Diversity of the free helical rim flap: A case series tailoring the microsurgical technique to esthetically optimize full-thickness nasal defect reconstructions

INTRODUCTION

The free helical rim (FHR) flap offers like-with-like reconstruction for full-thickness nasal defects. A case series of nasal reconstruction using an FHR flap was presented, detailing surgical steps and refinements, as well as functional and esthetic outcomes.

METHODS AND MATERIALS

This is a retrospective cohort study of composite nasal defect reconstruction with FHR flap from August 2018 to March 2020. Descriptive data were analyzed by SPSS software.

RESULTS

Six cases were recruited, four were unilateral alar defects, one was hemi-nose, and one was ala plus tip. The average size of the defect was 2.5 × 2.8 cm2. Three FHR flaps were designed with retrograde pedicles and three with anterograde pedicles. The facial artery and veins were the recipient vessels in all cases. Vascular grafts were used in all six cases. Descending branch of the lateral circumflex femoral (DLCxF) artery and vein functioned as interposition vascular conduits in five cases. Superficial forearm vein grafts were used in one case. One patient needed flap re-exploration due to venous congestion. One patient had partial flap necrosis due to delayed infection, and one developed delayed wound dehiscence in the irradiated wound. The average follow-up was 18 months.

CONCLUSION

The FHR flap has consistent vascular anatomy. It can be raised as an anterograde or retrograde flap for a contralateral or ipsilateral inset. FHR flap can be used in extensive composite nasal defects. This case series demonstrates that interposition vascular grafts are invariably needed and the possibility of using forearm vessels as grafts instead of DLCxF artery and vein.

FDG PET metabolic signatures distinguishing prodromal DLB and prodromal AD

BACKGROUND AND PURPOSE

Patients with dementia with Lewy bodies (DLB) are characterized by hypometabolism in the parieto-occipital cortex and the cingulate island sign (CIS) on 18F-fluorodeoxyglucose (FDG) PET. Whether this pattern of hypometabolism is present as early as the prodromal stage of DLB is unknown. We investigated the pattern of hypometabolism in patients with mild cognitive impairment (MCI) who progressed to probable DLB compared to MCI patients who progressed to Alzheimer's disease (AD) dementia and clinically unimpaired (CU) controls.

METHODS

Patients with MCI from the Mayo Clinic Alzheimer's Disease Research Center who underwent FDG PET at baseline and progressed to either probable DLB (MCI-DLB; n = 17) or AD dementia (MCI-AD; n = 41) during follow-up, and a comparison cohort of CU controls (n = 100) were included.

RESULTS

Patients with MCI-DLB had hypometabolism in the parieto-occipital cortex extending into temporal lobes, substantia nigra and thalamus. When compared to MCI-AD, medial temporal and posterior cingulate metabolism were preserved in patients with MCI-DLB, accompanied by greater hypometabolism in the substantia nigra in MCI-DLB compared to MCI-AD. In distinguishing MCI-DLB from MCI-AD at the maximum value of Youden's index, CIS ratio was highly specific (90%) but not sensitive (59%), but a higher medial temporal to substantia nigra ratio was both sensitive (94%) and specific (83%).

CONCLUSION

FDG PET is a potential biomarker for the prodromal stage of DLB. A higher medial temporal metabolism and CIS ratio, and lower substantia nigra metabolism have additive value in distinguishing prodromal DLB and AD.

Emerging techniques for elucidating mechanism of action of deep brain stimulation

Deep brain stimulation (DBS) within the basal ganglia complex is an effective neurosurgical approach for treating symptoms of Parkinson's disease (PD), Essential Tremor, Dystonia, Depression, Obssessive Compulsive Disorder, and Tourette's Syndrome, among others. Elucidating DBS mechanism has become a critical clinical and research goal in stereotactic and functional neurosurgery and in neural engineering. Along with electro-physiological and microdialysis techniques, two additional powerful technologies, notably functional Magnetic Resonance Imaging (fMRI) and in vivo neurochemical monitoring have recently been used to investigate DBS-mediated activation of basal ganglia network circuitry. For this purpose, we have previously developed WINCS (Wireless Instantaneous Neurotransmitter Concentration Sensor System), which is an MRI-compatible wireless monitoring device to obtain chemically resolved neurotransmitter measurements at implanted microsensors in a large mammalian model (pig) as well as in human patients. This device supports an array of electrochemical measurements that includes fast-scan cyclic voltammetry (FSCV) for real-time simultaneous in vivo monitoring of dopamine and adenosine release at carbon-fiber microelectrodes as well as fixed potential amperometry for monitoring of glutamate at enzyme-linked biosensors. In addition, we have utilized fMRI to investigate subthalamic nucleus (STN) DBS activation in the pig with 3Tesla MR scanner. We demonstrate the activation of specific basal ganglia circuitry during STN DBS using both fMRI and FSCV in the pig model. Our results suggest that fMRI and electrochemistry are important emerging techniques for use in elucidating mechanism of action of DBS.

Small molecule pan-bcl-2 inhibitor AT-101 induces apoptosis in NSCLC by up-regulating noxa and enhances antitumor activity of docetaxel or targeted kinase inhibitors

e14591

Background: AT-101 is an orally active pan Bcl-2 inhibitor currently under clinical development in Phase II trials. We investigated the effect of AT-101 alone or in combination with chemotherapies or targeted kinase inhibitors in NSCLC both in vitro and in vivo. Methods: Growth inhibition was measured by WST assays. The CalculSyn method was used to assess drug interaction by calculating the Combination Index (CI) value. The ability of AT-101 to potentiate the anti-cancer effect of chemotherapies or kinase inhibitors was evaluated in xenograft models. Results: A panel of 11 NSCLC cell lines with overexpression of Bcl-2, Bcl- XL or Mcl-1 proteins was treated with AT-101, docetaxel, pemetrexed, erlotinib, sorafenib, sunitinib, rapamycin, as a single agent and in combination. AT-101 inhibited the growth with IC50 at 3–9 uM. When treating cells simultaneously with both agents, AT-101 demonstrated strong synergy with those agents in A549 or H460 cells with CI values < 1.0. Protein analysis results indicated that AT-101 caused apoptosis by a time- and dose-dependent induction of Noxa expression in those cells. The expression of Bcl- XL was not influenced by AT-101. Pro-Caspase-3 was reduced with increasing doses of AT-101. In vivo, combined treatment of AT-101 with docetaxel, erlotinib, or sorafenib synergistically suppressed subcutaneous NSCLC A549 cells tumor growth compared with treatment with either agent alone. The synergist effects with the ErbB1 inhibitor Erlotinib is associated with the overexpression of the target protein ErbB1 in those cells. Only combination therapy resulted in significant tumor growth delay and no significant toxicities were observed. Conclusions: Our results demonstrate that AT-101significantly enhances the anti-tumor activity of chemotherapy and targeted agents and may represent a promising new anticancer agent with a novel molecular mechanism. Molecular targeted therapy with AT-101 may improve the outcome of current chemotherapy for NSCLC with Bcl-2, Bcl-xL and/or Mcl-1 overexpression.

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Congestion of right liver graft in living donor liver transplantation

BACKGROUND

Left liver graft from a small donor will not meet the metabolic demands of a larger adult recipient. One solution to this problem is to use a right liver graft without a middle hepatic vein (MHV). However, the need for drainage from the MHV tributaries has not yet been described.

METHODS

Five right liver grafts without a MHV were transplanted in patients including two hepatitis B virus-cirrhosis, two fulminant hepatic failure and one secondary biliary cirrhosis. The graft weight ranged from 650 to 1,000 g, corresponding to 48 to 83% of the standard liver volume of the recipients.

RESULTS

Two of five recipients were complicated with severe congestion of the right median sector immediately after reperfusion, followed by prolonged massive ascites and severe liver dysfunction. One of the patients died of sepsis with progressive hepatic dysfunction 20 days after the operation.

CONCLUSIONS

Preservation and reconstruction of the MHV tributaries is recommended to prevent congestion of the right liver graft without MHV.

Cavernous transformation of the portal vein secondary to tumor thrombosis of hepatocellular carcinoma: spiral CT visualization of the collateral vessels

BACKGROUND

We investigated the constituting collateral vessels in cavernous transformation of the portal vein (CTPV) caused by tumor thrombosis of hepatocellular carcinoma (HCC) by using contrast-enhanced spiral computed tomographic (CT) examination.

METHODS

Fifty-four histopathologically proven HCC patients with tumor thrombosis-induced CTPV were retrospectively included and assigned to cirrhosis negative (n = 31) and positive (n = 23) groups. Another 15 cirrhotic patients with portal hypertension but no HCC and CTPV were used for comparison. Standardized dual-phase contrast-enhanced spiral CT was performed for all patients. CT appearances of the collateral vessels of CTPV were observed, and their visualization rates were analyzed.

RESULTS

Biliary (cystic and paracholedochal veins) and gastric (left and right gastric veins) branches of the portal vein were the most frequently visualized collateral vessels of CTPV. There was a marked difference in CT visualization rates for biliary branches between patients with and without CTPV (83-94% vs. 0). No difference existed in visualization rates for gastric branches across the three groups (77-87% for left gastric, 58-61% for right gastric vein).

CONCLUSIONS

Biliary and gastric branches of the portal vein are the major collateral vessels of CTPV. The intergroup differences in CT visualization rates may provide clues to the roles that they might play in the hemodynamic adaptation process of CTPV.

[Distribution and contrast enhanced CT appearance of abdominal tuberculous lymphadenopathy]

PURPOSE

To clarify the contrast enhanced CT features and anatomic distribution of the disseminated vs non-disseminated tuberculosis (TB) involving abdominal lymph nodes.

MATERIALS AND METHODS

The contrast enhanced CT findings of abdominal lymphadenopathy in 25 patients, including disseminated TB associated with miliary TB of the lung (n = 5) and non-disseminated TB (n = 20), were retrospectively evaluated in a blind review to assess our criteria of morphology, density and location of the involved lymphadenopathy.

RESULTS

The enhancement patterns of disseminated TB were not different from those of non-disseminated TB. Ninety-six percent of the patients had peripheral rim enhancement, and 60% showed a multilocular appearance. The enlarged lymph nodes of TB were less than 4 cm in diameter. Lymphadenopathy caused by hematogenous dissemination often accompanied splenic involvement showing multiple low-density foci in the spleen. The predominant sites of lymphadenopathy of disseminated TB were hepatoduodenal ligamentous, hepatogastric ligamentous, mesenteric, and both upper and lower portions of the retroperitoneal lymph nodes, whereas non-disseminated TB mainly involved hepatoduodenal ligamentous, hepatogastric ligamentous, mesenteric and upper retroperitoneal lymph nodes, excluding the lower retroperitoneal lymph nodes. By combining contrast enhancement patterns and the anatomic distribution of lymphadenopathy shown on the contrast enhanced CT images, reviewers made a correct diagnoses of tuberculosis in 94%, of cases, with a specificity of 95% and sensitivity of 92%.

CONCLUSION

Contrast enhanced CT patterns correlate well with the pathologic features of tuberculous lymphadenopathy. A different anatomic distribution between disseminated and non-disseminated TB involving the lower retropentoneal lymph nodes was recognized in this study.

The middleman minority characteristics of Korean immigrants in the United States

"This paper examines the middleman minority characteristics of Korean immigrants in the United States. Like middleman groups in other societies, Korean immigrants in the United States are heavily concentrated in small business. A large proportion of Korean-owned businesses distribute merchandise to minority customers on behalf of large corporations. Korean merchants, like other middleman groups, maintain strong ethnic cohesion, which facilitates their commercial activities.... We conclude that Korean immigrants in the United States exhibit middleman minority characteristics."