Evaluating micronized adipose tissue niche and artificial dermis grafts following nonmelanoma skin cancer excision: a pilot study

BACKGROUND

Recently, micronized adipose tissue (MAT) grafts have shown promising results in wound healing, including diabetic ulcers.

OBJECTIVE

To assess the possibility of using 3D printed MAT niche grafts in the management of skin and soft tissue defects resulting from non-melanoma skin cancer (NMSC) resections.

MATERIALS AND METHODS

A retrospective feasibility study was conducted on patients with skin and soft tissue defects resulting from NMSC resections. Twenty-one patients were treated using either artificial dermis (n = 11) or MAT niche (n = 10) grafting. Healing time and POSAS scores were compared. The Mann-Whitney U test and the Pearson chi-square test were used in statistical analysis to compare between and within groups based on preoperative and postoperative measurements.

RESULTS

Wounds in the MAT niche group reepithelialized significantly faster than those in the artificial dermis group (mean [SD] 39.2 [11.4] days vs 63.7 [34.8] days; P = .04). In the 21 scar parameters evaluated, the MAT niche group demonstrated significantly superior outcomes in only 2 parameters based on operator assessment scores: relief (mean [SD] 1.6 [0.7] vs 2.2 [0.6]; P = .047) and scar contracture (mean [SD] 1.3 [0.5] vs 2.5 [1.0]; P = .011).

CONCLUSION

This study proves the feasibility of exploring the effects of MAT niche grafting following NMSC excision on healing time and specific parameters of scarring, including scar relief and scar contracture.

Developing a Practical Tool for Predicting Wound Healing Outcomes of Patients with Diabetic Forefoot Ulcers: Focus on Vasculopathy and Infection

OBJECTIVE

To develop a preliminary risk scoring system to predict the prognosis of patients with diabetic forefoot ulcers based on the severity of vasculopathy and infection, which are the major risk factors for amputation.

METHODS

Forefoot was defined as the distal part of the foot composed of the metatarsal bones and phalanges and associated soft tissue structures. The degree of vasculopathy was graded as V0, V1, or V2 according to transcutaneous partial oxygen tension values and toe pressure. The degree of infection was graded as I0, I1, or I2 according to tissue and bone biopsy culture results. The risk scores were calculated by adding the scores for the degree of vasculopathy and infection and ranged from 0 to 4. Wound healing outcomes were graded as healed without amputation, minor amputation, or major amputation. The authors evaluated wound healing outcomes according to risk scores.

RESULTS

As the risk score increased, the proportion of patients who underwent both major and minor amputations increased (P < .001). In the multivariate logistic analysis, the odds ratios of amputation also increased as the risk score increased. Patients with a risk score of 4 were 75- and 19-fold more likely to undergo major and minor amputations, respectively, than patients with a risk score of 0 (P = .006 and P < .001).

CONCLUSIONS

The risk score can be used as an indicator to predict the probability of amputation in patients with diabetic forefoot ulcers.

Diagnostic accuracy of a fluorescence imaging device in diabetic wounds: a pilot study using a tissue culture system

INTRODUCTION

DFUs are challenging chronic wounds that are vulnerable to infections. A fluorescence imaging device was developed to detect bacterial presence in wounds. This device utilizes the principle that when illuminated by violet light, some bacteria emit red fluorescence and others, such as Pseudomonas aeruginosa, emit cyan fluorescence. Several studies have reported the accuracy of this device. However, to the best of the authors' knowledge, no studies have examined the correlation between bacterial presence and tissue biopsy culture results in diabetic wounds.

OBJECTIVE

This study aimed to investigate the diagnostic accuracy of a fluorescence imaging device using a tissue culture system.

MATERIALS AND METHODS

Thirty-five patients (48 wounds) were included. Wounds were sampled using tissue culture methods and photographed using the fluorescence imaging device. Culture outcomes were categorized into non-Pseudomonas bacterial, Pseudomonas bacterial, both bacterial, and no-growth groups. Image outcomes were categorized into red, cyan, both colors, and negative groups.

RESULTS

For detecting the presence of bacteria, the fluorescence imaging device showed a sensitivity, specificity, PPV, and NPV of 64.1%, 55.6%, 86.2%, and 26.3%, respectively, with an accuracy of 62.5%. For P aeruginosa, the device showed a sensitivity, specificity, PPV, and NPV of 66.7%, 87.2%, 54.6%, and 91.9%, respectively, with an accuracy of 83.3%. For non-Pseudomonas bacteria, the device showed a sensitivity, specificity, PPV, and NPV of 43.8%, 62.5%, 70.0%, and 35.7%, respectively, with an accuracy of 50.0%.

CONCLUSION

The fluorescence imaging device can help to detect the bacterial bioburden; however, its accuracy may be lower than that reported in previous studies of diabetic wounds.

Anatomical Reconstruction of Extensive Inferomedial Blow-Out Fractures Involving the Inferomedial Orbital Strut Using a Single Fan-shaped Titanium-Reinforced Porous Polyethylene Plate

Extensive inferomedial blow-out fractures involving the inferomedial orbit strut frequently result in severe ophthalmic complications. Therefore, anatomical reconstruction is essential but is still technically challenging. Thus, the authors have used a novel technique using a combination of single fan-shaped titanium-reinforced porous polyethylene (TR-PPE) implants and a bidirectionally extended transconjunctival approach. Herein, the authors describe our surgical technique and discuss its effectiveness. First, the transconjunctival approach was performed and was subsequently extended medially using the transcaruncular approach and laterally using lateral blepharotomy. After the origin of the inferior oblique muscle was identified, a trimmed fan-shaped TR-PPE implant was inserted into the orbital floor. It was subsequently rotated and bent at the site of origin of the IO muscle and moved upward to cover the superior bony ledge of the medial wall. Finally, the implant was fixed to the orbital rim. Anatomical orbital reconstruction was confirmed by a computed tomographic scan. The preoperative diplopia in 19 patients, resolved within 1 week in 16 patients and in 3 to 6 months in the remaining 3 patients. Preoperative enophthalmos >2 mm in all patients improved to <2 mm in 67 patients and 3 mm in 2 patients (>7 mm preoperatively). The postoperative course was uneventful, and no severe complications were observed. The authors believe that the placement of a fan-shaped TR-PEE implant into the orbit through the bidirectionally extended transconjunctival approach could be a viable option for the anatomical reconstruction of extensive inferomedial blow-out fractures involving the inferomedial orbital strut.

Developing and Establishing a Wound Dressing Team: Experience and Recommendations

BACKGROUND

The existing literature has comprehensively examined the benefits of specialized wound-care services and multidisciplinary team care. However, information on the development and integration of wound-dressing teams for patients who do not require specialized wound care is scarce. Therefore, the present study aimed to elucidate the benefits of a wound-dressing team by reporting our experiences with the establishment of a wound-dressing team.

METHODS

The wound-dressing team was established at Korea University Guro Hospital. Between July 2018 and June 2022, 180,872 cases were managed for wounds at the wound-dressing team. The data were analyzed to assess the types of wounds and their outcomes. In addition, questionnaires assessing the satisfaction with the service were administered to patients, ward nurses, residents/internists, and team members.

RESULTS

Regarding the wound type, 80,297 (45.3%) were catheter-related, while 48,036 (27.1%), 26,056 (14.7%), and 20,739 (11.7%) were pressure ulcers, dirty wounds, and simple wounds, respectively. In the satisfaction survey, the scores of the patient, ward nurse, dressing team nurse, and physician groups were 8.9, 8.1, 8.2, and 9.1, respectively. Additionally, 136 dressing-related complications (0.08%) were reported.

CONCLUSION

The wound dressing team can enhance satisfaction among patients and healthcare providers with low complications. Our findings may provide a potential framework for establishing similar service models.

An algorithmic approach to soft-tissue reconstruction around the knee using anterolateral thigh perforator flap in patients with post-traumatic knee osteomyelitis

Background

Free tissue transfer to the knee region in patients with chronic post-traumatic knee osteomyelitis (CTKOM) poses a great challenge to surgeons because the remaining soft tissues adjacent to defects, including vascular structures, are usually damaged by chronic inflammation and multiple debridements. Thus, we developed an algorithm to help select the optimal recipient vessels and appropriate anterolateral thigh perforator (ALTP) flap type. In addition, we performed surgery using this algorithm and achieved successful reconstructions. This study aims to review our experiences in algorithmic reconstruction and assess its efficacy.

Methods

According to the defect size and location, our algorithm suggested the use of various-shaped ALTP flaps with centrally located perforators (Cen-ALTP flap) or eccentrically located perforators (Ecc-ALTP flap). Besides, through the algorithm, one recipient vessel was selected among three candidates, including descending branch of the lateral circumflex femoral artery (DB-LCFA), anterior tibial artery (ATA), and posterior tibial artery (PTA). Based on this algorithmic decision, we performed individualized soft tissue reconstructions of the knee in 21 patients with CTKOM, between March 2013 and June 2021. The medical records of the patients were retrospectively reviewed.

Results

The Cen-ALTP flap (n = 15) and ATA (n = 9) were the most commonly used for reconstruction. The Cen-ALTP flap anastomosed to the ATA was most commonly selected (n = 7) using the algorithm, followed by the Cen-ALTP flap anastomosed to the DB-LCFA (n = 5), and the Cen-ALTP flap anastomosed to the PTA (n = 3). All transferred ALTP flaps survived the follow-up period. Postoperative venous congestion in two patients and hematoma in one patient were resolved by immediate treatment. The postoperative course was uneventful.

Conclusion

During free ALTP flap transfer to CTKOM-related knee defects, we could select the optimal recipient vessel and appropriate flap type using our algorithm and obtain excellent reconstructive outcomes. Therefore, we believe that our algorithm could provide helpful guidance to reconstructive surgeons on free ALTP flap transfer to reconstruct CTKOM-related soft tissue defects.

Skin hydration level cutoff value to predict wound healing potential in diabetic foot ulcers

AIMS

Transcutaneous oxygen pressure (TcPO₂) is a reliable predictor of wound healing in diabetes patients; however, measurements are cumbersome. Previously, we demonstrated that skin hydration in the feet of patients with diabetic foot ulcers (DFU) is influenced by microcirculation rather than peripheral nerve function. Furthermore, skin hydration level before recanalization can predict wound healing better than TcPO₂. This study investigated the skin hydration level cutoff value to predict DFU healing.

METHODS

We retrospectively enrolled 834 patients with DFU. Wound healing outcomes were graded as healed without amputation or with minor/major amputation. Receiver operating characteristic analysis was used to evaluate the ability of skin hydration to predict wound healing outcomes and determine the optimal cutoff value for subsequent analyses.

RESULTS

Average skin hydration values in the healed without and with amputation groups were 25.0 ± 7.4 arbitrary units (a.u.) and 17.5 ± 5.7 a.u., respectively (P < 0.001). The healing rate without amputation increased with skin hydration. A skin hydration value ≥ 21 a.u. significantly lowered the incidence of amputation. The cutoff value was 21 a.u. [(Youden's index, sensitivity, specificity, P-value) = (1.6, 92, 69.6, P < 0.001)].

CONCLUSIONS

A minimal skin hydration value of 21 a.u. is required for diabetic wound healing.

The turbocharged wide anterolateral thigh perforator flap to reconstruct massive soft tissue defects in traumatized lower extremities: A case series

BACKGROUND

Extensive traumatic soft tissue defects in the lower extremities typically require complete coverage of exposed bone because inadequate coverage, such as partial flap loss, may result in bony infection and ultimately lead to limb salvage failure. To achieve complete coverage of these defects, we used the wide anterolateral thigh perforator flap in which the turbocharging procedure augments the blood flow. Herein, we describe our turbocharging technique and discuss its effectiveness.

METHODS

From January 2014 to December 2020, the turbocharged wide ALTP free flaps were used to treat 13 patients with massive traumatic soft tissue defects in the lower extremities, ranging in size from 22 × 10 cm2 (220 cm2) to 21 × 17 cm2 (357 cm2) (mean, 270 cm2). All ALTP flaps were supplied by perforators from both the transverse branch of the lateral circumflex artery (TB-LCFA) and descending branch of the lateral circumflex artery (DB-LCFA) simultaneously. The turbocharging procedure by connecting the TB-LCFA to a side branch of the DB-LCFA was carried out in all these flaps. A retrospective review of medical records for each patient was performed.

RESULTS

The size of the transferred ALTP flap ranged from 23 × 12 cm2 (276 cm2) to 23 × 19 (437 cm2) (mean, 331 cm2). The total number of perforators included in the flaps was three on average. All ALTP flaps survived completely without partial necrosis. The postoperative course was uneventful except for two cases with minor complications, including hematoma and partial necrosis of the recipient's skin.

CONCLUSION

Free transfer of the turbocharged wide ALTP flap can be a reliable and effective reconstructive method to obtain complete coverage of extensive traumatic soft tissue defects in the lower extremities and achieve successful limb salvage.

Deep vein thrombosis in donor or recipient veins encountered during lower extremity reconstruction with a free anterolateral thigh perforator flap: How do we deal with it?

Background

The free anterolateral thigh perforator (ALTP) flap has been successfully adopted to reconstruct traumatic soft tissue defects in the lower extremities. However, the occurrence of deep vein thrombosis (DVT) in donor or recipient veins has been overlooked, and there has been no reliable guideline to manage it. Therefore, in this study, we review our cases where the ALTP flaps were transferred to traumatic lower limbs even though DVT was found in the pedicle or recipient veins. Furthermore, based on our experiences, we suggest an algorithmic approach for dealing with DVT.

Patients and methods

This study included 108 patients who underwent lower extremity reconstruction using a free ALTP flap between January 2014 and January 2021. All medical records were reviewed, including preoperative assessment data, intraoperative findings, and postoperative complications. Notably, when DVT was found in both the donor and recipient veins, we thoroughly assessed operative findings, surgical solutions, and final outcomes.

Results

Sixty-one of 108 (56.4%) patients underwent computed tomographic venography (CTV) preoperatively, revealing DVT in 11 of these 61 (18%) patients. Three of these 11 patients had iliofemoral DVT, and surgery was delayed more than two weeks after detection. The remaining eight patients had calf DVT and underwent free ALTP flap transfer as scheduled. Conversely, 47 of 108 (43.6%) patients did not undergo CTV, and an occult DVT was found in five of these 47 (10.6%) patients. In two of these five patients, free flap surgery was replaced with amputation and local flap coverage. In the remaining three patients and one patient with an occult DVT that was not found on CTV, the free ALTP flap transfer was carried out. In 15 patients with DVT, free ALTP flap transfer was performed using various alternative methods for venorrhaphy. Consequently, all flaps survived, with partial necrosis occurring in two patients.

Conclusion

If DVT-affected veins are appropriately managed, the free ALTP flap can be successfully transferred to the traumatic lower limb even when DVT occurs in donor or recipient veins. The author's algorithm can help surgeons overcome the insufficiency of veins for pedicle anastomosis due to DVT and avoid postoperative thromboembolic complications.

Staged Excision Technique to Reduce Scar Length

Patients and surgeons are often disappointed with the scar length after conventional staged excision of large disfiguring skin lesions. We have developed an alternative approach to facilitate scar length reduction. We aimed to report the efficacy of our staged excision method, which includes a hexagonal-pattern excision, wide undermining, and purse-string suture. Sixty-five patients, each with one lesion, were included in the current study. The lesion length and width were recorded, and the scar area was calculated at each stage. The final scar length after performing the altered staged excision method was compared with that obtained after the conventional staged excision method, which was calculated using a theoretical scar model. Patient satisfaction was also evaluated. The mean longest axis length was 9.41 ± 3.83 cm preoperatively, 9.50 ± 3.92 cm after the first stage postoperatively, and 10.19 ± 3.98 cm after the final stage. The mean lesion width was 6.50 ± 3.48 cm preoperatively, 3.60 ± 1.77 cm after the first stage postoperatively, and 0.42 ± 0.31 cm after the final stage. The final scar length obtained using the altered procedure was much shorter than what would be obtained using conventional staged excision. The patient satisfaction score was 8.8 ± 1.1 out of a possible 10.0 rating. Staged excision with a hexagonal-pattern excision, wide undermining, and purse-string closure may improve aesthetic results.

Solar background noise mitigation using the orbital angular momentum mode in vertical FSO downlink transmissions

Free-space optical communication (FSO) is used to provide network configuration flexibility. A network-flying platform-based vertical FSO connection can be employed to enhance mobile network coverage and capacity. Solar background noise can be a potential risk that disrupts the seamless connection in the vertical FSO downlink channel. In this paper, we propose signal transmission using an orbital angular momentum (OAM) beam. The OAM demodulation process can filter sunlight out of the optical receiver except for the signal corresponding to the azimuthal state. We experimentally verified that most of the solar background noise could be reduced. To verify the feasibility of the proposed scheme in a vertical FSO channel, we modeled a FSO vertical downlink with an OAM modulation/demodulation process.

Risk Factors for Major Amputation for Midfoot Ulcers in Hospitalized Patients With Diabetes: A Retrospective Study

PURPOSE

The purpose of this study was to investigate the risk factors for major amputation in persons hospitalized with diabetic foot ulcers involving the midfoot.

DESIGN

Retrospective study.

SUBJECTS AND SETTING

Between January 2003 and May 2019, a total of 1931 patients with diabetes were admitted to the diabetic wound center for the management of foot ulcers. Among the admitted patients, 169 patients with midfoot ulcers were included in this study. One hundred fifty-four patients (91%) healed without major amputation, while 15 patients (9%) healed post-major amputation.

METHODS

Data related to 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology, and serology were collected from patients in these 2 groups for comparison. Univariate and multivariate logistic regression analyses were performed to analyze risk factors for major amputation.

RESULTS

Among the 88 potential risk factors, 15 showed statistically significant differences between the 2 groups. Using univariate analysis of 88 potential risk factors, 8 showed statistically significant differences. Using stepwise multiple logistic regression analysis, 3 of the 8 risk factors remained statistically significant. Multivariate-adjusted odds ratios for deep ulcers invading bone, cardiac disorders, and Charcot foot were 26.718, 18.739, and 16.997, respectively.

CONCLUSION

The risk factors for major amputation in patients hospitalized with diabetic midfoot ulcers included deep ulcers invading the bone, cardiac disorders, and Charcot foot.

Folded Cymba Concha: Is It Large and Stable Enough for Caudal Septal Extension Graft in Asian Rhinoplasty?

BACKGROUND

Septal extension grafting (SEG) is used for nasal tip projection and positioning. Often, insufficient quadrangular cartilage is available for grafting in Asians, and in most secondary cases the septum is already harvested. We utilized the folded cymba concha as an alternative for caudal SEG (CSEG) by modifying a tongue-in-groove technique.

OBJECTIVES

The aim of this study was to evaluate the physical suitability of the cymba concha for CSEG and compare its outcomes with those of septal quadrangular cartilage.

METHODS

The mean length and width of 311 harvested consecutive folded cymba conchae were measured from intraoperative photographs. Data from 220 patients with >12 months of follow-up were retrospectively reviewed for clinical outcomes. Clinical demography was determined based on the need for additional spreader grafts. For clinical reliability, anthropometric photographs of patients in whom folded cymba conchae were used were compared with those in whom quadrangular cartilage was used.

RESULTS

Mean [standard deviation] lengths and widths of the folded cymba conchae in men and women were 24.2 [3.9] and 22.4 [3.7] mm, and 7.8 [1.9] and 7.2 [1.9] mm, respectively. Use of the folded cymba concha graft significantly increased nasal tip projection by 28.9% and columellar-labial angle by 9.7%, improving both aspects postoperatively. Anthropometric comparison revealed no significant differences between folded cymba conchae and septal cartilage in terms of nasal tip projection (P = 0.264) and postoperative columellar-labial angle (P = 0.182).

CONCLUSIONS

Folded cymba conchal cartilage can be a primary option for CSEG in Asian septorhinoplasty cases or for individuals with insufficient septal cartilage remnants.

Preoperative Nasal Swab Culture: Is It Beneficial in Preventing Postoperative Infection in Complicated Septorhinoplasty?

BACKGROUND

Surgical-site infection following complicated septorhinoplasty may result in serious complications. Therefore, efforts to prevent surgical-site infections after complicated septorhinoplasty are important. The purpose of this study was to analyze the microbiological profile of preoperative nasal swab cultures and to evaluate the effect of antibiotic prophylaxis and topical antibiotic decolonization according to the antibiotic sensitivity results of surgical-site infections in complicated septorhinoplasty.

METHODS

This 10-year cohort study included the data on 437 consecutive patients who underwent complicated septorhinoplasty. The patients were categorized into three cohorts based on the time of preoperative nasal swab culture collection. Patients in cohort 1 did not undergo nasal swab cultures and received empirical antibiotics. Patients in cohort 2 underwent only one preoperative nasal swab culture and received microorganism-sensitive antibiotics. Patients in cohort 3 underwent repeated nasal swab cultures. The antibiotics were changed when microorganisms resistant to the empirical antibiotics were isolated. Microbiological data and the rates of surgical-site infection and inflammation were compared among the three cohorts.

RESULTS

Methicillin-sensitive Staphylococcus aureus was the most commonly isolated microorganism. In cohort 1, two (5 percent) and two (5 percent) patients experienced surgical-site infections and inflammation, respectively. In cohort 2, two (3 percent) and three (4 percent) patients experienced surgical-site infections and inflammation, respectively. In cohort 3, one (0.3 percent) and one (0.3 percent) patient experienced surgical-site infection and inflammation, respectively.

CONCLUSION

The present study demonstrated that preoperative screening using repeated nasal swab cultures, followed by appropriate antibiotic prophylaxis and topical antibiotic decolonization, may reduce surgical-site infection in complicated septorhinoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Multidrug-resistant tuberculosis over 20 years at a referral hospital in South Korea: trends and outcomes

SETTING

A referral centre in South Korea.

OBJECTIVE

To investigate trends in drug resistance, treatment modalities and outcomes, and adverse events of multidrug-resistant tuberculosis (MDR-TB) over two decades.

DESIGN

MDR-TB patients treated at Seoul National Hospital University between 1996 and 2015 were divided into four 5-year cohorts according to the date of initial diagnosis. Changes in demographic characteristics, drug resistance, drugs used, treatment outcomes and adverse events over time were elucidated.

RESULTS

Between 1996 and 2015, 418 patients were treated for MDR-TB: 86 patients between 1996 and 2000, 125 between 2001 and 2005, 123 between 2006 and 2010, and 84 between 2011 and 2015. The proportion of patients with positive acid-fast bacilli sputum (60.5-29.7%, P < 0.001) or cavities on chest radiographs (86.0-40.5%, P < 0.001) decreased over time. Resistance to pyrazinamide, fluoroquinolones, cycloserine and p-aminosalicylic acid decreased. Later-generation fluoroquinolones (77.9-90.5%) and linezolid (0-26.2%) became more frequently prescribed. The treatment success rate increased (45.3-88.1%, P < 0.001); neurological adverse events, including peripheral neuropathy also increased (4.7-13.1%, P = 0.027).

CONCLUSION

MDR-TB patients presented with less severe disease and better resistance profiles over time in South Korea, with treatment outcomes improving continuously.

Risk factors for major amputation in hospitalized diabetic patients with forefoot ulcers

AIMS

The purpose of this study was to investigate the risk factors for major amputation in patients hospitalized with diabetic forefoot ulcers.

METHODS

Between January 2003 and December 2018, a total of 1792 diabetic patients were admitted to the diabetic wound center for the management of diabetic foot ulcers. Among the patients, 1032 diabetic patients with forefoot ulcers were included in this study. Nine hundred and eighty-three patients (95%) healed without major amputations while 49 patients (5%) healed after major amputations. Data related to 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology, and serology were collected from the patients in these two groups for comparison.

RESULTS

Among the 88 potential risk factors, 34 showed statistically significant differences between the two groups. In the univariate analysis of 88 risk factors, 33 showed statistically significant differences. In stepwise multiple logistic regression analysis, four of the 33 risk factors remained statistically significant. The multivariate-adjusted odds ratios for gender, magnesium levels, platelet levels, and glycated hemoglobin (HbA1c) levels were 8.216, 2.480, 1.009, and 0.570, respectively.

CONCLUSION

Risk factors for major amputation in patients hospitalized with diabetic forefoot ulcers include male gender, increased magnesium, increased platelet levels, and low levels of HbA1c.

Clinical Analysis of Nasal Bone Fracture in Patients Who Have Previously Undergone Dorsal Augmentation Using Silicone Implants: A Pilot Study

BACKGROUND

There are no studies about the treatment of nasal bone fractures in patients with dorsal augmentations using silicone implants. We aimed to describe the characteristics of nasal bone fracture in patients who underwent rhinoplasty and compare the difference between closed reduction and conservative treatment of nasal bone fractures in patients with a history of rhinoplasty.

METHODS

Between January 2013 and June 2018, a total of 463 patients were admitted to our center for nasal bone fracture; 17 patients with nasal bone fractures who underwent rhinoplasty were included, of which, five underwent closed reduction in the nasal bone and 12 underwent conservative treatment. Three of 12 patients who were initially treated conservatively underwent a secondary rhinoplasty for esthetic improvements. All patients were classified according to fracture site and the presence of a nasal septal fracture-in accordance with the modified Murray classification-and were analyzed for the correlation between fracture type and disease course.

RESULTS

The nasal bone fracture types per computed tomography findings were unilateral (n = 13), bilateral (n = 4), septal (n = 1), and M-type (n = 1). No significant differences in fracture site (P > 0.05) and the presence of a nasal septal fracture (P > 0.05) were found between the groups. Fracture type did not significantly differ among patients who underwent closed reduction, conservative treatment without secondary rhinoplasty, and secondary rhinoplasty (P > 0.05).

CONCLUSIONS

Despite risking traumatic capsular rupture, implant removal is seldom required and closed reduction is recommended if visible deviations are present; otherwise, only conservative treatment is recommended.

LEVEL OF EVIDENCE IV

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.

Tissue-engineered dermis grafts using stromal vascular fraction cells on the nose: A retrospective case-control study

BACKGROUND

In a previous study, our group demonstrated that cultured autologous fibroblast-seeded artificial dermis was superior to artificial dermis for covering defects after surgical excision of basal cell carcinoma (BCC) in terms of scar quality. However, utilizing cultured cells for clinical purposes requires Food and Drug Administration-approved facilities and techniques and a lengthy culture period. The purpose of this retrospective study was to compare the effects of tissue-engineered dermis containing stromal vascular fraction (SVF) cells with artificial dermis on scar quality after surgical excision of BCC on the nose.

METHODS

Between April 2010 and February 2018, patients who were treated with tissue-engineered or artificial dermis grafts and those with a follow-up period of greater than a year were included in this study. The Patient and Observer Scar Assessment Scales (POSAS) were compared between two groups according to the location of the graft, which was classified based on nasal subunits: the upper two-thirds zone; the lower one-third zone, except for the ala; and the alar zone.

RESULTS

A tissue-engineered dermis composed of SVF cells and an artificial dermis were applied to 30 and 47 patients, respectively. In upper two-thirds and lower one-third zones, except for the ala, no statistically significant differences were found in any parameters. In the alar zone, statistically significant differences were detected in 10 of 21 POSAS parameters.

CONCLUSION

To cover nasal defects, the tissue-engineered dermis graft may be superior to the artificial dermis graft regarding scar quality at the ala. However, there were no significant differences in other zones.

Paranasal Augmentation Using Multi-Folded Expanded Polytetrafluorethylene (ePTFE) in the East Asian Nose

BACKGROUND

Paranasal augmentation has commonly been performed utilizing alloplastic materials such as silicone or porous polyethylene. However, there are problems such as bone absorption, implant migration, and infection risk attributable to intraoral approaches.

OBJECTIVES

The authors attempted anterior positioning of the alar crease junction as an adjunct method of rhinoplasty. The authors aimed to determine the long-term results of the intranasal approach for placement of multi-folded expanded polytetrafluorethylene (ePTFE).

METHODS

A retrospective review was conducted of patients who underwent intranasal surgical approach for paranasal augmentation employing multi-folded ePTFE implants in 19 septorhinoplasties who were followed-up for 3 to 10 years. Patient charts were reviewed for demographic information, concomitant operations, and complications. Preoperative and postoperative photographs were utilized to evaluate operative outcomes. The photographs were reformatted to 2-dimensional images employing standard photographic methods.

RESULTS

Of the 19 patients treated, 17 were female and 2 were male; ages ranged from 18 to 58 years. All patients reported improvement in their lateral profiles and were pleased at follow-up. There were no major complications, no nerve or vascular supply compromise, and no cases of implant malposition. The average increase in soft tissue outline near the alar crease junction was more than 3.2 mm (P < 0.001), but the alar base did not became wider.

CONCLUSIONS

Paranasal augmentation with multi-folded ePTFE is a simple, safe, and effective method that can readily improve the lateral profile. In particular, the intranasal approach combined with rhinoplasty can synergistically improve outcomes and lead to greater patient satisfaction.

LEVEL OF EVIDENCE: 4

Clinical experience with surgical debridement and simultaneous meshed skin grafts in treating biofilm-associated infection: an exploratory retrospective pilot study

Current treatment guidelines for biofilm-associated infections (BAI) recommend repeated sharp/surgical debridement followed by treatment with antimicrobial agents until the wound becomes self-sustaining in terms of a positive wound-healing trajectory. However, complete removal of a biofilm is unlikely, and biofilms reform rapidly. We have treated BAI in patients with chronic diabetic ulcers using a meshed skin graft combined with negative pressure wound therapy (NPWT) immediately after surgical debridement, rather than waiting until the development of clean and healthy granulation tissue; the purpose of this exploratory study was to report the clinical results of this treatment strategy. This retrospective study included 75 patients with chronic diabetic ulcers who were treated for BAI by using surgical debridement, simultaneous meshed skin grafts, and NPWT. Healing time along with the percentage of complete wound closure within 12 weeks were evaluated; bacteria isolated from the wounds and their relation to the wound healing rate were investigated. All 75 wounds healed successfully, and the mean time for complete wound healing was 3.5 ± 1.8 weeks. In particular, 76% of wounds healed uneventfully without graft loss. A mean of 3.3 bacterial colonies/wound were isolated; however, no significant difference in wound healing was observed between the monomicrobial and polymicrobial groups. This exploratory study suggests that surgical debridement and simultaneous meshed skin grafts combined with NPWT may be successfully used to combat BAI in patients with chronic diabetic ulcers. We look forward to larger pivotal studies to confirm or refute these initially promising findings.

Septorhinoplasty for Destructed Septal L-Strut in Patients with Previously Applied Porous High-Density Polyethylene Implants (Medpor®)

BACKGROUND

Porous high-density polyethylene implants (Medpor^®) have been extensively used for septal extension grafts in Asian rhinoplasty. However, studies on the long-term complications associated with Medpor^® have not been reported. Therefore, the purpose of this study was to evaluate the long-term complications of septal extension grafts using Medpor^® and present a reconstructive strategy for destructed septal L-struts.

METHODS

We conducted a 12-year retrospective medical chart review of 428 patients who visited our center for septorhinoplasty. Among 428 patients, 43 patients had Medpor^® for septal extension grafts previously applied at other clinics. The quadrangular cartilage was devoid or destructed in the area where Medpor^® was previously applied. Therefore, all patients underwent secondary septorhinoplasty using autogenous cartilage grafts. Patient outcome was assessed to evaluate satisfaction, hardness of nasal tip, functional nasal obstruction symptom evaluation (NOSE) scores, and pain scores. Anthropometric analyses were carried out with patients' photographs. Postoperative complications were also evaluated.

RESULTS

After septal L-strut reconstruction, 87% of patients were satisfied with their aesthetic results. Hardness of nasal tip, NOSE scores, and pain scores also improved after reconstruction. Anthropometric analyses demonstrated that increased nasal length and decreased columellar-labial angle were achieved in patients with short nose deformities. No postoperative complications related to the reconstruction were recorded for any patient.

CONCLUSIONS

The devastated destruction of nasal support lines was found after the use of Medpor^® for septorhinoplasty. Therefore, the use of Medpor^® should be reduced. Autogenous cartilage grafts are the last resort for reconstruction of destructed septal L-struts.

LEVEL OF EVIDENCE IV

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 .

Comparative Biological Effects of Human Amnion and Chorion Membrane Extracts on Human Adipose-Derived Stromal Cells

Although therapies with human amnion/chorion are used to ameliorate acute and chronic wounds, it is unclear which component of the amnion/chorion tissue promotes wound healing. To characterize the comparative effects of amnion and chorion in wound healing, we used human adipose-derived stromal cells to assess cell viability, migration, and gel contraction after treatment with amnion membrane extract (AME) or chorion membrane extract (CME). We then correlated the possible effectors via AME and CME protein profiling, and compared them by enzyme-linked immunosorbent assay (ELISA), western blotting, and immunocytochemistry. Cell viability was significantly increased with 50 and 100 μg/mL AME treatment, but with CME treatment, a significant increase was only observed with 100 μg/mL. With CME treatment, cell migration was 2.22-fold greater than the control, and collagen gels showed 20% greater contraction. Compared to control, the expression levels of α-smooth muscle actin (SMA) and smooth muscle protein 22-alpha (SM22α) increased both with AME and CME treatments, whereas calponin expression decreased. Protein profiling revealed significantly higher tissue inhibitor of metalloproteinase-1 (TIMP-1), interleukin-8, exotoxin, and adiponectin levels in CME than in AME, and ELISA revealed 8-fold higher adiponectin levels in cells treated with CME than those treated with AME. Immunocytochemistry revealed that α-SMA, SM22α, and calponin were significantly higher in CME- than AME-treated cells; however, adiponectin treatment did not enhance α-SMA, SM22α, or calponin expression. In conclusion, amnion and chorion membrane extracts exerted differential effects on proliferation and contraction of human adipose-derived stromal cells. Amnion extract was superior at inducing cell proliferation and migration, whereas CME was superior at inducing cell contraction.

Influence of Peripheral Neuropathy and Microangiopathy on Skin Hydration in the Feet of Patients With Diabetes Mellitus

INTRODUCTION

Maintaining adequate skin hydration is crucial in the feet of patients with diabetes because xerotic skin may crack and develop fissures, thereby increasing vulnerability to ulceration and infection. The nervous system is considered the powerhouse for maintaining adequate skin hydration; however, no clinical study has assessed the effect of the nervous system on skin hydration. In addition, it is hypothesized that microcirculation may play an important role in maintaining adequate hydration in patients with diabetes.

OBJECTIVE

This study aims to evaluate the influence of peripheral nerve function and microvascularity on skin hydration in the feet of patients with diabetes mellitus and compare the effects of these 2 functions on skin hydration.

MATERIALS AND METHODS

This study included 266 patients with diabetic foot disease. Skin hydration was evaluated using corneometry and microvascularity by measuring the transcutaneous oximetry (TcpO₂) of the foot. The Semmes-Weinstein 5.07/10-g monofilament test, electromyography, and nerve conduction velocity test were conducted to evaluate peripheral neuropathy. Patient data were divided into 3 subgroups according to test values, and statistical comparisons were performed using the linear-by-linear association trend and Pearson's chi-square tests.

RESULTS

There was a significant correlation between skin hydration and TcpO₂. However, there was no significant correlation between skin hydration and peripheral nerve function (P = .338).

CONCLUSIONS

The results of this study demonstrated that skin hydration in the feet of patients with diabetes mellitus mainly is influenced by microcirculation rather than peripheral nerve function.

Assessment of Long-term Outcomes of Soft-Tissue Augmentation by Injecting Fibroblasts Suspended in Hyaluronic Acid Filler

Importance

In previous studies, this group has reported that cultured human fibroblasts suspended in hyaluronic acid (HA) filler might have potential use as a long-lasting injectable soft-tissue filler. However, the data were insufficient to determine the long-term outcomes.

Objective

To evaluate the long-term outcomes of cultured human fibroblasts suspended in HA filler used for soft-tissue augmentation.

Design, Setting, and Participants

A long-term case series study was performed. Between January 2010 and December 2013, a total of 38 patients were treated with fibroblast-HA filler mixture to augment nasal dorsa, nasolabial folds, and cheek depressions. Of these 38 patients, patients with follow-up period of greater than 3 years were included in this study. A total of 22 patients met the inclusion criteria.

Main Outcomes and Measures

Subjective assessment was performed to evaluate degree and time of resorption, improvement, satisfaction, softness of injection sites, and willingness to recommend this treatment to others. Objective assessment was carried out with patients' photographs. Safety and tolerability were also evaluated for this treatment.

Results

Of the 22 patients included in this study, 19 were women; mean (SD) patient age was 43 (15) years. All 22 patients experienced improvement following the treatment. Twenty (91%) patients were satisfied with the treatment. Nineteen patients (86%) considered that the injection site was as soft as it was before treatment. Patients' mean (SD) grading of improvement, satisfaction, and softness were 4.50 (0.51) (95% CI, 4.27-4.73), 4.14 (0.71) (95% CI, 3.82-4.45), and 4.82 (0.50) (95% CI, 4.59-5.00) at the last visit, respectively. Objective assessment demonstrated postoperative improvement in all patients: a rating of "much improved" was given to 7 patients (32%) by investigator 1; 8 patients (36%) by investigator 2; and 12 patients (55%) the injecting physician. This treatment was well tolerated; no adverse event was recorded for any patient.

Conclusions and Relevance

Injection of cultured human fibroblasts suspended in HA filler might be successful for long-term soft-tissue augmentation. To our knowledge, this study represents the longest follow-up study of soft-tissue augmentation with a fibroblast-HA filler mixture to date.

Level of Evidence

4.

Risk Factors for Major Amputation on Hindfoot Ulcers in Hospitalized Diabetic Patients

Objective: The purpose of this study was to investigate the risk factors for major amputation in patients hospitalized with diabetic foot ulcers involving the hindfoot. Approach: Between January 2003 and October 2017, a total of 1,657 diabetic patients were admitted to the diabetic wound center of Korea University Guro Hospital, for the management of foot ulcers. Among the admitted patients, 117 diabetic patients with hindfoot ulcers were included in this study. One hundred and four patients (89%) healed without major amputation, while 13 patients (11%) healed with major amputation. Data related to 88 potential risk factors, including demographics, ulcer condition, vascularity, bioburden, neurology, and serology, were collected from patients in these two groups for comparison. Results: Among the 88 potential risk factors, 15 showed statistically significant differences between the two groups. In univariate analysis of 88 potential risk factors, nine showed statistically significant differences. In stepwise multiple logistic regression analysis, three of the nine risk factors remained statistically significant. Multivariate-adjusted odds ratios for pulmonary disorders, erythrocyte sedimentation rate (ESR) levels, and total iron-binding capacity (TIBC) levels were 38.525, 1.047, and 0.976, respectively. Innovation: Compared with forefoot and midfoot ulcers, diabetic foot ulcers involving the hindfoot are at increased risk of major amputation because infection may spread proximal to the ankle. However, large-scale cohort studies that specifically discuss the outcomes and characteristics of diabetic hindfoot ulcers are not widely available. Conclusion: Risk factors for major amputation in patients hospitalized with diabetic hindfoot ulcers include pulmonary disorders, high levels of ESR, and decreased TIBC levels.

Subnasal Lip Lifting in Aging Upper Lip: Combined Operation with Nasal Tip Plasty in Asians

BACKGROUND

The objective of this study was to illustrate a novel technique for lifting of the aging upper lip with nasal tip plasty in Asians. With this procedure, a shortening of the philtrum, an increase of the vermilion, and a natural and nicer mouth can be obtained, with increase of the tip of the nose simultaneously.

METHODS

Thirty patients were the subjects of this study. Incisions were made bilaterally beginning at the alar fold, entering nostrils, and rising medially on the skin below the lower margin of the medial crura. Excess skin of the philtrum was eliminated in two separate pieces and the muscle was suspended to the base of the nose with interrupted stitches.

RESULTS

All patients expressed a high degree of satisfaction. The average ratio between the L1 reference line and the height of the upper lip measurement preoperatively was 0.43 ± 0.05. This ratio was improved postoperatively to an average of 0.32 ± 0.05. The nasolabial angle was 91.31 ± 4.19 degrees before surgery and 105.62 ± 5.04 degrees after surgery. The angle of the upper lip was 48.97 ± 2.41 degrees before surgery and 38.21 ± 3.34 degrees after surgery.

CONCLUSIONS

Lip lift is an effective tool for correcting a natural tendency of the upper lip to cover the upper teeth during aging. There is a dramatic improvement in the patient's facial aesthetic appearance during smiling and at rest. The authors strongly recommend this technique as part of the surgical procedure to achieve a youthful face.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Potential of Allogeneic Adipose-Derived Stem Cell-Hydrogel Complex for Treating Diabetic Foot Ulcers

Mesenchymal stem cells (MSCs) may hold great promise for treating diabetic wounds. However, it is difficult for a clinician to use MSCs because they have not been commercialized. Meanwhile, a new commercial drug that contains adipose-derived stem cells (ASCs) has been developed. The purpose of this study was to examine the potential of allogeneic ASC sheets for treating diabetic foot ulcers. Fifty-nine patients with diabetic foot ulcers were randomized to either the ASC treatment group (n = 30) or a control group treated with polyurethane film (n = 29). Either an allogeneic ASC sheet or polyurethane film was applied on diabetic wounds weekly. These wounds were evaluated for a maximum of 12 weeks. Complete wound closure was achieved for 73% in the treatment group and 47% in the control group at week 8. Complete wound closure was achieved for 82% in the treatment group and 53% in the control group at week 12. The Kaplan-Meier median times to complete closure were 28.5 and 63.0 days for the treatment group and the control group, respectively. There were no serious adverse events related to allogeneic ASC treatment. Thus, allogeneic ASCs might be effective and safe to treat diabetic foot ulcers.

Possibility of Injecting Adipose-Derived Stromal Vascular Fraction Cells to Accelerate Microcirculation in Ischemic Diabetic Feet: A Pilot Study

Background and Objectives

Beneficial effects of human adipose-derived stromal vascular fraction (SVF) cell injection on microcirculation have been recently reported in in vitro and in vivo studies. However, no clinical studies have reported its effect in diabetic patients who commonly experience compromised tissue perfusion, regardless of the status of intravascular blood flow. The present piloting study was designed to clinically examine the possibility of SVF cell injection to accelerate microcirculation, particularly in ischemic diabetic feet.

Methods

Ten diabetic feet were included to receive subcutaneous injection of SVF cells around wounds. Transcutaneous partial oxygen pressure (TcPO₂) and cutaneous microvascular blood flow were measured before and every four weeks after cell injection until the 12^th week visit.

Results

TcPO₂ values increased from 31.3±7.4 before injection to 46.4±8.2 mmHg at 12 weeks after SVF injection (1.5-fold, p<0.05). Cutaneous microvascular blood flow levels increased from 34.0±21.1 before injection to 76.1±32.5 perfusion unit at 12 weeks after SVF injection (2.2-fold, p<0.05). There were no adverse events related to SVF cell injection.

Conclusions

Results of this study demonstrate that adipose-derived SVF cell injection have the possibility to provide beneficial effects on microcirculation in ischemic diabetic feet.

Comparison of perfusion values after percutaneous transluminal angioplasty according to the severity of ischaemia in the diabetic foot

Percutaneous transluminal angioplasty (PTA) is now more frequently used to improve tissue perfusion in ischemic diabetic feet. However, there are concerns about its feasibility and effectiveness in severely ischaemic feet. This study aimed to compare the perfusion values after PTA according to the ischaemic degree of diabetic feet. This study included 133 ischaemic diabetic feet. The foot transcutaneous oxygen pressure (TcPO₂ ) and toe pressure were measured before the procedure and every second postoperative week for 6 weeks. The patients were divided into three groups according to ischaemic severity on the basis of TcPO₂ and toe pressures. In the "severely ischaemic" group, the TcPO₂ increased from 7.5 ± 4.9 to 40.3 ± 11.3 mm Hg (5.4-fold) 6 weeks after the PTA (P < 0.001). The toe pressure increased from 8.5 ± 8.8 to 42.2 ± 19.3 mm Hg (5.0-fold, P < 0.001). In the "mild" group, the TcPO₂ increased from 35.4 ± 2.5 to 41.8 ± 12.4 mm Hg (1.2-fold, P = 0.003), and the toe pressure increased from 45.7 ± 12.3 to 54.3 ± 31.3 mm Hg (1.2-fold, P > 0.05). Results of the "intermediate" group were in between. The most severely ischaemic group had the most dramatic increase of tissue perfusion after PTA. As such, PTA can be an effective method for increasing tissue perfusion even in the severely ischaemic diabetic feet.

Topical epidermal growth factor spray for the treatment of chronic diabetic foot ulcers: A phase III multicenter, double-blind, randomized, placebo-controlled trial

AIMS

This study was conducted to evaluate the efficacy and safety of a novel spray-applied growth factor therapy containing recombinant human epidermal growth factor (rhEGF) for the treatment of chronic diabetic foot ulcers (DFU).

METHODS

This study was a phase III double-blind, randomized, placebo-controlled trial. 167 adult patients at six medical centers were randomized to receive routine wound care plus either topical spray treatment with 0.005% rhEGF (n = 82) or an equivalent volume of saline spray (n = 85) twice a day until ulcer healing or for up to 12 weeks.

RESULTS

Demographics, medical status, and wound characteristics were comparable between rhEGF and placebo groups. More patients in the rhEGF group significantly had complete wound healing compared to placebo (73.2% versus 50.6%, respectively; P = .001). Wound healing velocity was faster in the rhEGF group (P = .029) regardless of HbA1c levels. The rhEGF group had a shorter median time to 50% ulcer size reduction (21 versus 35 days; hazard ratio = 3.13, P < .001) and shorter time to complete ulcer healing (56 versus 84 days; hazard ratio = 2.13, P < .001).

CONCLUSIONS

This study confirms that application of spray-applied rhEGF in DFU patients results in faster healing velocity and higher complete healing rate regardless of HbA1c levels.

Correcting Nasojugal Groove with Autologous Cultured Fibroblast Injection: A Pilot Study

BACKGROUND

A new commercial drug that contains autologous cultured fibroblasts has been developed and approved by the United States Food and Drug Administration for improving the appearance of nasolabial folds. However, the treatment requires three sessions every 3-6 weeks. It is known that the skin overlying the nasojugal groove is thinner, and the wrinkle is generally shallower than nasolabial folds. Therefore, we hypothesized that the nasojugal groove could be improved by just one treatment session. Therefore, the purpose of this study was to evaluate the efficacy and safety of autologous cultured fibroblast injection to correct nasojugal grooves.

METHODS

Forty-six subjects with nasojugal grooves were enrolled in this study. They were injected with autologous cultured fibroblasts or placebo in one session. Blinded evaluators and subjects assessed the efficacy using a validated wrinkle assessment scale at 4, 12, and 24 weeks after the injection. Information of adverse events was collected at each visit.

RESULTS

Based on the evaluators' assessment at 24 weeks after the injection, 76% of subjects treated with autologous cultured fibroblasts showed improvement whereas 0% of subjects treated with placebo showed improvement (P < 0.0001). Based on self-assessment at 24 weeks after the injection, 72% of subjects treated with autologous cultured fibroblasts and 45% of subjects treated with placebo showed improvement (P = 0.0662). There were no serious adverse events related to autologous cultured fibroblast injection.

CONCLUSIONS

Autologous cultured fibroblast injection might be effective and safe to correct nasojugal grooves.

LEVEL OF EVIDENCE I

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 .

Rapidly Progressive Lactic Acidosis in Patients with Flufenoxuron Poisoning

Flufenoxuron is an insect growth regulator which inhibits chitin (exoskeleton) biosynthesis in insect's body. Not much is known about its toxicity to human. This report describes three patients who developed worsening lactic acidosis and hypotension after ingestion of flufenoxuron-containing materials. Two of the three patients received continuous renal replacement therapy and survived. (Hong Kong j.emerg.med. 2014;21:181-184)

Comparison of human umbilical cord blood-derived mesenchymal stem cells with healthy fibroblasts on wound-healing activity of diabetic fibroblasts

Various types of skin substitutes composed of fibroblasts and/or keratinocytes have been used for the treatment of diabetic ulcers. However, the effects have generally not been very dramatic. Recently, human umbilical cord blood-derived mesenchymal stromal cells (hUCB-MSCs) have been commercialised for cartilage repair as a first cell therapy product using allogeneic stem cells. In a previous pilot study, we reported that hUCB-MSCs have a superior wound-healing capability compared with fibroblasts. The present study was designed to compare the treatment effect of hUCB-MSCs with that of fibroblasts on the diabetic wound healing in vitro. Diabetic fibroblasts were cocultured with healthy fibroblasts or hUCB-MSCs. Five groups were evaluated: group I, diabetic fibroblasts without coculture; groups II and III, diabetic fibroblasts cocultured with healthy fibroblasts or hUCB-MSCs; and groups IV and V, no cell cocultured with healthy fibroblasts or hUCB-MSCs. After a 3-day incubation, cell proliferation, collagen synthesis levels and glycosaminoglycan levels, which are the major contributing factors in wound healing, were measured. As a result, a hUCB-MSC-treated group showed higher cell proliferation, collagen synthesis and glycosaminoglycan level than a fibroblast-treated group. In particular, there were significant statistical differences in collagen synthesis and glycosaminoglycan levels (P = 0·029 and P = 0·019, respectively). In conclusion, these results demonstrate that hUCB-MSCs may have a superior effect to fibroblasts in stimulating diabetic wound healing.

Status of wound management in Korea

In spite of a period of intense economic, social, and political hardship following the Korean War, the Republic of Korea has made great strides in economic growth over the past half century, and also remarkable progress in the medical field. However, wound research has been slow to take off in South Korea. Meanwhile, as is the case in many countries in Western Europe and North America, South Korea is seeing a steady increase in its aged population. The growth in the geriatric population has in turn brought on more cases of chronic wounds. Though South Korea only began to recognize the importance of wound management in the early 2000s, it was fortunate enough to have sophisticated related industries, such as biotechnology and information technology, and brilliant, industrious, and eager wound researchers, contributing to rapid development of the field. The country has particular strengths in research for innovative cell-based treatments and products for managing wounds. Notwithstanding government policy ill-equipped to sufficiently support such advancement, better communication between experts and public officials will no doubt bring forth even more achievements in this very promising field. It is in this context that this article aims to summarize current wound management practices, research, training, product development, and government policies regarding wound management in South Korea as of the year 2017.

Do IL-3/GM-CSF effect on the myofibroblastic differentiation of human adipose derived stromal cells?

BACKGROUND

Capsular contracture is an incurable complication after silicone-based implant surgery. Myofibroblast is the predominant cell in the contracted capsule. We hypothesized that human adipose derive stromal cells (hASCs) together with fibroblast may show a similar phenotypic characteristics of myofibroblast after the treatment of inflammatory cytokines in vitro.

MATERIALS AND METHODS

Interleukin 3 (IL-3) and granulocyte macrophage colony stimulating factor (GM-CSF) were treated in the culture of hASCs and HDFs. Lyn peptide inhibitor was applied as an inhibitor. The changes of cell surface markers (CD105, CD73, CD34, CD45, CD31, CD325 and CD146) were assessed. The expression of various cytokines related to wound contraction were tested such as TGF-β, α-SMA, HGF, FGF, ENT-1, and TSP-1. Myo-D, α-SMA, and glial fibrillary acidic protein (GFAP) were evaluated by blotting and immunocytochemical staining. The collagen-gel contraction assay was performed for the functional contraction of myofibroblastic phenotype.

RESULTS

The expression of α-SMA, Myo-D and GFAP after the treatment of IL-3/GM-CSF showed similar results in hASCs and HDFs. Enhanced expression of TGF- β was observed in HDFs and the increase of ENT-1 and TSP-1 was significant in hASCs. Collagen-gel with HDFs contracted significantly within 24h after the treatment of IL-3/GM-CSF, and the contraction was inhibited by Lyn peptide inhibitor. But in hASCs, the gel-contraction was not significant.

CONCLUSION

IL-3/ GM-CSF effected on the myofibroblastic differentiation of hASCs as well as it did on HDFs. But hASCs did not show the phenotypic gel-contraction within 24h.

Effects of human umbilical cord blood-derived mesenchymal stromal cells and dermal fibroblasts on diabetic wound healing

BACKGROUND AIMS

A previous study demonstrated that human umbilical cord blood-derived mesenchymal stromal cells (hUCB-MSCs) have superior wound-healing activity compared with fibroblasts in vitro. However, wound healing in vivo is a complex process that involves multiple factors. The purpose of this study was to compare the effects of hUCB-MSCs and fibroblasts on diabetic wound healing in vivo. This study especially focused on collagen synthesis and angiogenesis, which are considered to be the important factors affecting diabetic wound healing.

METHODS

Porous polyethylene discs were loaded with either fibroblasts or hUCB-MSCs, and a third group, which served as a control, was not loaded with cells. The discs were then implanted in the back of diabetic mice. During the first and the second week after implantation, the discs were harvested, and collagen level and microvascular density were compared.

RESULTS

In terms of collagen synthesis, the hUCB-MSC group showed the highest collagen level (117.7 ± 8.9 ng/mL), followed by the fibroblast group (83.2 ± 5.2 ng/mL) and the no-cell group (60.0 ± 4.7 ng/mL) in the second week after implantation. In terms of angiogenesis, the microvascular density in the hUCB-MSC group was 56.8 ± 16.4, which was much higher than that in the fibroblast group (14.3 ± 4.0) and the no-cell group (5.7 ± 2.1) in the second week after implantation.

CONCLUSIONS

These results demonstrate that hUCB-MSCs are superior to fibroblasts in terms of their effect on diabetic wound healing in vivo.

Evaluation of Xpert(®) MTB/RIF assay: diagnosis and treatment outcomes in rifampicin-resistant tuberculosis

SETTING

The Xpert(®) MTB/RIF assay is endorsed by the World Health Organization for the detection of rifampicin (RMP) resistant tuberculosis (TB).

OBJECTIVE

To evaluate Xpert for its diagnostic accuracy in detecting RMP-resistant TB and its impact on treatment outcomes.

DESIGN

Patients with available phenotypic drug susceptibility testing (DST) results and those in whom RMP-resistant pulmonary TB was diagnosed using Xpert were evaluated. The accuracy and turnaround time (TAT) of Xpert for determining RMP-resistant TB was calculated. The TATs for treatment between patients diagnosed with RMP-resistant TB using Xpert and those diagnosed without the assay (phenotypic DST group) were compared.

RESULTS

In 321 patients, when phenotypic DST was used as the gold standard, Xpert sensitivity and specificity for RMP resistance diagnosis was respectively 100% and 98.7%; the positive and negative predictive values were respectively 86.2% and 100%. The Xpert group had a much shorter interval from initial evaluation to commencing second-line anti-tuberculosis treatment (64 vs. 2 days, P < 0.001), and negative conversion of mycobacterial cultures (197 vs. 62.5 days, P < 0.001) than the phenotypic DST group.

CONCLUSION

Xpert was accurate at diagnosing RMP resistance in this setting with an intermediate TB burden and a low level of RMP resistance. Xpert might reduce disease transmission by reducing the sputum culture conversion times for patients with RMP-resistant TB.

Changes in treatment outcomes of multidrug-resistant tuberculosis

SETTING

After several changes in treatment modalities, it is time to re-evaluate treatment outcomes of multidrug-resistant tuberculosis (MDR-TB).

OBJECTIVE

To evaluate treatment outcomes, elucidate changes in outcomes over time and identify predictors of treatment success for MDR-TB.

DESIGN

Patients diagnosed with MDR-TB at a tertiary referral centre in South Korea between January 2006 and December 2010 were included. Treatment modalities and outcomes were assessed. Predictors of treatment success were analysed using multiple logistic regression. The treatment modalities and outcomes of these patients were compared with those of MDR-TB patients between January 1996 and December 2005.

RESULTS

Of the 123 MDR-TB patients diagnosed during the later study period, treatment was successful in 103 (83.7%). Extensive drug resistance (OR 0.31, P = 0.044) and additional resistance to fluoroquinolones (OR 0.23, P = 0.039) were inversely associated with treatment success. The treatment success rate improved from 53.5% in 1996-2000 to 68.8% in 2001-2005 and 83.7% in 2006-2010 (P < 0.001). Improved outcomes were accompanied with more frequent use of later-generation fluoroquinolones and linezolid and less frequent surgical resection.

CONCLUSION

Treatment outcomes for MDR-TB improved at a tertiary referral centre in South Korea. The improvement was associated with more frequent use of later-generation fluoroquinolones and linezolid.

Effect of inhalers on the development of haemoptysis in patients with non-cystic fibrosis bronchiectasis

BACKGROUND

The association of inhaler use with haemoptysis has rarely been reported in patients with non-cystic fibrosis (CF) bronchiectasis.

OBJECTIVE

To elucidate the effect of inhaler use on the development of haemoptysis in patients with non-CF bronchiectasis.

METHODS

In a case-crossover study of 192 non-CF bronchiectasis patients with a history of haemoptysis and inhaler use, the risk of haemoptysis associated with the use of inhalers was elucidated. Two inhaled corticosteroids/long-acting β₂-agonists (ICS/LABA), one long-acting muscarinic antagonist and one short-acting β₂-agonist (SABA) were evaluated. The case and control periods were defined respectively as 030 and 180210 days before haemoptysis.

RESULTS

The risk of haemoptysis during the case period was 3.51 times higher than during the control period with any use of inhalers (95%CI 1.966.28). The results of clinically significant haemoptysis showed good agreement with those of total events. These associations were consistent with the sensitivity analyses. In the sub-analysis according to inhaler type, ICS/LABA and SABA were significantly associated with an increased risk of haemoptysis (aOR 2.62, 95%CI 1.255.45; aOR 2.51, 95%CI 2.235.15).

CONCLUSIONS

In patients with non-CF bronchiectasis, the use of inhalers, especially including 2-agonist, was associated with an increased risk of haemoptysis.

Effects of Panax ginseng extract on human dermal fibroblast proliferation and collagen synthesis

Current studies of Panax ginseng (or Korean ginseng) have demonstrated that it has various biological effects, including angiogenesis, immunostimulation, antimicrobial and anti-inflammatory effects. Therefore, we hypothesised that P. ginseng may also play an important role in wound healing. However, few studies have been conducted on the wound-healing effects of P. ginseng. Thus, the purpose of this in vitro pilot study was to determine the effects of P. ginseng on the activities of fibroblasts, which are key wound-healing cells. Cultured human dermal fibroblasts were treated with one of six concentrations of P. ginseng: 0, 1, 10 and 100 ng/ml and 1 and 10 µg/ml. Cell proliferation was determined 3 days post-treatment using the 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyl tetrazolium bromide assay, and collagen synthesis was evaluated by the collagen type I carboxy-terminal propeptide method. Cell proliferation levels and collagen synthesis were compared among the groups. The 10 ng/ml to 1 µg/ml P. ginseng treatments significantly increased cell proliferation, and the 1 ng/ml to 1 µg/ml concentrations significantly increased collagen synthesis. The maximum effects for both parameters were observed at 10 ng/ml. P. ginseng stimulated human dermal fibroblast proliferation and collagen synthesis at an optimal concentration of 10 ng/ml.

Risk factors for major amputation in hospitalised diabetic foot patients

Diabetic foot ulcers are the main cause of non-traumatic lower extremity amputation. The objective of this study was to evaluate the risk factors for major amputation in diabetic foot patients. Eight hundred and sixty diabetic patients were admitted to the diabetic wound centre of the Korea University Guro Hospital for foot ulcers between January 2010 and December 2013. Among them, 837 patients were successfully monitored until complete healing. Ulcers in 809 patients (96·7%) healed without major amputation and those in 28 patients (3·3%) healed with major amputation. Data of 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology and serology were collected from patients in the two groups and compared. Among the 88 potential risk factors, statistically significant differences between the two groups were observed in 26 risk factors. In the univariate analysis, which was carried out for these 26 risk factors, statistically significant differences were observed in 22 risk factors. In a stepwise multiple logistic analysis, six of the 22 risk factors remained statistically significant. Multivariate-adjusted odds ratios were 11·673 for ulcers penetrating into the bone, 8·683 for dialysis, 6·740 for gastrointestinal (GI) disorders, 6·158 for hind foot ulcers, 0·641 for haemoglobin levels and 1·007 for fasting blood sugar levels. The risk factors for major amputation in diabetic foot patients were bony invasions, dialysis, GI disorders, hind foot locations, low levels of haemoglobin and elevated fasting blood sugar levels.

Accuracy of the Xpert® MTB/RIF assay for the diagnosis of extra-pulmonary tuberculosis in South Korea

SETTING

The Xpert(®) MTB/RIF assay has been endorsed by the World Health Organization for the detection of pulmonary and extra-pulmonary tuberculosis (EPTB).

OBJECTIVE

To determine the accuracy of the Xpert assay in diagnosing EPTB in South Korea, a country with an intermediate TB burden.

DESIGN

We retrospectively reviewed the medical records of 1429 patients in whom the Xpert assay using EPTB specimens was requested between 1 January 2011 and 31 October 2013 in a tertiary referral hospital in South Korea. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of EPTB and detection of rifampicin (RMP) resistance were calculated.

RESULTS

Using culture as gold standard, the sensitivity, specificity, PPV and NPV of the assay were respectively 67.7%, 98.1%, 60% and 98.6%. Using a composite reference standard, the sensitivity, specificity, PPV and NPV were respectively 49.3%, 100%, 100% and 95.1%. The sensitivity, specificity, PPV and NPV for the detection of RMP resistance among specimens with positive results for Mycobacterium tuberculosis were respectively 80%, 100%, 100% and 97.7%.

CONCLUSION

The Xpert assay showed acceptable sensitivity in certain groups and excellent specificity in diagnosing EPTB and detecting RMP resistance in an intermediate TB burden country.

Wound-healing potential of human umbilical cord blood-derived mesenchymal stromal cells in vitro--a pilot study

BACKGROUND AIMS

Our previous studies demonstrated that human bone marrow-derived mesenchymal stromal cells have great potential for wound healing. However, it is difficult to clinically utilize cultured stem cells. Recently, human umbilical cord blood-derived mesenchymal stromal cells (hUCB-MSCs) have been commercialized for cartilage repair as a first cell therapy product that uses allogeneic stem cells. Should hUCB-MSCs have a superior effect on wound healing as compared with fibroblasts, which are the main cell source in current cell therapy products for wound healing, they may possibly replace fibroblasts. The purpose of this in vitro study was to compare the wound-healing activity of hUCB-MSCs with that of fibroblasts.

METHODS

This study was particularly designed to compare the effect of hUCB-MSCs on diabetic wound healing with those of allogeneic and autologous fibroblasts. Healthy (n = 5) and diabetic (n = 5) fibroblasts were used as the representatives of allogeneic and autologous fibroblasts for diabetic patients in the control group. Human UCB-MSCs (n = 5) were used in the experimental group. Cell proliferation, collagen synthesis and growth factor (basic fibroblast growth factor, vascular endothelial growth factor and transforming growth factor-β) production were compared among the three cell groups.

RESULTS

Human UCB-MSCs produced significantly higher amounts of vascular endothelial growth factor and basic fibroblast growth factor when compared with both fibroblast groups. Human UCB-MSCs were superior to diabetic fibroblasts but not to healthy fibroblasts in collagen synthesis. There were no significant differences in cell proliferation and transforming growth factor-β production.

CONCLUSIONS

Human UCB-MSCs may have greater capacity for diabetic wound healing than allogeneic or autologous fibroblasts, especially in angiogenesis.

Clinical results of treatment of garden type 1 and 2 femoral neck fractures in patients over 70-year old

INTRODUCTION

We retrospectively analyzed the clinical results of treatment of impacted or undisplaced femoral neck fractures (Garden types 1 and 2) by osteosynthesis in elderly patients >70-year old.

MATERIALS AND METHODS

We retrospectively reviewed the radiological results of 52 patients who were followed up for at least 6 months from April 2002 to December 2008. The average age of the patients was 77.6 years (range 70-97 years), and 38 patients were females. The mean follow-up period was 11.7 months (range 6-19 months). Thirteen cases were Garden type 1 fractures, and 39 were Garden type 2 fractures. We assessed the relationships between the occurrence of complications and age, sex, Garden stage, bone mineral density (BMD), history of contralateral hip fracture, and any additional hip injury.

RESULTS

Major complications occurred in 18 cases (34.6 %), including nonunion (8 cases), osteonecrosis (6 cases), stress fracture of the subtrochanter (2 cases), excessive pull-out of a screw (1 case), and deep infection (1 case). The development of complications was associated with Garden stage 2, BMD, and additional hip injury. However, other factors were not associated with complications. Reoperations were performed in 16 cases (30.1 %), and 2 of the patients died during follow-up.

CONCLUSION

A relatively high rate of complications or reoperations developed after treatment of Garden 2 femoral neck fractures in senile patients >70 years of age with osteoporosis. Although internal fixation has been recommended in the literature for undisplaced femoral neck fractures, primary arthroplasty may be a better option for treatment of Garden type 2 fractures in elderly patients.

Randomised controlled clinical trial for autologous fibroblast-hyaluronic acid complex in treating diabetic foot ulcers

OBJECTIVE

Diabetic foot ulcers (DFUs) often pose a treatment problem. Bioengineered skin substitutes have been reported to result in accelerated diabetic wound healing. The purpose of this clinical trial was to evaluate the efficacy and safety of the autologous fibroblast-hyaluronic acid complex for treating DFUs.

METHOD

A stratified, randomised, controlled, multicentre study was carried out. Patients with DFUs were allocated to either a treatment group with grafting of an autologous fibroblast-hyaluronic acid complex or a control group with non-adherent foam dressing. Except for application of the fibroblast complex, treatment of the study ulcers was identical for patients in both groups. The maximum follow-up period for each patient was 12 weeks.

RESULTS

Complete ulcer healing was achieved in 84% (26/31 patients) of the treatment group and 34% (11/32 patients) of the control group (p<0.05). The times required for complete healing were 36.4 ± 17.6 and 48.4 ± 13.1 days in the treatment and control groups, respectively (p<0.05). No adverse events related to treatment occurred.

CONCLUSION

These results indicate that autologous fibroblast-hyaluronic acid complex may offer a safe and effective treatment for DFUs.