX1 and significantly increased DNA/RNA-damage, together with significantly increased CM superoxide production and significantly increased expression of the superoxide generating enzyme gp91phox/NOX2. Correspondingly, deficiency of gp91phox/NOX2 significantly prevented AngII-induced CM telomere shortening, DNA/RNA-damage and PRDX1-depletion. A similar effect could be observed upon stimulation of CMs with the specific histone deacetylase (HDAC) 6-inhibitor tubastatin, which prevents deacetylation of PRDX1.

Conclusion

We could provide first evidence that in heart failure, ROS originating from increased NOX2-activity leads to depletion of the telomere-targeted antioxidant and repair-protein PRDX1, which results in damage to the telomeric DNA. Both depletion of NOX2 as well as harnessing the intrinsic antioxidant defense by stabilizing PRDX1 via HDAC6-inhibition prevented CM telomere shortening and could be further evaluated as potential therapeutic targets to address heart failure.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry for Education and Research

Inhibition of coagulation factor XI attenuates inflammation in myocardial ischemia/reperfusion injury

Background

Increasing evidence suggests that FXI is an attractive target for antithrombotic therapy because it reduces thrombosis without increasing bleeding risk. Patients with decreased levels of FXI are at reduced risk of cardiovascular diseases and thromboembolic events. We have already revealed that depletion of FXI inhibits the vascular coagulation-inflammatory circuit in angiotensin II-induced arterial hypertension. However, the effect of FXI depletion on cardiac inflammation and vascular function in ischemia/reperfusion (I/R) injury is unknown.

Purpose

Using FXI-depleted mice to investigate the role of FXI in inflammation response post cardiac I/R injury.

Methods

8–12 weeks old C57BL/6J male mice were injected intraperitoneally with FXI antisense oligonucleotide (FXI ASO) or scrambled controls for a period of 2 weeks. Then we temporarily ligated the left anterior descending (LAD) for 45 minutes to induce myocardial ischemia, followed by the reperfusion for 72 hours (ischemia/reperfusion injury, IRI). Myocardial inflammation and vascular function were analyzed by flow cytometry, real-time PCR, vascular relaxation studies from isolated aortic segment in organ chamber and chemiluminescence photon counting of oxidative burst in whole blood.

Results

FXI ASO treatment reduced hepatic FXI mRNA levels and prolonged activated partial thromboplastin time. Compared to scrambled ASO injected mice, oxidative burst from whole blood and endothelial dysfunction were decreased in FXI ASO injected mice with IRI. Compared to control groups, depletion of FXI attenuated cardiac infiltration of CD45+CD11b+ cells, especially LyG-LyChigh monocytes and LyG+ neutrophils at day 3 in I/R injury. Furthermore, the expression levels of adhesion molecules and expression of pro-inflammatory cytokines, such as Vcam-1, CCL2, IL-6 and IL-1b, in ischemic myocardium were significantly decreased in the FXI depleted mice of I/R injury.

Conclusion

Our results suggest that Inhibition of FXI leads to reduction of vascular dysfunction and ROS production in I/R injury, as well as attenuation of the inflammatory response and the influx of inflammatory cells in ischemic myocardium. This indicates that FXI could be a potential target for further treatment in cardiac IRI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): TICARDIO project has received funding from the European Union's Horizon 2020 research and Innovation programme under the Marie Skłodowska-Curie grant agreement No 813409.

The Effect of Vascular Endothelial Growth Factor C and Adipose-Derived Stem Cells on Lymphatic Regeneration in a Rat Vascularized Lymph Node Transfer Model

Background Lymphedema is a chronic condition characterized by progressive edema with complicated treatment. Recently, new treatment strategies inducing lymphangiogenesis were proposed. The aim of our study was to examine the effect of VEGF-C and ADSC (adipose derived stem cells) on lymphatic regeneration and drainage reestablishment in vascularized lymph node transfer model using a pedicled VLN groin flap. Materials and methods Female Lewis rats with groin VLN flaps were utilized as a lymphedema model. Group A served as the control. Group B received VEGF-C. Group C received both VEGF-C and ADSCs. Group D received ADSCs only. Lymphatic drainage reestablishment was evaluated by ultrasound-photoacoustic imaging after ICG injection. Results The fastest regeneration of elevated flaps was observed in Groups B and C in all monitored periods. After the first month, ICG positivity was detected in 14.3% of animals in Group A, 71.43% of animals in Group B (OR=15; p= 0.048), and 83.33% in Group C (OR=30; p=0.027). Contrary, the difference between control group and Group D (16.67%; p=0.905) was statistically insignificant. Administration of VEGF-C, ADCs + VEGF-C, and ADSC led to full flap regeneration after six months. The control group had the lowest percentage of ICG positivity at all monitored time points. Conclusion We found that the fastest regeneration occurred with the combination of the VLN flap and VEGF-C. The addition of ADSC had an insignificant effect in our study. Furthermore, we proved the feasibility of photoacoustic imaging as an assessment tool of the lymphatic drainage recovery in a VLNT model.

Acute induction of psoriasis-like skin inflammation disturbes vascular tone and provokes a rapid blood pressure response in mice

Background

Psoriasis is the most common chronic skin disease worldwide. Furthermore, it is an independent cardiovascular risk factor. Several genetic and inducible murine models reproduce specific aspects of the human disease. In mice genetically overexpressing IL-17A in keratinocytes or dendritic cells, we coulod show both aspects of the disease: cutaneous hallmarks and the vascular phenotype. The most popular inducible model consists of topical application of Imiquimod (IMQ), a Toll-like receptor 7/8 agonist. In this model, cardiovascular aspects have not been studied yet. Therefore, we examined vascular and hemodynamic effects in this most popular murine psoriasis model.

Methods

C57BL/6J mice were treated with 5% IMQ or sham cream. During treatment, we measured bodyweight, skin thickness and skin water loss. After 10 days, aortic relaxation studies were performed. For assessment of vascular inflammation, inflammatory cell infiltration into the aortic tissue was investigated by flow cytometric analysis. To record physical activity, blood pressure and heart rate, carotid catheters were implanted two weeks before treatment with IMQ. Blood pressure and heart rate were continuously recorded by receiver platforms.

Results

IMQ treatment resulted in severe skin inflammation and induced a skin barrier defect resulting in a 7-fold increase of transcutaneous water loss (from 11±6 ml/m2h to 77±30 ml/m2h). Physical activity decreased more than 50% after d1 of treatment and normalized at d7. Telemetric recording revealed a reflex tachycardia at 1d of IMQ-application (from 492±21 bpm to 524±20 bpm) followed by a significant reduction of heart rate for the next two days (456±18bpm). Systolic blood pressure showed a similar trend: after a fast increase (from 120±13 mmHg to 127±18 mmHg), blood pressure dropped below baseline at d2/3 with a subsequent recovery. We could display a highly significant positive correlation between blood pressure and heart rate during the treatment (R=0.6; p≤0.0001). Aortas from animals after 10d of IMQ-treatment showed an increased infiltration of CD45+ and CD11b+ inflammatory cells but no change of responsiveness to endothelium dependent and independent vasodilators in organ chamber studies.

Conclusion

Skin treatment with IMQ had severe implications on the hemodynamic system: After an initial peak of heart rate and blood pressure, mice showed significantly lower values for two days with a subsequent full recovery. Moreover, bodyweight and physical activity were significantly altered during treatment. Our data indicate that skin inflammation and inflammatory skin barrier disruption by IMQ forces a compensatory whole-body response. 10 days of IMQ-treatment resulted in vascular inflammation without mediating vascular dysfunction. In summary, we could reveal that IMQ-induced psoriasis, as the most popular murine psoriasis model worldwide, has extensive effects on the cardiovascular system.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Boehringer Ingelheim Foundation “Novel and neglected cardiovascular risk factors: molecular mechanisms and therapeutic implications”German Federal Ministry for Education and Research (BMBF EDU-V24)

Tubulin-folding cofactor E deficiency is associated with vascular dysfunction and endoplasmatic reticulum stress of vascular smooth muscle cells

Introduction

Endothelial function assessed via flow mediated dilatation (FMD) has shown to predict risk in individuals with established cardiovascular diseases, whereas its predictive value is uncertain in the setting primary prevention.

Purpose

The aim of the current work was to discover and evaluate novel mediators of vascular dysfunction in the general population and in conditional knock-out transgenic animal models.

Methods

In order to identify novel targets that were negatively correlated with FMD and investigate their contribution in vascular function, a Genome Wide Association Study (GWAS) of 5,000 participants was performed and subsequently immune cell-, endothelial- and vascular smooth muscle cell (VSMCs)-targeted conditional knockout mouse models were generated and characterized.

Results

GWAS analysis revealed that single nucleotide polymorphisms (SNPs) in the tubulin folding cofactor E (TBCE) gene were negatively correlated with FMD and TBCE expression in the peripheral blood mononuclear cells (PBMCs). Myelomonocytic cell-targeted TBCE deficiency did not lead to any vascular dysfunction in vivo in the LysM+Cre+/−TBCEfl/fl mice. Endothelial-targeted TBCE deficiency led to an NLR family pyrin domain containing 3 (NLRP3)-dependent activation of the inflammasome in the endothelial cells of Tie2-ERT2Cre+/−TBCEfl/fl mice. Importantly, VSMC-targeted TBCE deficiency was associated with endothelial dysfunction, increased aortic wall thickness and endoplasmatic reticulum (ER) stress-mediated VSMC hyperproliferation in vivo (SMMHC-ERT2Cre+/−TBCEfl/fl), paralleled by calnexin upregulation. Administration of the blood pressure hormone angiotensin II exacerbated the vascular dysfunction and phenotype. Administration of the ER stress modulator tauroursodeoxycholic acid to the SMMHC-ERT2Cre+/−TBCEfl/fl mice reversed vascular dysfunction, paralleled by induction of Raptor/Beclin-1-dependent autophagy both in vitro and in vivo.

Conclusion

TBCE and tubulin homeostasis in the vascular musculature seem to be novel markers of vascular function and represent a new druggable target for the treatment of ER-stress-mediated vascular dysfunction.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This work was supported by grants of the German Federal Ministry for Education and Research (BMBF01EO1003 and BMBF01EO1503), the DFG Major Research Instrumentation Programme (DFG INST 371/47-1 FUGG) as well as the Boehringer Ingelheim Foundation. PW received funds from the German Research Foundation in support of his work (DFG WE4361-4-1 and WE 4361/7-1). KS, TM and PW are PIs of the DZHK.

The Influence of High and Low Negative Pressure Liposuction and Various Harvesting Techniques on the Viability and Function of Harvested Cells-a Systematic Review of Animal and Human Studies

BACKGROUND

An understanding of fat grafting methodology, techniques and patient-related factors is crucial when considering fat grafting. Multiple factors can influence the success of a fat graft and consequently the outcome of the procedure. The aim of this systematic review is to elucidate the influence of negative pressure and various techniques of fat harvesting on the viability and function of cells, particularly adipocytes and adipose-derived stem cells.

METHODS

We conducted a literature search from 1975 to 2020 using the PubMed bibliography, ScienceDirect, SCOPUS and the Google Scholar databases which produced 168,628 articles on the first pass. After applying all the exclusion criteria by two independent reviewers, we were left with 21 articles (level IV of Oxford Centre for Evidence-Based Studies and Grade C of Grade Practice Recommendation from the American Society of Plastic Surgeons) on which this review is based.

RESULTS

From 11 studies focused on different negative pressures, no one found using high negative pressure advantageous. Summarising 13 studies focused on various harvesting techniques (excision, syringe, and pump-machine), most often equal results were reported, followed by excision being better than either syringe or liposuction.

CONCLUSION

From our systematic review, we can conclude that the low negative pressure seems to yield better results and that the excision seems to be the most sparing method for fat graft harvesting. However, we have to point out that this conclusion is based on a very limited number of statistically challengeable articles and we recommend well-conducted further research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Antibiotic therapy in the treatment of skin abscess meta-analysis

Skin abscess is one of the most common infections of skin and soft tissues. Incision and drainage under local anesthesia is the mainstay of treatment. Although previous small-scale studies failed to show a benefit of antibiotics in patients with simple abscesses, the use of antibiotic therapy is still encountered in the treatment of uncomplicated skin abscesses in our practice. The purpose of our study was to evaluate existing data assessing the effect of adjuvant antibiotic therapy on abscess management. Although as indicated by two recent multicenter studies, antibiotics may provide a positive effect in the management, it is important to consider the risk of resistance associated with antibiotic overuse and to approach each case individually.

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part I: Summary and brief description of monitoring methods

Micro-vascular flaps have been used for the repair of challenging defects for over 45 years. The risk of failure is reported to be around 5-10% which despite medical and technical advances in recent years remains essentially unchanged. Precise, continuous, sensitive and specific monitoring together with prompt notification of vascular compromise is crucial for the success of the procedure. In this review, we provide a classification and brief description of the reported methods for monitoring the micro-vascular flap and a summary of the benefits over direct visual monitoring. Over 40 different monitoring techniques have been reported but their comparative merits are not always obvious. One looks for early detection of a flap's compromise, improved flap salvage rate and a minimal false-positive or false-negative rate. The cost-effectiveness of any method should also be considered. Direct visualisation of the flap is the method most generally used and still seems to be the simplest, cheapest and most reliable method for flap monitoring. Considering the alternatives, only implantable Doppler ultrasound probes, near infrared spectroscopy and laser Doppler flowmetry have shown any evidence of improved flap salvage rates over direct visual monitoring.

The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part II: Clinical application

Despite the high success rate of micro-vascular flaps, anastomosis compromise occurs in 5-10% and that can lead to flap failure. Reliable monitoring of the flap is therefore of similar importance to that of the precise surgical procedure itself. Multiple methods have been reported for monitoring of the flap vitality, the first one being direct visual monitoring. In buried flaps direct visualisation is not feasible or is unreliable. In these cases we can extend the buried flap to expose a segment of it to act as a monitoring sentinel. For the purpose of this review we used our clinical experience as a starting point, and for the extended information and expertise we conducted a search of the PubMed database. Over 40 monitoring techniques have been reported to-date. Direct visual monitoring is still generally used method with a reliability of up to 100% and an overall success rate of up to 99%. Direct visualisation remains as the simplest, cheapest and yet a very reliable method of flap monitoring. In this review we provide a description of various possible techniques for externalising part of a buried flap, define the tissues that can be used for this purpose and we summarise the procedures that should be followed to achieve the best reliability and validity of monitoring the skin island.

Differentiation of adipose tissue-derived stem cells towards vascular smooth muscle cells on modified poly(L-lactide) foils

The aim of our research was to study the behaviour of adipose tissue-derived stem cells (ADSCs) and vascular smooth muscle cells (VSMCs) on variously modified poly(L-lactide) (PLLA) foils, namely on pristine PLLA, plasma-treated PLLA, PLLA grafted with polyethylene glycol (PEG), PLLA grafted with dextran (Dex), and the tissue culture polystyrene (PS) control. On these materials, the ADSCs were biochemically differentiated towards VSMCs by a medium supplemented with TGFβ1, BMP4 and ascorbic acid (i.e. differentiation medium). ADSCs cultured in a non-differentiation medium were used as a negative control. Mature VSMCs cultured in both types of medium were used as a positive control. The impact of the variously modified PLLA foils and/or differences in the composition of the medium were studied with reference to cell adhesion, growth and differentiation. We observed similar adhesion and growth of ADSCs on all PLLA samples when they were cultured in the non-differentiation medium. The differentiation medium supported the expression of specific early, mid-term and/or late markers of differentiation (i.e. type I collagen, αSMA, calponin, smoothelin, and smooth muscle myosin heavy chain) in ADSCs on all tested samples. Moreover, ADSCs cultured in the differentiation medium revealed significant differences in cell growth among the samples that were similar to the differences observed in the cultures of VSMCs. The round morphology of the VSMCs indicated worse adhesion to pristine PLLA, and this sample was also characterized by the lowest cell proliferation. Culturing VSMCs in the differentiation medium inhibited their metabolic activity and reduced the cell numbers. Both cell types formed the most stable monolayer on plasma-treated PLLA and on the PS control. The behaviour of ADSCs and VSMCs on the tested PLLA foils differed according to the specific cell type and culture conditions. The suitable biocompatibility of both cell types on the tested PLLA foils seems to be favourable for vascular tissue engineering purposes.

Nox2+ myeloid cells drive vascular inflammation and endothelial dysfunction in heart failure after myocardial infarction via angiotensin II receptor type 1

Background

Ischemic heart failure (HF) ensuing myocardial infarction (MI) leads to impaired left ventricular function, reduced cardiac output and counterregulatory activation of angiotensin II (AngII) levels. Furthermore, it is characterized by the initiation of a systemic inflammatory response.

Objective

We aimed to elucidate the impact of myelomonocytic cells and their activation by angiotensin II on vascular endothelial function in a mouse model of HF after MI.

Results

HF was induced in male C57BL/6J mice by permanent ligation of the left anterior descending coronary artery. Compared to sham, HF mice had significantly impaired endothelial function accompanied by enhanced mobilization of Sca-1+c-Kit+ hematopoietic stem cells and Sca-1-c-Kit+ common myeloid and granulocyte-macrophage progenitors in the bone marrow as well as increased vascular infiltration of CD11b+Ly6G-Ly6Chigh monocytes and accumulation of CD11b+ F4/80+ macrophages, assessed by flow cytometry. Using mice with Cre-inducible expression of diphtheria toxin receptor in myeloid cells, we selectively depleted lysozyme M+ myelomonocytic cells for 10 d starting 28d after MI. While the cardiac phenotype remained unaltered until 38d post MI, myeloid cell depletion attenuated vascular accumulation of Nox2+CD45+ cells, endothelial dysfunction, oxidative stress and vascular expression of adhesion molecules and angiotensin II receptor type 1 (AT1R). Pharmacological blockade of this receptor for 4 weeks did not significantly alter cardiac function, but mimicked the effects of myeloid cell depletion: Telmisartan (20 mg/kg/d, fed to C57BL/6J mice) diminished bone marrow myelopoesis and myeloid ROS production, attenuated endothelial leukocyte rolling and vascular accumulation of CD11b+Ly6G-Ly6Chigh monocytes and macrophages, resulting in improved vascular function with less abundance of Nox2+CD45+ cells.

Conclusion

Endothelial dysfunction in HF ensuing MI is mediated by inflammatory Nox2+ myeloid cells infiltrating the vessel wall that can be targeted by AT1R blockade.

Funding Acknowledgement

Type of funding source: None

Tissue factor cytoplasmic tail regulates myeloid cell derived superoxide formation and TGF-beta 1 driven cardiac remodeling in myocardial infarction

Background

In the setting of myocardial infarction (MI), patients with coronary no-reflow and/or delayed presentation after onset of symptoms (sub-acute MI) are inflicted by severe thrombo-inflammation and are marked by worse clinical outcome. However, it is unclear whether tissue factor (TF) contributes to outcome post MI solely by the regulatory functions of its cytoplasmic tail independently of its coagulation activity.

Purpose

We analyzed the role of the TF cytoplasmic domain in the recruitment of myeloid cells into the infarcted myocardium and the consequences on cardiac remodeling, scar formation, development of heart failure and survival post MI.

Methods

Twelve Patients enrolled in the MICAT (Mainzer Intracoronary Database, ClinicalTrials.gov Identifier: NCT02180178) study were examined. Patients with sub-acute MI and stable coronary artery disease were defined and monocytes were isolated from peripheral blood mononuclear cells (PBMCs). Human heart samples acquired from the left ventricular wall of explanted hearts following cardiac transplantation or obtained during implantation of left ventricular assist device. Samples were investigated for downstream analysis of protein by western blots, RNA quantification and cryo-sectioning. MI was induced in 9 to 12 weeks old male C57BL/6J mice, mice specifically lacking the cytoplasmic tail (CT) of TF (TFΔCT mice) and TFfl/flLysMCre+/− mice by permanent ligation of the left anterior descending artery. Left ventricular function was assessed by High-Frequency Ultrasound System. Infiltration of immune cells into the infarcted myocardium was analyzed by performing flow cytometric analysis after enzymatic digestion of the myocardium. Superoxide levels were quantified by HPLC-based measurement of dihydroethidium derived oxidation product 2-hydroxy ethidium.

Results

Circulating monocytes in patients with sub-acute MI showed increased nitrosative stress as well as increased phosphorylation of TF CT along with TGF-β1 and NF-kB inflammatory activation, which was recapitulated in cardiac tissue of end-stage heart failure patients with chronic MI. MI results in phosphorylation of the CT of TF within myeloid cells. Using mice with conditional knockout of TF on myeloid cells or TFΔCT mice, we found that this regulatory intracellular domain of TF within myeloid cells is required for cardiac infiltration of inflammatory Ly6Chigh TF+ monocytes, Rac-1 GTPase and superoxide formation of gp91phox + myeloid cells in MI. TGF-β1 dependent SMAD2 activation and cardiac collagen deposition as late sequel of MI was reduced in TFΔCT mice, resulting in attenuated cardiac dysfunction and reduced mortality.

Conclusion

We conclude that, TF CT drives NADPH-oxidase derived superoxide formation, thrombo-inflammation and cardiac fibrosis. Therefore, it might serve as putative biomarker and risk predictor in MI

Funding Acknowledgement

Type of funding source: None

Breast implant rupture: A sports trauma report

OBJECTIVE

Breast augmentation is one of the most commonly performed plastic surgery procedures worldwide. Because of the quality of the implant material, implant rupture may first occur about 10 years after implantation. Ruptured breast implants caused by competitive sport events are rare but should be considered in women athletes as a potential risk factor. The authors report a noteworthy case of this kind.

DESIGN

Literature overview and case report.

SETTING

Department of Plastic and Obstetrics and Gynaecology 1st faculty of Charls University, Bulovka hospital, Prague.

METHODS

Evaluation of the literature and an observational study.

CONCLUSION

Breast implant ruptures are generally at high risk in competitive contact sports. We do not recommend the use of breast implants in women competing in contact sports such as boxing.

The CD34+ Cell Number Alone Predicts Retention of the Human Fat-Graft Volume in a Nude Mouse Model

Prediction of the final transferred fat volume is essential for the success of fat grafting, but remains elusive. Between 20 and 80 % of the initial transplanted volume can be reabsorbed. Although graft survival has many determinants, CD34+ progenitor cells from the vascular stroma of adipose tissue play a central role by promoting growth of blood vessels and adipocytes. We aimed to verify the hypothesis that a higher proportion of total CD34+ cells in the transplant is associated with better preservation of the graft volume. Human lipoaspirates from 16 patients were processed by centrifugation and two grafts per donor were subcutaneously injected into 32 nude mice in 1 ml volumes in the right upper flank area. The volume of each graft was measured using a preclinical MRI scanner immediately after grafting and at three months. The percentage of CD34+ cells in the graft before implantation was determined by flow cytometry. The final graft volume at three months after implantation directly correlated with the percentage of CD34+ cells in the grafted material (r = 0.637, P = 0.019). The minimum retention of the fat graft was 28 % and the maximum retention was 81 %, with an average of 54 %. Our study found that fat retention after fat transfer directly correlated with the fraction of CD34+ cells in the graft. The simple and fast determination of the CD34+ cell percentage on site can help predicting outcomes of fat transplantation.

Abdominal wall allotransplantation

Allotransplantation of vascularized composite tissue is a new field of transplantation surgery. One application of this technique is abdominal wall transplantation used as a supplementary procedure to the transplantation of visceral organs in patients with abdominal compartment deficits. As abdominal wall closure problems are experienced in around 30-40% of such patients, peer reviewed conclusions on the viability of various options, are important for an informed choice of possible procedures. This review focuses on the abdominal wall allotransplantion procedure. Our search provided 35 appropriate references which we used to support our findings as follows: abdominal wall transplantation was performed in 33 patients at seven centres. Of these, 30 had a full thickness abdominal wall transplanted from the same donor, 3 from a second donor. Three had visceral organ transplants and in addition, the posterior sheet of the rectus muscle fascia. In summary, our findings were that abdominal wall allotransplantation does not jeopardize the outcome of visceral organs transplantation. There is no higher risk of complications or rejection of the visceral organs. There have been no fatalities as a direct result of complications due to abdominal wall transplantation. Finally, the transplanted abdominal wall may provide an early warning of rejection before diagnostic tests on the bowel are symptomatic.

From open packing to negative wound pressure therapy: A critical overview of deep sternal wound infection treatment strategies after cardiac surgery

Deep sternal wound infection is a challenging aspect of modern cardiac surgery. The considerable mortality rate, devastating morbidity and, negative impact on long-term survival has driven cardiac and plastic surgeons to seek a more advantageous treatment solution. This review summarizes progress in the field of deep sternal wound infection treatment after cardiac surgery. Emphasis is placed on outcomes analysis of contemporary treatment strategy based on negative pressure wound therapy followed by sternotomy wound reconstruction, and its comparison with conventional treatment modalities used afore. Furthermore, complications and drawbacks of treatment strategies are critically evaluated to outline current options for successfully managing this life-threatening complication following cardiac surgery.

Graft orientation influences meshing ratio

OBJECTIVES

The technique of meshed skin grafting is known since 1960s. It was shown that there is a difference between the declared and real expansion ratio of the skin meshed graft. We hypothesize that the orientation of the Langer's lines in a split thickness skin graft is a key parameter in the resulting expansion ratio.

METHODS

The skin graft meshing process was analyzed in two steps. In the first step, ex vivo uniaxial tests of human skin were performed. This served as an input for the constitutive model used for numerical simulations. In the second step, finite element analyses were performed so that stress distributions and expansion ratios could be determined.

RESULTS

It was shown that peaks of true stress tended to be concentrated around the vertex of the mesh pattern region for all cases. The declared expansion was impossible to obtain for all expansion ratios having the meshing incision perpendicular to the Langer's lines. The highest difference between declared and real expansion ratio reaches 37%.

CONCLUSIONS

With regard to literature dealing with expansion of skin grafts by meshing, a high scatter amongst data results is observed. This finding was also explained by our research, demonstrating the significance of Langer's lines and their relative orientation to the direction of meshing.

Stem cells: their source, potency and use in regenerative therapies with focus on adipose-derived stem cells - a review

Stem cells can be defined as units of biological organization that are responsible for the development and the regeneration of organ and tissue systems. They are able to renew their populations and to differentiate into multiple cell lineages. Therefore, these cells have great potential in advanced tissue engineering and cell therapies. When seeded on synthetic or nature-derived scaffolds in vitro, stem cells can be differentiated towards the desired phenotype by an appropriate composition, by an appropriate architecture, and by appropriate physicochemical and mechanical properties of the scaffolds, particularly if the scaffold properties are combined with a suitable composition of cell culture media, and with suitable mechanical, electrical or magnetic stimulation. For cell therapy, stem cells can be injected directly into damaged tissues and organs in vivo. Since the regenerative effect of stem cells is based mainly on the autocrine production of growth factors, immunomodulators and other bioactive molecules stored in extracellular vesicles, these structures can be isolated and used instead of cells for a novel therapeutic approach called "stem cell-based cell-free therapy". There are four main sources of stem cells, i.e. embryonic tissues, fetal tissues, adult tissues and differentiated somatic cells after they have been genetically reprogrammed, which are referred to as induced pluripotent stem cells (iPSCs). Although adult stem cells have lower potency than the other three stem cell types, i.e. they are capable of differentiating into only a limited quantity of specific cell types, these cells are able to overcome the ethical and legal issues accompanying the application of embryonic and fetal stem cells and the mutational effects associated with iPSCs. Moreover, adult stem cells can be used in autogenous form. These cells are present in practically all tissues in the organism. However, adipose tissue seems to be the most advantageous tissue from which to isolate them, because of its abundancy, its subcutaneous location, and the need for less invasive techniques. Adipose tissue-derived stem cells (ASCs) are therefore considered highly promising in present-day regenerative medicine.

[Treatment Options for Inveterate Injuries of Deep Finger Flexors - Primary Transplantation with Tendon Graft]

Injuries of the flexor finger apparatus are very common. Primarily, it is routinely treated by suture of the tendon. Isolated deep flexor injuries, when the flexion restriction only reaches the DIP joint, are sometimes overlooked by the surgeon or by the patients themselves, especially if the deep flexor is injured, after a closed rupture or cutaneous injury with a small skin wound. The patient is then sent to a department specializing in hand surgery after a few weeks. Subsequent shortening of the tendon apparatus makes flexor suture more difficult or sometimes even impossible. Many ways of suturing the tendons and subsequent treatment are described. The treatment results vary immensely. It depends on the mechanism of injury, injury zone, the suture suture technique used, time that has elapsed since primary treatment, surgeon experience and subsequent postoperative and rehabilitative care. One of them is reconstruction of the flexor apparatus by primary transplantation of an autologous tendon graft. Most commonly, the tendon graft is taken from the palmaris longusfrom the same hand. The tendon graft can subsitute the entire area of zones I and II. The tendon suture is made in the palm proximal to the A1 pulley outside the tendon sheath in the area where the muscular belly of thelumbricalis is located on the tendon of the deep flexor. The distal end is reinserted to the base of the distal phalanx. The primary use of the autologous tendon graft can be used in the reconstruction of obsolete deep-flexor injuries in Zone II, but also in primary treatments. This type of treatment has a number of advantages. Performing the reinforcement of the tendon at the base of the distal phalanxand the suture in the palm of the hand completely eliminates the complications caused by the tendon suture in zone II. There is no injury to the tendon sheath, or the need for intersection of the tendons. The transplanted tendon is smaller in diameter than the deep flexor, so it can also be used for older injuries when the tendon sheath is in partially missing. It removes painful palmar resistance by restoring the right position and a tension of tendon of lumbricalis and the tendon of the deep flexor. This type of reconstruction allows immediate active or semi-rehabilitation of the hand and fingers. Key words:tendon, injury, hand, transplantation, surgery, flexor, reconstruction, rupture, treatment.

PULMONARY EMBOLISM AFTER ABDOMINOPLASTY - ARE WE REALLY ABLE TO AVOID ALL COMPLICATIONS? CASE REPORTS AND LITERATURE REVIEW

Pulmonary embolism is a potentially lethal complication in plastic surgery patients. About 34% of the members of American Society of Plastic Surgery have diagnosed pulmonary embolism in their patients, and 7% had experienced at least 1 death due to this complication. The American Society of Plastic Surgeons Executive Committee approved the Venous Thromboembolism Task Force Report. The members agreed that there was not enough evidence to make all-inclusive recommendations for plastic surgery deep vein thrombosis and pulmonary embolism prophylaxis, but released the 2005 Caprini Scale accompanied by the Task Force recommendations for use in plastic surgery. It is generally strongly advised to use appropriate prophylactic measures against venous thromboembolism in all surgical procedures. However, even then we cannot completely avoid this serious complication.

TRACHEAL ALLOTRANSPLANTATION AND REGENERATION

Non-malignant and malignant obstruction of the tracheal airway causes significant morbidity and mortality. With increased use of artificial airways, benign and iatrogenic complications are increasing. A tracheal stenosis that is less than 5 cm in length can be resected with end-to-end anastomosis. Longer tracheal lesions can be treated in a palliative way by placement of a stent to secure airway lumen patency. The management of tracheal defects is an evolving field. Tracheal transplantation and tracheal regeneration may provide major treatment advances to cases with long-segment tracheal involvement. This review examines the current possibilities and future prospects in the area of tracheal transplantation and regeneration.

NUMERICAL EVALUATION OF SCAR AFTER BREAST RECONSTRUCTION WITH ABDOMINAL ADVANCEMENT FLAP

BACKGROUND

The treatment of breast cancer has developed a lot during the last decade, nevertheless it still remains a considerable social and economical problem all over the world. The choice of the surgical procedure depends on a patients protocol and the surgeons preferences. The aim of this study is to evaluate the stress on the scar after breast reconstruction.

METHODS

Mathematical modeling of the sutured skin flap used for breast implant placement was divided into the following two steps. At first, material model of the selected silicone implant was identified. Afterwards, the mathematical model of the breast and implant was performed.

RESULTS

Maximal geometrical deviation for anatomical and round implant is placed on the lower surface of the breast and upper surface of the breast, while in the area of lateral geometry and the area around the nipple the agreement reaches very high level. The maximal tension is located in two median stitches. The maximal force reaches 0.025 N. The Cauchy stress equivalent is located around the nipple and reaches the value of 380 kPa.

CONCLUSION

From our results it can be seen, that the anatomical and round breast implants do not result in the same stress on the scar. The maximal value difference reaches 13.4% between stress values for these two breast implants and the round implant results in higher loaded scar compared to the anatomical implant.

TRANSPLANTATION OF VASCULARIZED COMPOSITE ALLOGRAFTS. REVIEW OF CURRENT KNOWLEDGE

Transplantation in reconstructive surgery has been performed for more than 20 years, although the official beginning of these procedures is considered the first successful transplantation of the hand in 1998. The original name "Composite Tissue Transplantation" has been used less frequently; more common is the term "Vascularized Composite Allotransplant", which better describes the basis of the procedure. There have been so far approximately 180 transplantations performed, the exact number is difficult to find. The most known transplantation from this group include transplantation of the hand and face, the other, such as transplantation of the abdominal wall, joints, bones, trachea, larynx, tongue, penis, uterus, etc. are less common and less well known. The common characteristics is that they are not used for salvage or prolongation of life, but to improve its quality. The quality of life is a value, which cannot be objectively measured and the opinions regarding its importance significantly differ. Therefore there is still an unsolved ethical issue regarding these procedures, which is based on the justification to use immunosuppressive therapy with its serious risks in cases when the procedure is not needed for salvage or preservation of life.

Reconstructive procedures in maxillofacial oncosurgery

OBJECTIVE

Oropharyngeal cancers are a biologically heterogenous group of tumors with diverse risk factors including tobacco, alcohol, HPV, inherited disorders, the acquired immunodeficiency of Karposi's Sarcoma and non Hodgkin's lymphoma. In the Czech Republic, oropharyngeal cancers represent around 2% of all cancers. The treatment of these tumors is long and complex. Reconstructive procedures in maxillofacial oncosurgery demand good interdisciplinary collaboration and great professional preparedness of the surgical and nursing team. Patient age and stage of disease, including the presence of metastases are of key importance. A prerequisite for the success of surgical treatment is removal of the tumor with a sufficient safety margin. Reconstructive procedures then follow.

AIM

To highlight the importance of radical tumor resection and describe reconstruction of the defect in a group of our patients.

METHODS AND RESULTS

From 2008 to 2013, 23 patients with oropharyngeal carcinoma underwent radical surgical removal of tumor, followed by reconstruction of postoperative defects using distant and free flaps. The histopathology showed predominantly squamous cell carcinomas and one of Merkel cell carcinoma. 16 patients had malignant disease detected in III-IV. In only 7 cases was treatment initiated in the first and second stages of the disease. In these patients, the tumors were removed with a safety margin of healthy tissue and in none, did the basic cancer recur . The postoperative course in terms of flap engraftment and overall condition of the patient was uneventful. All of these patients still enjoy a good life quality with a current mean survival in range 5 - 76 months. Radical surgical removal of a malignant tumor in the early stages of the disease is associated with fewer postoperative complications and longer survival.

CONCLUSION

To avoid the risk of local and/or systemic postoperative complications, appropriate patient selection is important. Overall, the traditional, classic reconstructive procedures with the use of prostheses, in many cases is still the best option in our experience.

Comparison of Cross-linked and Non-Cross-linked Acellular Porcine Dermal Scaffolds for Long-term Full-Thickness Hernia Repair in a Small Animal Model

BACKGROUND

This study compared the strength of incorporation and biocompatibility of 2 porcine-derived grafts (cross-linked and non-cross-linked) in a rat hernia model.

METHODS

A standardized 2 × 4 cm(2) fascial defect was created in 30 Wistar rats and repaired with either a cross-linked or a non-cross-linked graft. The rats were killed 3, 6, and 12 months later. The strength of incorporation, vascularization, cellular invasion, foreign body reaction, and capsule formation were evaluated.

RESULTS

Both graft materials showed cellular ingrowth and neovascularization by 3 months postimplantation. The average level of cellularization was significantly higher in the non-cross-linked grafts than in the cross-linked grafts at 6 months (2 vs 1; P = .029). Vascularization was significantly higher in the non-cross-linked grafts than in the cross-linked grafts at 6 months postimplantation (2 vs 1; P = .029) and insignificant at 3 months (2 vs 1.75; P = .311) and 12 months (1 vs 0.67; P = 1). The maximum load and breaking strength of both biomaterials increased during the study period. Overall, the strength of incorporation of the non-cross-linked grafts increased from 3 months (0.75 MPa) to 12 months (3.06 MPa) postimplantation. The strength of incorporation of the cross-linked grafts also increased from 3 months (0.59 MPa) to 12 months (1.58 MPa) postimplantation.

CONCLUSIONS

The results of our study suggest that non-cross-linked grafts may be slightly more biocompatible and allow a more rapid and higher degree of cellular penetration and vascularization, resulting in stronger attachment to the tissues.

Centrifugation versus PureGraft for fatgrafting to the breast after breast-conserving therapy

Background

Breast-conserving treatment (BCT) leads to a progressive and deteriorating breast deformity. Fatgrafting is ideal for breast reconstruction after BCT. The most frequently utilized technique for fat processing is centrifugation. The PureGraft device (Cytori Therapeutics, San Diego, CA, USA) is a new method that involves washing and filtering the fat to prepare the graft. We compared the subjective and objective outcomes of two fat-processing methods, centrifugation and PureGraft filtration.

Methods

Thirty patients underwent breast reconstruction performed by a single surgeon (OM) after BCT in our department between April 2011 and September 2012. The patients were preoperatively divided into two groups randomly: 15 received fatgrafts processed by centrifugation, and 15 received fatgrafts processed by washing in PureGraft bags. The patients were followed up for 12 to 30 months. To measure the subjective outcome, we distributed the BREAST-Q questionnaire to all the patients both preoperatively and 1 year postoperatively. The BCCT.core software evaluated the objective outcome of breast reconstruction by fatgrafting.

Results

The Breast-Q results indicated a tremendous improvement in the modules “Satisfaction with Breast” and “Psychosocial Well-being”. The “Sexual Well-being” scale also improved. Only the module “Satisfaction with Breasts” significantly differed between groups; patients treated with the PureGraft fat exhibited better outcomes. The BCCT.core results did not significantly differ between the groups.

Conclusion

One year postoperatively, the outcomes of the use of PureGraft bags or centrifugation to process fat for breast reconstruction after BCT did not differ. The unpredictability of the results following fatgrafting procedures is likely due to interindividual differences with yet-undisclosed causes.

NMR Studies on Intercalation Compounds of Layered Chalcogenides with Methylamines and Ammonia

NMR wideline and pulse techniques have been used to study orientation and molecular motions of the intercalation compounds of niobium disulfide with monolayers of mono-, di-, and trimethylamine, tetramethylammonium and ammonia. Specific information has been obtained from the 1H and 2D spectra and from spin-lattice relaxation measurements of the selectively deuterated monomethylamines. Models for the arrangement of the various molecules within the layers and for the motions have been derived. One-dimensional rotation of CH3 and NH3 groups, rapid intermolecular exchange of NH, NH2 and NH3 protons, as well as translational and reorientational motions of whole molecules are of importance. Interpretation of spin-lattice relaxation rates at various temperatures and frequencies yields details of some of these motion and numerical values for the activation energies.

The history and safety of breast implants

Breast implants are medical devices used for augmentation of the breast, to reconstruct the breast after mastectomy and to correct breast asymmetry. The breast prostheses are likely the most frequently used medical implants. The evolution of modern silicone breast implants was not straightforward and is characterised with a lot of medical, forensic and public attention. Currently it is sufficiently established that implants are safe and can be used for breast reconstruction and aesthetic augmentation. Prosthesis can rupture and produce local symptoms but there is no evidence that silicone breast implants can be of any health hazards for the patients.

Pectoral muscle flap with V-Y skin paddle for covering sternal defects

Deep sternal wound infection (DSWI) after a cardiac operation is a rare but serious complication associated with significant morbidity and mortality. It can lead to wound dehiscence with sternal osteomyelitis and both bony and soft tissue residual defects. When the infection is eradicated, reconstruction of the thoracic wall remains the main challenge. Tissue used for covering the defect must be well nourished and sutures must be tension free. We present our unique modification of the method using the pectoral muscle axial flap with a V-Y skin paddle.

Merkel cell carcinoma. Case report

BACKGROUND

Merkel cell carcinoma (MCC) is a rare aggressive skin tumour affecting mainly older and immuno suppressed individuals (see our review on MCC in this volume).

AIM

This is a case report describing our first experience with Merkel cell carcinoma in an elderly woman on chemo therapy for lymphoma and it covers the diagnosis, treatment and outcome.

METHODS

We did a radical excision of the soft tissue in the tumor area in conjunction with total paroditectomy and resection of the body of the zygomatic bone by radical block neck dissection. The skin defect was reconstructed myocutaneous free flap by a plastic surgeon.

RESULTS AND CONCLUSION

At 12 months follow-up, the MCC had not recurred.

Merkel cell carcinoma. A review

BACKGROUND

Merkel cell carcinoma (MCC) is a rare potentially fatal skin tumour affecting older mainly white people and younger immunosuppressed individuals. While uncommon, the incidence is increasing relative to melanoma and with twice the lethality. The benign appearance of the tumour usually on exposed skin parts, contrasting with its extensive microscopic invasion, can delay timely diagnosis. Recurrent MCC is currently attributed to the recently discovered Merkel cell polyomavirus This brief review of MCC covers the history, epidemiology,etiology,clinical and histological features, treatment and prognosis.

METHODS

Literature search using PubMed and search words Merkel cell carcinoma (MCC), etiology, treatment for the years 1972 to 2010.

RESULTS AND CONCLUSION

Merkel cell carcinoma is a rare malignancy with uncertain prognosis. Due to the uncommon occurrence and dearth of randomized studies, there is no agreement on optimal treatment. The tumor has only recently been included in the international classification of tumors (NCCN). The treatment approaches found to be best are radical surgery of primary tumor, drainage of lymph node extension and possibly adjuvant loco-regional radiotherapy. The basis of successful treatment however, remains prevention regular dermatological examination in immunosuppressed patients and early initiation of combination therapy, based on radical surgery supplemented by radiotherapy and palliative chemotherapy in the last resort.

Use of allogenous bone graft and osteosynthetic stabilization in treatment of massive post-sternotomy defects

Thoracic stabilization using transverse plate fixation represents a modern and safe method of sternal dehiscence treatment. However, it still remains difficult to apply in cases of massive loss of bone tissue of the chest wall. An unsatisfactory stability of thorax often results in severe respiratory insufficiency, and also affects healing of soft tissue closure while increasing the risk of development of chronic fistulas and other dehiscences. In the reported case, we opted for a unique treatment of massive post-sternotomy defect using an allogenous bone graft of calva. Transverse titanium plates were applied to achieve stabilization of bone grafts and chest wall.

Superiority of topical negative pressure over closed irrigation therapy of deep sternal wound infection in cardiac surgery

AIM

We sought to compare clinical outcomes, in-hospital mortality and 1-year survival of two different treatment modalities of deep sternal wound infection, topical negative pressure and the closed irrigation therapy.

METHODS

Retrospective analysis of 66 consecutive patients treated for deep sternal infection at our institution. A total of 28 patients (February 2002 through September 2004) underwent primarily closed irrigation therapy, and 34 patients (November 2004 through December 2007) had the application of topical negative pressure. Four patients (July 2004 through December 2004) who underwent a combination of both strategies were excluded from the study. Clinical and wound care outcomes were compared, focusing on therapeutic failure rate, in-hospital stay and the 1-year mortality of both treatment strategies.

RESULTS

Topical negative pressure was associated with a significantly lower failure rate of the primary therapy (P<0.05), shortening of the intensive care unit stay (P<0.001), a particular decrease in the in-hospital stay (P<0.05) and the 1-year mortality (P<0.05) in comparison with closed irrigation therapy. Comparable overall length of the therapy, in-hospital stay and the risk of wire-related fistulas after chest reconstruction were found.

CONCLUSION

Topical negative pressure is a superior method of treatment for deep sternal wound infection, which is based on lower therapeutic failure rate, significant decrease in-hospital stay, and the decrease of the 1-year mortality rate, compared with primarily applied closed irrigation.