The influence of the COVID-19 pandemic on blood donation and supply in China

INTRODUCTION

During the COVID-19 pandemic, there was a sharp decline in blood donation which posed a serious threat to the clinical blood supply worldwide. The aim of this study was to evaluate the influence of the COVID-19 pandemic on blood donation and supply in China on a nationwide level.

METHODS

A comprehensive review of the published literature was performed using eight databases including PubMed, Web of Science, Cochrane Library, Ovid, Embase, CNKI, WANFANG, and VIP by searching relevant words combinations.

RESULTS

Twenty-seven studies were determined to be eligible and included. Among them, 21 studies reported the situation of blood donation during the COVID-19 pandemic in China. The donation of both whole blood and platelet concentrates declined (with a decline of 5%-86% for whole blood and 3%-34% for platelet concentrates), with this especially evident in February 2020. The COVID-19 pandemic changed the pattern of blood donation and the composition of blood donors accordingly. Fifteen articles reported the supply of various blood components during the COVID-19 pandemic. The supply and usage of both packed red blood cell (PRBC) and fresh-frozen plasma (FFP) decreased (with a decrease of 4%-40% for PRBC and 9%-58% for FFP). The proportion of blood transfusions in different departments changed too. Compared to 2019, there was a decrease in surgical blood transfusions, and an increase in that used in treatments performed in emergency and internal medicine departments.

CONCLUSION

The COVID-19 pandemic has led to an overall reduction of blood transfusion activities in most cities in China, in particular blood donations and blood demands.

Pathogen reduced red blood cells as an alternative to irradiated and washed components with potential for up to 42 days storage

BACKGROUND

The urgency of maintaining a safe and adequate blood supply is increasing. One approach to ensure a sufficient supply is to limit the outdating frequency of blood components. Pathogen inactivation technology was developed primarily to increase safety by preventing transmission of infectious diseases. The Intercept Blood System for pathogen reduction of red blood cells (RBC) has additional benefits such as inactivation of leucocytes and removal of plasma and storage debris through centrifugation. Irradiation and automated washing are detrimental to the RBC membrane and often implicate shortened shelf-life. We aimed to assess whether pathogen inactivation can replace RBC irradiation and washing to avoid shelf-life reduction.

MATERIALS AND METHODS

RBC concentrates (No.=48) were pooled-and-split into four study arms, which underwent pathogen inactivation treatment, irradiation, automated washing or no treatment (reference). RBC quality was evaluated during 42 days by assessment of storage lesion. Washing efficacy was defined by IgA and albumin reduction.

RESULTS

Pathogen reduced RBCs had similar membrane preservation to reference RBCs (hemolysis, microvesicles and extracellular potassium ions), whereas the RBCs were negatively impacted by irradiation or automated washing. ATP increased substantially post-pathogen inactivation, while 2,3-DPG decreased. Pathogen inactivation considerably reduced albumin and IgA, though slightly less efficiently than automated washing.

DISCUSSION

RBCs exhibit superior membrane preservation after pathogen inactivation treatment, compared to both irradiation and automated washing. This suggests that replacement is possible, even though the plasma reduction protocol could be further optimised.Replacement of irradiated and washed RBC concentrates with pathogen reduced RBC concentrates storable up to 42 days would be advantageous for both the blood supply and patient safety.

Anatomical View of the Internal Carotid Artery Occlusion in Japanese Black Cattle

The internal carotid artery (ICA) is a branch of the common carotid artery (CCA), along with the external carotid artery (ECA), which together provide the blood supply for the brain. The description of the ICA in cattle is vague, including denial of its existence or degeneration at an early stage after birth. This anatomical study investigated the internal carotid artery in Japanese black cattle. Sixty-five heads of Japanese black cattle aged from newborn to 13 years were dissected and injected with colored latex from the CCA after separating the head and body. Diameter measurements of the artery branches from the CCA on its bifurcation were conducted. Furthermore, a histological examination of the ICA wall's structures, which consist of the tunica intima, tunica media, and tunica externa, was performed. The ICA of Japanese black cattle is closed on the left side after age 3 years, except for a small lumen at 13 years, whereas the right ICA remains open at all ages. The location of occlusion of the left internal carotid artery (LICA) shows thickness of the tunica intima and an increased connective tissue layer area. The diameter of the ICA does not differ between the left and right sides, and there is no correlation with age. Therefore, further studies are needed, especially of ICA occlusion related to Japanese black cattle's physiology or cerebrospinal disease.

Changes in the pulmonary circulation due to gravitational loads in high altitude conditions

BACKGROUND

The impact of gravity on the existence of all living things has long been of interest to scientists. The force of the Earth's gravity combined with hypoxia significantly affects blood circulation and blood accumulation in various parts of the human and animal body. To date, the relationship between body position and blood circulation in pulmonary circulation under hypobaric hypoxia has not been sufficiently studied.

OBJECTIVES

Therefore, the research aims to determine the possibility of changing the body position in space on the reactions in the pulmonary circulation in the plains and highlands.

METHODS

For this purpose, research was conducted on male Wistar rats, 44 of whom spent 150 days at an altitude of 3200 m above sea level, and 25 representatives of the control group - at an altitude of 164 m.

RESULTS

The study revealed that gravitational redistribution of blood in mountainous conditions is less pronounced compared to the control group. This is explained by the remodeling of the vascular wall and an increase in its stiffness. It was found that a change in pulmonary artery pressure at the time of a change in body position was recorded both on the plains and in the highlands. On the plains, when the body position of rats was changed to passive orthostatic, a decrease in systolic and diastolic pulmonary artery pressure was noted, and when the body position was changed to passive anti-orthostatic, an increase in pulmonary artery pressure was observed. The increase in pulmonary artery pressure was a compensatory mechanism due to the increased stiffness of the pulmonary vasculature.

CONCLUSIONS

The practical significance of this research is to expand the understanding of the pathogenesis of pulmonary hypertension in high-altitude hypoxia.

Exploring Physical Lumbar Microvascular Geometry Through Endoscopy and Illustrations: Implications for Clinical Interpretation

STUDY DESIGN

Retrospective Study.

OBJECTIVES

Minimally invasive endoscopic spinal surgery is gaining popularity, but our understanding of the lumbar spine's microvascular geometry relies heavily on cadaver studies and textbook illustrations. Additionally, inconsistent nomenclature of vessels in the literature hampers effective communication among surgeons. This study aims to improve the clarity and comprehensibility of the lumbar spinal microvascular geometry under endoscopic view.

METHODS

The study included 400 patients who underwent endoscopic spinal surgery for lumbar spinal canal stenosis and foraminal stenosis. The surgeries were performed by an experienced surgeon using either the interlaminar or transforaminal approach. Endoscopic video recordings were further analyzed to map the microvascular geometry and common bleeding foci. The observed results were cross-referenced with existing literature to reconstruct a comprehensive view of the vascular anatomy.

RESULTS

The transforaminal approach commonly encounters bleeding foci originating from the major branches of the segmental lumbar artery and the emissary veins within the foramen. The interlaminar approach primarily encounters bleeding foci from the muscle vessels in the dorsal lamina, which are believed to be located near the ends of the three main branches. In the intracanal region, epidural vessels form a rotary loop above the disc, which can contribute to most of the bleeding during discectomy.

CONCLUSIONS

This study provides a comprehensive understanding of the microvascular anatomy in the lumbar spine during endoscopic spinal surgery. Recognizing the geometry will help surgeons anticipate and control bleeding, reducing the risk of complications. The findings contribute to the improvement of surgical techniques and patient safety in endoscopic spinal surgery.

Doppler ultrasonographic evaluation of tissue revascularization following connective tissue graft at implant sites

AIM

To assess the Doppler ultrasonographic tissue perfusion at dental implant sites augmented with connective tissue graft (CTG) using coronally advanced flap (CAF) or tunnel technique (TUN).

MATERIALS AND METHODS

Twenty-eight patients presenting with isolated healthy peri-implant soft-tissue dehiscence (PSTD) were included in this randomized clinical trial. PSTDs were treated with either CAF + CTG or TUN + CTG. Ultrasound scans were taken at baseline, 1 week, 1 month, 6 months and 12 months. Tissue perfusion at the mid-facial, mesial and distal aspects of the implant sites was assessed by colour Doppler velocity (CDV) and power Doppler imaging (PDI). Early vascularization of the graft and the flap at 1 week and at 1 month were evaluated via dynamic tissue perfusion measurements (DTPMs), including flow intensity (FI), mean perfusion relief intensity (pRI) and mean perfused area (pA).

RESULTS

Regression analysis did not reveal significant differences in terms of mid-facial CDV and PDI changes between CAF and TUN over 12 months (p > .05), while significant differences between the two groups were observed at the interproximal areas (p < .001 for both CDV and PDI changes). Higher early DTPMs were observed at the TUN-treated sites in terms of mean FI of the graft (p = .027) and mean FI (p = .024) and pRI of the flap (p = .031) compared with CAF-treated sites at 1 week. Assessment of the FI direction showed that CTG perfusion at 1 week and at 1 month mainly occurred from the flap towards the implant/bone. Early tissue perfusion outcomes were found to be associated with the 12-month mean PSTD coverage and mucosal thickness gain.

CONCLUSIONS

Doppler ultrasonography shows tissue perfusion changes occurring at implant sites augmented with CTG. The main differences in tissue perfusion between CAF and TUN were observed at the interproximal sites, with early perfusion associated with clinical and volumetric outcomes at 12 months.

A Wireless Infrared Thermometry Device for Postoperative Flap Monitoring: Proof of Concept in Patients

BACKGROUND/NEED

Postoperative flap perfusion assessment methods still rely on the evaluation of traditional clinical indicators, which have the disadvantage of being subjective and burdensome.

METHODOLOGY

This study describes a self-designed infrared wireless thermometer for flap blood supply monitoring and evaluates its efficacy in the postoperative monitoring of 40 free flaps.

DEVICE DESCRIPTION

The device consists of multiple temperature and humidity modules as well as a wireless module, which has the advantages of low cost and continuous remote monitoring.

PRELIMINARY RESULTS

The alarm time of the wireless infrared thermometer was 30.5 ± 3.1 hours, and the clinical observation reported 41.7 ± 13.6 hours.

CURRENT STATUS

In future studies, the device will be tested on different types of flaps in a porcine model.

Split Spinal Cord Malformation Fed by Bilateral, Enlarged Radiculopial Arteries

Anatomical variations of the spinal cord are seen in many manifestations; one rare variant that does not stem from a neural tube defect is known as a split cord malformation (SCM). In this variation, a deviation from normal development causes the spinal cord to divide into two hemicords, typically in the lumbar region. In the case described here, a SCM was observed with large, bilateral, radiculopial arteries. To our knowledge, such large vessels in conjunction with a SCM has not previously been documented in the literature. Such variants could be problematic during surgical approaches to the lumbar spine. Herein, we report the case and discuss the development of the findings with relevant clinical applications.

Transcatheter arterial embolization in patients with neuroendocrine neoplasms related to liver metastasis with different blood supplies

PURPOSE

Liver metastasis is one of the most important factors affecting the prognosis of patients with neuroendocrine neoplasms (NENs). Transhepatic artery embolization (TAE) is the main local treatment of NENs with liver metastasis (NENLM). This study aimed to elucidate the differences between pancreatic and rectal NENLM with a discrepancy in blood supply.

METHODS

A total of 32 patients with NENLM of different primary sites received 102 TAE treatments at our hospital. Clinical features, such as age, sex, World Health Organization (WHO) tumour grade and progression-free survival (PFS), were compared between patients with pancreatic and rectal NENLM with different blood supplies. The total follow-up time is 1-5 years.

RESULTS

There were 12 cases with tumours originating from the rectum or pancreas, respectively. Other tumour-originated sites included the duodenum (two cases, 6.25%), the thymus and lung (four cases, 12.5%), and the unknown (two cases, 6.25%). The average age of patients was 51.59 years, and 17 (53.1%) were men. WHO grade 1, 2 or 3 tumours occurred in three (9.4%), 23 (71.9%) and six (18.7%) patients, respectively. Hepatic tumour burdens of low (<25%), middle (25%-50%) and high (>50%) levels were found in 13 (40.6%), eight (25%) and 11 (34.4%) patients, respectively. There were more patients with hypervascular pancreatic NENLM than with hypovascular rectal NENLM (p = 0.005). Tumour shrinkage in all cases with NENLM was 50% with an objective response rate of 37.5%, disease control rate of 75% and PFS of 12 months. Disease progression (p = 0.09), tumour shrinkage (p = 0.07) and death (p = 0.19) were more prominent in the pancreatic NENLM group than in the rectal NENLM group. Progression-free survival was not reached in the pancreatic NENLM group, which was more prominent than in the rectal NENLM group (7 months; hazard ration, 0.22; 95% confidence interval, 0.07-0.76; p = 0.016). The main adverse events were abdominal pain (71.9%) and transaminase elevation (50%), which were more common in pancreatic NENLM than in rectal NENLM.

CONCLUSIONS

Transhepatic artery embolization treatment is markedly effective and safe for treating NENLM, especially pancreatic NENLM.

Intracorporeal linear‑stapled gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: Consideration of the intraoperative management of the duodenal wall between the transecting staple line and anastomotic staple line (Review)

The first part of the duodenum consists of the intraperitoneal segment, called the duodenal bulb, and the retroperitoneal segment. Regarding the blood supplying the duodenal bulb, which is the portion utilized in anastomosing the duodenum and remnant stomach following distal gastrectomy, the arterial pedicles branching off from the gastroduodenal artery are reported to reach the posterior wall first and then spread over the anterior wall, where they anastomose. When performing intracorporeal linear-stapled gastroduodenostomy following totally laparoscopic distal gastrectomy, the blood supply of the duodenal wall between the transecting staple line and anastomotic staple line needs to be considered because both transection of the duodenal bulb and the gastroduodenostomy are performed using an endoscopic linear stapler and the duodenal wall between the staple lines can be ischemic after the anastomosis. Since it needs to be decided intraoperatively whether this duodenal site is preserved or removed, the present review discusses the technical differences among several procedures for intracorporeal linear-stapled gastroduodenostomy, classifying them into two groups on the basis of the intraoperative management of this duodenal site. When this site is preserved, the blood supply of the duodenal wall needs to be retained with certainty. On the other hand, when this site is removed, the ischemic portion of the duodenal wall needs to be identified and removed. Furthermore, in both groups, an adequate anastomotic area needs to be secured. In conclusion, surgeons need to be familiar with the anatomical features of the duodenal bulb, including its blood perfusion and shape, when carrying out intracorporeal linear-stapled gastroduodenostomy.

3D Reconstruction of the Blood Supply in an Elephant's Forefoot Using Fused CT and MRI Sequences

Being the largest still-living terrestrial mammal on earth, an elephant's feet play an important role in its health status. The musculoskeletal structures in the forefoot are well described in the literature, but information about vascularization is limited. The novel aim of this work is to provide anatomical guidance to structures found in the forefoot, focusing on the arterial system. Initially, native CT and MRI sequences were taken of the left forefoot of a deceased 6-year-old female Asian elephant; the foot was then filled with an iodine-containing contrast medium through the a. mediana and the CT scans were repeated in the same position. The images obtained were processed with 3D Slicer software for the 3D reconstruction of the bones and arteries. The results clearly showed the palmar blood supply of the forefoot. A so far undescribed vessel was revealed, stemming from the a. metacarpea, supplying the first digit and the digital cushion. The course of the deep palmar arch's terminal section was also established. This paper provides the first description of the exact disposition of the arteries in the palmar aspect of an elephant's forefoot and may be used in planning surgeries in clinically affected animals.

Pelvic pain and venous congestion revisited: examining relationship between chronic pelvic pain and uterine venous size and blood flow

OBJECTIVE

To investigate the relationship between increased uterine venous plexus diameter and chronic pelvic pain in women attending a gynecology clinic.

METHODS

This was a retrospective study of patients attending a tertiary university hospital in London, UK. Women presenting to the gynecology clinic undergoing transvaginal ultrasound examination were recruited into the study. The largest trunk of the uterine venous plexus was measured on each side. Blood flow within the uterine veins was categorized into continuous or interrupted flow and evaluated using color and spectral Doppler ultrasound during normal respiration and on Valsalva maneuver to demonstrate the presence of venous reflux. The largest uterine vein diameter and its blood flow were used for the analysis. The main variables of interest were chronic pelvic pain, uterine vein diameter and type of blood flow.

RESULTS

We included 1500 women in the study, of whom 584 (38.9% (95% CI, 36.5-41.5%)) reported chronic pelvic pain. Dysmenorrhea was the most common type of pelvic pain. Age (P < 0.001), menopausal status (P = 0.02), varicose veins (P = 0.01), adenomyosis (P < 0.001) and endometriosis (P < 0.001) were found to be independently associated with the occurrence of pain on multiple logistic regression analysis. There was no difference in uterine vein diameter between women with and those without pain (P = 0.10). Neither uterine vein diameter (P = 0.47) nor type of blood flow (P = 0.07) was significantly associated with the occurrence of pelvic pain on multiple logistic regression.

CONCLUSIONS

Our findings show that uterine vein diameter is not associated with pelvic pain. However, we found other important clinical and demographic factors that are associated with chronic pelvic pain. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Association between endometrial blood and clinical outcome in frozen single blastocyst transfer cycles

Background: The success of embryo transfer cycle depends mainly on the quality of embryo and endometrial receptivity. Ultrasound examination is still the most widely used non-invasive evaluation method for its advantages of convenience, non-invasiveness and repeatability. Ultrasound-measured endometrial blood flow is one of the important evaluation indicators of morphology. Aims: To investigate the effect of the number of endometrial blood flow branches on pregnancy outcome of frozen-thawed embryo transfer cycles which have undergoing hormone replacement therapy (HRT-FET). Material and methods: A retrospective cohort study was performed looking at a total of 1390 HRT-FET cycles from our reproductive medicine center between January 2017 to December 2021, which transferred one blastocyst frozen on day 5 with good quality in morphology. Associations between endometrial blood flow branches and pregnancy outcomes were evaluated with multivariable linear regression analysis. Results: The number of endometrial blood flow branches was independently associated with clinical pregnancy (OR 1.10; 95% CI 1.02-1.20). After adjusting for potential confounders, the effect size (odds ratio) was 1.09 (95% CI 1.00-1.19), and the results showed that the clinical pregnancy rate and live birth rate of T2 and T3 groups were significantly higher than those in group T1 (p < 0.05). Subgroup analysis showed that a consistent association between the endometrial blood flow branches and clinical pregnancy in all subgroups. Conclusion: Our study provided evidence for the influence of endometrial blood flow on pregnancy outcomes. There may be an independent association between the number of endometrial blood flow branches and pregnancy outcomes in frozen-thawed single blastocyst transfer cycles.

The Associative Pattern Between Segmental Arterial Damage and Complete Neurological Disorder After Spinal Cord Injury: A Case-Control Study

INTRODUCTION

The prevalence of vascular trauma surrounding the thoracic spine following Spinal Cord Injury (SCI) is unknown. The potential for neurologic recovery is uncertain in many cases; in some cases, neurologic assessment is not possible, for example, in severe head injury or early intubation, and detection of segmental artery injury may help as a predictive factor.

OBJECTIVE

To assess the prevalence of segmental vessel disruption in two groups, with and without neurologic deficit.

MATERIAL AND METHODS

This is a retrospective cohort study, with a group SCI American Spinal Injury Association (ASIA) E and a group SCI ASIA A. All patients had a high-energy thoracic or thoracolumbar fracture from T1 to L1. Patients were matched 1:1 (one ASIA A matched with one ASIA E) according to the fracture type, age, and level. The primary variable was the assessment of the presence/disruption of the segmental arteries, bilaterally, around the fracture. Analysis was performed twice by two independent surgeons in a blinded fashion.

RESULTS

Both groups had 2 type A, 8 type B, and 4 type C fractures. The right segmental artery was detected in 14/14 (100%) of the patients with ASIA E and in 3/14 (21%) or 2/14 (14%) of the patients with ASIA A, according to the observers, p=0.001. The left segmental artery was detectable in 13/14 (93%) or 14/14 (100%) of the patients ASIA E and in 3/14 (21%) of the patients ASIA A for both observers. All in all, 13/14 of the patients with ASIA A had at least one segmental artery undetectable. The sensibility varied between 78%to 92%, and the specificity from 82% to 100%. The Kappa Score varied between 0.55 and 0.78.

CONCLUSION

Segmental arteries disruption was common in the group ASIA A. This may help to predict the neurological status of patients with no complete neurological assessment or potential for recovery post-injury.

Histopathologic study of keloid vascular structures shows the vascular origin pattern of keloid subepidermal vascular network flaps

BACKGROUND

Keloid subepidermal vascular network flaps (KSVNFs) have achieved satisfactory results in clinical practice. Through this retrospective study, we further examined keloid vascular structure to better understand vascular origin pattern in KSVNFs.

METHODS

Paraffin-embedded keloid tissues were stained for CD31. Distances from keloid subepidermal capillaries to the skin surface were measured. The included angle between the pedicle vessels and skin surface (angle PV), as well as the included angle between the keloid margin and skin surface (angle KM), were also measured. The major and minor axes of the capillary in the central areas of keloid (KDC), adjacent skin (AS) and marginal areas of keloid (KDM) were analyzed, and the major:minor axis ratios (M/m) were calculated. Vessels in KSVNF pedicle sites (KDP) were compared with vessels in adjacent skin as a subgroup analysis.

RESULTS

Twenty-nine keloid specimens in total were collected. Based on 1630 measured data points, the capillary distance to the skin surface was 387.2±96.7 μm. The angle PV was 70.1±36.6°, and the angle KM was 67.0±18.1°. The major axis of the KDM capillaries was significantly longer than that of KDC and AS (both P < 0.001). The major and minor axes were longer in KDP than in AS (both P < 0.001).

CONCLUSION

Suprakeloidal blood vessels are mainly distributed at a depth of 387.2±96.7 μm from the skin. The subepidermal plexus in KSVNF pedicle sites enters the skin at an acute angle and runs parallel to the keloid margin layer. Vessels in keloid marginal areas had crushed vascular lumen, but vessels in KSVNF pedicles did not.

Contralateral and Ipsilateral Arterial Vasculature of the Human Uterus: The Pilot Results of an Anatomical Study

Arterial blood to the human uterus is provided by a pair of uterine arteries (UA) and supported by terminal branches of ovarian (OA) and vaginal arteries (VA). Literature reports the existence of ipsilateral and contralateral anastomoses between these arteries and the UA, but data on the prevalence of such anastomoses are discrepant. The aim of this trial is to study whether contralateral and ipsilateral anastomoses exist. We studied nine human uterine specimens, which were obtained from (i) human cadavers (n = 6), (ii) uterine transplant recipients (n = 2), and (iii) one altruistic uterine donor (n = 1). We injected India ink into the graft through the UA of each specimen (n = 8) or OA (n = 1). We semiquantitatively observed and evaluated the extent of the injection on horizontal, vertical, and transmural levels. The dye permeated beyond the midline in 9/9 (100 %) cases. Near-complete/complete permeation to the contralateral side was observed in 6/9 (66 %) cases. The dye permeated ipsilaterally throughout all uterine levels in 8/8 cases (100 %) of UA injection. The entire wall of the myometrium was permeated in 2/9 (22 %) cases. In 7/9 (78 %) cases, the wall of the myometrium was permeated less than halfway through. In conclusion, the preliminary results of this study prove the existence of ipsilateral and contralateral anastomoses. Complete transmural injection was observed in only 22 % of cases; however, this finding does not provide information about the functional capacity of these anastomoses. More data and studies are necessary to make definitive conclusions.

Xenografts on nude mouse diaphragm of human DU145 prostate carcinoma cells: mesothelium removal by outgrowths and angiogenesis

Human prostate carcinoma DU145 cells, androgen-independent malignant cells, implanted in the athymic nu/nu male mouse, developed numerous tumors on peritoneal and retro-peritoneal organs whose growth aspects and vascular supply have yet to be investigated with fine structure techniques. A series of necropsies from moribund implanted mice diaphragms were examined with light, scanning, and transmission electron microscopy. DU145 xenografts installations, far away from the implanted site, were described as the smallest installation to large diaphragm outgrowths in moribund mice. Carcinomas did not show extracellular matrix and, reaching more than 0.15 mm in thickness, they revealed new structures in these outgrowths. Voids to be gland-like structures with mediocre secretion and, unexpectedly, intercellular spaces connected with fascicles of elongated DU145 cells that merged with a vascular supply originated from either the tumor cells and/or some perimysium vessels. In the largest carcinomas, most important vascular invasions coincidently accompanied the mouse lethality, similarly to human cancers. This androgen-independent model would be useful to study tumor outgrowth's changes related to testing anticancer strategy, including anti-angiogenic therapies involving toxicity, simultaneously with those of other vital organs with combined biomolecular and fine structure techniques.

Radiologic Evaluation of Uterine Vasculature of Uterus Transplant Living Donor Candidates: DUETS Classification

Uterus transplantation is a treatment solution for women suffering from absolute uterine factor infertility. As much as 19.5% of uterus-transplanted patients underwent urgent graft hysterectomy due to thrombosis/hypoperfusion. The necessity to identify candidates with high-quality uterine vasculature is paramount. We retrospectively evaluated and compared the imaging results with actual vascular findings from the back table. In this article, we present a novel radiologic grading scale (DUETS classification) for evaluating both uterine arteries and veins concerning their suitability for uterus procurement and transplantation. This classification defines several criteria for arteries (caliber, tapering, atherosclerosis, tortuosity, segment, take-off, and course) and veins (caliber, tapering, plethora, fenestrations, duplication/multiplicity, dominant route of venous drainage, radiologist’s confidence with imaging and assessment). In conclusion, magnetic resonance angiography can provide reliable information on uterine venous characteristics if performed consistently according to a well-established protocol and assessed by a dedicated radiologist. The caliber of uterine arteries seems to be inversely related to the time passed since the last delivery. We recommend that the radiologist comments on the reliability and confidence of the imaging study. It cannot be over-emphasized that the most crucial aspect of surgical imaging is the necessity of high-quality communication between a surgeon and a radiologist.

Prediction of Higher Ki-67 Index in Pituitary Adenomas by Pre- and Intra-Operative Clinical Characteristics

Objective: The Ki-67 index is an indicator of the active proliferation and aggressive behavior of pituitary adenomas (PAs). Appropriate pre- and intra-operatives of the Ki-67 index can help surgeons develop better and more personalized treatment strategies for patients with PAs. This study aimed to investigate the influence factors for predicting the Ki-67 index in PAs. Methods: Data of 178 patients with PAs confirmed by pathology were retrospectively analyzed. According to the Ki-67 index, the patients were divided into the Ki-67 < 3% and Ki-67 ≥ 3% cohorts. Patient data, including age, sex, postoperative immunohistochemical pituitary hormone positive index, Knosp grade, tumor breaking through the sellar floor, rich blood supply to the tumor, tumor located inside the sella, erosion of the dorsum sellae bone, and pituitary-specific transcription factor, were collected. A univariate logistic analysis was used to evaluate the influence factors for a high Ki-67 index. Multiple regression and receiver operating characteristic (ROC) curve were used to analyze the factors with p < 0.05. The mutant status of Ki-67 index was predicted by nomogram. Results: Multivariate regression analysis showed that rich blood supply to the tumor and erosion of the dorsum sellae bone were independent risk factors for the Ki-67 proliferation index. The ROC curves demonstrated that age, rich blood supply to the tumor, and erosion of the dorsum sellae bone can predict the occurrence of a high Ki-67 index. Together, the three risk factors provide a stronger ability to predict the Ki-67 index. The nomogram was developed and validated. Conclusion: Age, rich blood supply to the tumor, and erosion of the dorsum sellae bone are influencing factors for predicting the Ki-67 index. Suitable nomogram prediction models were developed and validated, and there is potential for personalized treatment for PA patients.

Influence of abdominal aortic calcification on the distal extent and branch blood supply of acute aortic dissection

OBJECTIVE

This study aimed to investigate the influence of abdominal aortic calcification on the distal extent, blood supply, and mid-term outcomes of acute aortic dissection (AAD).

METHODS

This single-centre retrospective study was conducted from August 2014 to May 2021. The aortic calcification index (ACI) was used to evaluate abdominal aortic calcification. The standardized method provided by the Society for Vascular Surgery (SVS) was used to evaluate the distal extent of AAD. Patients were divided into three groups according to the degree of calcification: no calcification (NC), low calcification (LC), and high calcification (HC).

RESULTS

In a cohort of 723 patients, abdominal aortic calcification was present in 424 (58.6%) patients. The prevalence of coronary heart disease increased with the degree of calcification (NC vs. LC vs. HC: 8.4% vs. 9.5% vs. 19.3%, P<0.001). The ACI of the distal extent at zone 9 was higher than that of the distal extent exceeding zone 9 (P=0.001). The proportions of the NC, LC and HC groups with distal extents exceeding zone 9 were 65.9% vs. 56.2% vs. 37.7%, P<0.001. In multivariate logistics analysis, the calcification grades was a protective factor of distal extents exceeding zone 9 (P<0.001, OR=0.592). Hypertension (P=0.019, OR=1.559) and D-dimer (P<.001, OR=1.045) were risk factors. There was a higher proportion of branch-vessels on the abdominal aorta supplied by the true lumen in the calcification group (NC vs. LC vs. HC: 27.8% vs. 43.8% vs. 51.1%, P<0.001). There were no significant differences in the mid-term outcomes among the groups.

CONCLUSIONS

Abdominal aortic calcification could limit the distal extent in patients with AAD and increase the proportion of branch-vessels on the abdominal aorta supplied by the true lumen.

hsa_circ_0058122 knockdown prevents steroid-induced osteonecrosis of the femoral head by inhibiting human umbilical vein endothelial cells apoptosis via the miR-7974/IGFBP5 axis

BACKGROUND

Steroid-induced osteonecrosis of femoral head (SONFH) is a serious complication of glucocorticoid overused. Recent evidence has demonstrated that circRNAs exert key pathophysiological roles in a variety of disease processes. However, the role of circRNA in SONFH remains largely unknown. The current study sought to evaluate how hsa_circ_0058122 affects SONFH in dexamethasone (DEX) treated human umbilical vein endothelial cells (HUVECs) model.

METHODS

RT-PCR was used to demonstrate the hsa_circ_0058122 expression level in Dex-treated HUVECs cells. The effects of hsa_circ_0058122 on HUVECs apoptosis were evaluated via overexpression plasmid and siRNA. Using dual-luciferase and fluorescence in situ hybridization assays, we demonstrated that hsa_circ_0058122 binds to miR-7974 thereby facilitating HUVECs apoptosis. Bioinformatics analysis and western blot were performed to confirm target genes of hsa-miR-7974.

RESULTS

In our previous work, we revealed the top 20 elevated circRNAs in SONFH patients were hsa_circ_0010027, hsa_circ_0058115, hsa_circ_0010026, hsa_circ_0058839, hsa_circ_0056886, hsa_circ_0056885, hsa_circ_0058146, hsa_circ_0058105, hsa_circ_0058112, hsa_circ_0058143, hsa_circ_0058102, hsa_circ_0058090, hsa_circ_0075353, hsa_circ_0058126, hsa_circ_0058130, hsa_circ_0058140, hsa_circ_0058122, hsa_circ_0058123, hsa_circ_0058103, and hsa_circ_0058121. Among these, hsa_circ_0058122 was finally selected for further investigation. We found hsa_circ_0058122 expression was markedly elevated in Dex-treated HUVECs cells, and the Dex-mediated HUVEC apoptosis was impaired in hsa_circ_0058122-silenced cells and increased in hsa_circ_0058122-overexpressing cells. hsa_circ_0058122 competitively binds to hsa-miR-7974, which in turn interacts with insulin-like growth factor binding protein 5 (IGFBP5).

CONCLUSIONS

hsa_circ_0058122/miR-7974/IGFBP5 was proposed to be a key regulatory pathway for SONFH. DEX treatment upregulated hsa_circ_0058122 expression in HUVECs, which sponged miR-7974, thereby increasing IGFBP5 expression, the hsa_circ_0058122/miR-7974/IGFBP5 axis contributed to the Dex-mediated apoptosis. These findings may identify novel targets for SONFH molecular therapy.

International Society of Blood Transfusion survey of experiences of blood banks and transfusion services during the COVID-19 pandemic

BACKGROUND AND OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has impacted blood systems worldwide. Challenges included maintaining blood supplies and initiating the collection and use of COVID-19 convalescent plasma (CCP). Sharing information on the challenges can help improve blood collection and utilization.

MATERIALS AND METHODS

A survey questionnaire was distributed to International Society of Blood Transfusion members in 95 countries. We recorded respondents' demographic information, impacts on the blood supply, CCP collection and use, transfusion demands and operational challenges.

RESULTS

Eighty-two responses from 42 countries, including 24 low- and middle-income countries, were analysed. Participants worked in national (26.8%) and regional (26.8%) blood establishments and hospital-based (42.7%) institutions. CCP collection and transfusion were reported by 63% and 36.6% of respondents, respectively. Decreases in blood donations occurred in 70.6% of collecting facilities. Despite safety measures and recruitment strategies, donor fear and refusal of institutions to host blood drives were major contributing factors. Almost half of respondents working at transfusion medicine services were from large hospitals with over 10,000 red cell transfusions per year, and 76.8% of those hospitals experienced blood shortages. Practices varied in accepting donors for blood or CCP donations after a history of COVID-19 infection, CCP transfusion, or vaccination. Operational challenges included loss of staff, increased workloads and delays in reagent supplies. Almost half of the institutions modified their disaster plans during the pandemic.

CONCLUSION

The challenges faced by blood systems during the COVID-19 pandemic highlight the need for guidance, harmonization, and strengthening of the preparedness and the capacity of blood systems against future infectious threats.

COVID-19 and the impact on blood availability and transfusion practices in low- and middle-income countries

BACKGROUND/CASE STUDIES

The coronavirus disease 2019 (COVID-19) pandemic disrupted the global blood supply. Low- and middle-income countries (LMICs) already experienced blood supply deficits that preceded the pandemic. We sought to characterize the challenges experienced during the pandemic, and adaptations, such as COVID-19 convalescent plasma (CCP).

STUDY DESIGN/METHODS

A cross-sectional survey explored blood availability, challenges, and adaptations. The survey contained 31 questions, e-mailed in English, French, or Spanish, to selected LMIC blood transfusion practitioners. Data acquisition occurred between October 28 and December 28, 2020. A mixed methods analysis followed.

RESULTS/FINDINGS

A total of 31 responses from 111 invitations represented 26 LMIC countries. Languages included English (22, 71%), Spanish (7, 22.6%), and French (2, 6.4%). Most respondents (29/31, 93.5%) collected blood; 58% also transfused blood (18/31). The supply of blood came from hospital-based blood donations (61%, 11/18); blood suppliers (17%, 3/18); and both sources (22%, 4/18). Collectively, 77.4% (24/31) of respondents experienced a decline in blood availability, ranging from 10% to 50%. Contributing factors included public fear of COVID-19 (21/24); stay-at-home measures (18/24); logistics (14/24); and canceled blood drives (16/24). Adaptations included increased collaboration within and between institutions (17/27), donor eligibility changes (21/31); social media or phone promotion (22/39); and replacement donation (3/27). Fifteen of 31 responses reported CCP donation (48.4%); CCP transfusion occurred in 6 (19.4%). The primary barrier was engaging recovered patients for donation (7/15).

CONCLUSION

Our survey describes challenges experienced by LMIC blood systems during the COVID-19 pandemic. While the decline in blood supplies was severe, adaptive measures included collaboration, outreach, and CCP programs.

Testing the circulation of expanded flaps-prevention of necrosis of expanded flaps (a clinic study)

BACKGROUND

Expanded flaps are commonly used in plastic surgery. Although expanded flaps are more resistant to hypoxia than unexpanded flaps, flap necrosis can sometimes occur, particularly with skin incisions of regular proportion. Distal skin necrosis of the expansion flap can be avoided by careful design; however, the utilization rate of the expansion flap decreases. Consequently, successfully avoiding distal skin flap necrosis remains a challenge. In this study, we designed a device for testing the circulation of the expanded flap that can decrease the risk of expanded flap necrosis, thus maximizing the use of an expanded flap.

METHODS

A total of 128 patients who underwent surgical repair between 2011 and 2019 and were retrospectively examined with the device for testing the circulation of the expanded flap were included in the study. The procedure included (1) making a device for testing the circulation, (2) implanting a skin expander, (3) injecting normal saline into the skin expander, (4) testing the circulation of the expanded flap, and (5) transferring the expanded flap to repair the defect.

RESULTS

One hundred forty-eight expanded flaps were implanted in 128 patients. The expanded flap that was transferred to repair the defect had no necrosis or infection. None of the expanded flaps with separated blood supply, which could be observed during operations, revealed complications. The survival rates of the expanded flap were increased by testing the circulation of the expanded flap. Expanded flaps designed by this method showed no swelling or paleness and no obvious temperature changes. In addition, the length-to-width ratio could be extended to 3:1.

CONCLUSIONS

Our proposed method resulted in an effective surgical procedure for the repair of tissue defects. This approach could effectively change the direction of the blood vessel of the expanded skin flap and prevent necrosis of the expanded flap, thus representing a practical way to increase the use of expanded flaps and the flap survival rate, making the whole expanded flap transfer procedure more convenient.

Impact of COVID-19 pandemic on the pattern of blood donation and blood safety: Experience from a hospital-based blood center in North India

INTRODUCTION:

Although coronavirus disease-2019 (COVID-19) pandemic does not result in increased blood needs, blood supply can be considerably compromised due to the unavailability of blood donors. The objective was to share our experience about blood donation patterns and concerns on blood safety during COVID-19 pandemic in India.

METHODS:

This was a retrospective study of approximately 4.5 months of data including both lockdown period (LD) and LD phases. LD phase was further subdivided into four phases of varying durations. Data of blood collected and various reasons for deferral of prospective donors were analyzed. The effectiveness of mitigation strategies adopted to maintain adequate blood inventory was also assessed. Events in transfusion services during the LD were compared with the pre-LD (P-LD) phase.

RESULTS:

The mean collection per day for WB and SDP was reduced by 70% and 50%, respectively, compared to pre-LD. Approximately 23% of WB and 27% of SDPs were collected on an appointment basis during LD. The proportion of indoor voluntary blood donation was increased by 7–8 times during LD compared to P-LD. Approximately 2% of total prospective donors screened were deferred after thermal scanning and due to risk of being infected with COVID-19. Donor deferrals due to high-risk behavior increased significantly in the LD phase compared to P-LD period.

CONCLUSION:

COVID-19 pandemic has a significant impact on the pattern of blood donation and blood safety. Transfusion services must develop appropriate plans to respond efficiently to various challenges posed by such pandemics.

Termination points of the facial artery-A meta-analysis

The facial artery (FA) is the main artery supplying the anterior face, making this artery a very important structure to consider while performing plastic and reconstructive procedures. The literature shows discrepancies in anatomical classifications and the frequency of occurrence of individual variations. Therefore, the goal of this meta-analysis is to provide surgeons with helpful knowledge about the variety of the termination of FA. Articles with data about the termination of the FA were found in major online medical databases such as PubMed, Scopus, Embase, Web Of Science, and Cochrane Library. A total of 1346 articles were initially evaluated by two independent reviewers. Out of those, 24 articles matched the required criteria, and were used in this meta-analysis. A total of 2119 studied FAs were included in this study. The FA termination patterns were divided into five previously classified types. The data show that the FA terminates most frequently as the lateral nasal or angular artery with the prevalence for this group being 69.81% (95% confidence interval [CI]: 59.83%-78.94%). Authors believe that this is the most accurate and up to date study regarding termination patterns and the prevalence of the FA. The results of this meta-analysis could provide a helpful tool for surgeons preforming plastic and cosmetic procedures, especially when injecting dermal fillers or choosing and preforming facial flaps. Detailed anatomical knowledge about the FA may prevent potential surgical complications.

Effect of eplerenone on choroidal blood flow changes during isometric exercise in patients with chronic central serous chorioretinopathy

PURPOSE

To investigate choroidal blood flow changes after isometric exercise in patients with chronic central serous chorioretinopathy nontreated or treated with mineralocorticoid receptor antagonists (MRA).

METHODS

Foveolar choroidal laser Doppler flowmetry parameters - velocity (ChVel), volume (ChVol) and blood flow (ChBF) - of 22 eyes of 22 treated patients, 16 eyes of 16 untreated patients and 19 healthy controls were measured during a squatting test. Treatment consisted in MRA administration (eplerenone 50 mg/day or spironolactone 50 mg/day). The experiment comprised three successive periods: 30 seconds of rest, 2 min of continuous squatting exercise, and 150 seconds of recovery. Significance levels were calculated using a generalized estimating equation.

RESULTS

During the squatting period, nontreated CSCR eyes had a similar change in ChVel (p = 0.8), ChVol (p = 0.8), ChBF (p = 0.5) and resistance to healthy eyes. Treated CSCR eyes exhibited significantly smaller changes in ChVel (-0.1 ± 11%, p = 0.04) than healthy eyes (6 ± 8%). No significant difference was found for ChVol and ChBF between the groups. The increase in ChVol from baseline in the nontreated CSCR group (4.4 ± 9%) was lower than that of treated group (6.7%±11%; p = 0.01). Finally, ChBF and ChVel changes in the CSCR groups were not significantly different.

CONCLUSIONS

No abnormalities were detected in the changes in ChBF parameters during increased ocular perfusion pressure in nontreated CSCR patients compared with controls. MRA treatment in CSCR patients induced a significant reduction in ChBVel and an increase in ChBVol in response to isometric exercise, suggesting that MRA exerts effects on choroidal vascular changes.

Avoiding the blood supply to the femoral head during cannulated screw fixation: A comparison of two techniques

Objectives

To compare the strength of the inverted triangle (IT) versus the L-shaped cannulated screw fixation technique for stabilizing a Pauwels 2 femoral neck fracture. To demonstrate the risk to the blood supply to the femoral head from a posterior-superior screw.

Methods

The IT construct was compared with the L-shaped design in 10 composite femurs. A Pauwels 2 fracture was made with a 5 mm gap. Each specimen was loaded over 5000 cycles, measuring angular/shear displacement then loaded to failure. The data were analyzed using Mann-Whitney U test. Three separate fresh frozen cadavers were injected with low-viscosity epoxy. The intraosseous bloody supply was inspected in each femoral head (no fixation, IT, L-shaped).

Results

There was no difference in angular (P = .3) or shear displacement (P = .99) between either screw design after cyclical loading. Also, there was not statistical difference in load to failure testing between either construct (P = .99). The average load to failure in the IT group was 3204.4 N. The average was 3180.2 N in the L-shaped design. We demonstrated the presence of the intraosseous portion of the lateral epiphyseal vessel in the specimen without screw fixation. This was preserved in the specimen with the L-shaped design but absent in the specimen following IT fixation.

Conclusions

The strength of the L-shaped construct was not statistically different than the strength of the IT design. The posterior-superior screw may put the main blood supply to the femoral head at risk and should be avoided.

Anatomical variations of the vascular supply of the cutaneous component of the serratus anterior myocutaneous flap: a systematic review

Although appealing from a reconstructive standpoint, the incorporation of the overlying skin in a serratus anterior muscle flap has not yet seen widespread use, due to considerations with its blood supply. In the present study, a systematic review of the literature has been performed, evaluating studies that investigated the vascular anatomy and variations of serratus anterior myocutaneous flap. The anatomy of the cutaneous blood supply, the size of the cutaneous territory, the design of the skin paddle and the reconstructive goals were analysed. The results showed that the main blood supply originates from the intramuscular anastomoses between intercostal artery perforators and the serratus artery branch in the form of choke vessels. Complementary perfusion from true intramuscular vessel anastomoses or from direct serratus artery cutaneous perforators could contribute to the skin blood supply but only in 25% of the cases. The design of the flap is elliptical with its long axis over the harvested muscle slips and maximum width is 6-8 cm. A myocutaneous serratus anterior flap could be applied in a variety of reconstructive fields, most commonly for head and neck defects. A delay procedure would considerably enhance the perfusion of the cutaneous component and improve the overall viability of the flap.

Pure Thalamic Infarct: 8-Year Follow-Up Study in a Hospital in China

Pure thalamic infarct is a rare lacunar stroke type, with little known about long-term outcomes. This 8-year, single-center, retrospective study evaluated the clinical background, etiology, Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification, and 8-year follow-up results in 27 patients with pure thalamic infarcts identified by MR diffusion-weighted imaging in Dalian, China. All patients presented chief complaints of limb weakness or sensory disturbances. Hypertension (24/27, 88.9%), diabetes (12/27, 44.4%), atrial fibrillation (1/27, 3.7%), hyperlipidemia (10/27, 37%), hyperhomocysteinemia (6/27, 22.2%), smoking history (10/27, 37%; 9/15, 60% for men; 1/12, 8.3% for women), and excessive alcohol consumption history (7/27, 25.9%; 7/15, 46.7% for men; 0 for women) were observed in our patient population. Based on TOAST classification, 1 patient had large artery atherosclerosis (7.14%), 23 had small vessel occlusion (SVO; 85.2%), and 3 patients were unidentified due to lack of cerebral angiography. The thalamic blood supply classification were as follows: 23 (85.2%), inferolateral territory; 1 (3.7%), tuberothalamic territory; 2 (7.4%), combination of tuberothalamic and paramedian arteries; 1 (3.7%), combination of inferolateral and paramedian arteries; 0, posterior choroidal arteries. During the 8-year follow-up, 3 patients died of colon cancer, multi-organ failure, and kidney failure, respectively; 7 presented with a recurrent stroke; while 10 recovered well with their risk factors under control. In conclusion, our cohort of pure thalamic infarcts were mainly due to SVO (TOAST), with hypertension as the main risk factor, and the inferolateral artery as the most implicated arterial territory. Less severe outcome or stroke recurrence are identified in long-term follow-up of pure thalamic infarcts. Other comorbidities would be cause of death in aged patients.

Hospital transfusion service operations during the SARS-CoV-2 pandemic: Lessons learned from the AABB hospital survey in preparation for the next infectious disease outbreak

Background

The SARS‐CoV‐2 pandemic disrupted hospital operations, affected the blood supply, and challenged the health care system to develop new therapeutic options, including convalescent plasma (CCP). The aim of this study is to describe and analyze blood supply fluctuations and the use of convalescent plasma in 2020.

Methods

AABB distributed a weekly and biweekly questionnaire through email to hospital‐based members (HBM).

Results

The survey was sent to 887 HBM with 479 unique respondents, most of the hospitals served pediatric and adult patients, and all states of the country participated, except Idaho and Vermont. Fifty four percent of HBM reported increased wastage in the early phase of the pandemic (May), which decreased to 4% by the end of June and throughout the rest of the year. The majority of HBM reported receiving alerts from their blood suppliers reporting blood shortages throughout the year. During March and April, only 12% of HBM were performing elective surgical procedures. The top reasons to delay procedures were: bed availability (28%); COVID‐19 caseload (23%; and blood availability (19%). By mid‐April, 42% HBM had transfused CCP and reported >24 h delay in getting the units; the vast majority obtained CCP using the Expanded Access Protocol, and later, the Emergency Use Authorization. HBM consistently prioritized the most severe patients to receive CCP, but the proportion of severely ill recipients fell from 52% to 37% between May and October, with an increase from 5% to 21% of HBM providing CCP transfusion early in the course of the disease.

Discussion

Blood utilization and availability fluctuated during the pandemic. The fluctuations appeared to be related to the number of COVID‐19 in the community. The use and regulatory landscape of CCP rapidly evolved over the first 8 months of the pandemic.

COX4I2 is a novel biomarker of blood supply in adrenal tumors

Background

Previous study has been reported that COX4I2 expression level demonstrated a positive correlation with microvessel density in pheochromocytomas (PCC) samples, suggesting that the expression of COX4I2 maybe related to blood supply level in other adrenal tumors as well. The aim of this study is to clarify the correlation of COX4I2 expression and blood supply in adrenal tumors.

Methods

A total of 84 patients were recruited, among which 46 was diagnosed as adrenocortical adenoma (ACA) and 38 was diagnosed as PCC. Contrast-enhanced CT values were used to evaluate the blood supply levels in those patients. The expression of mRNA was examined by quantitative real-time polymerase chain reaction (qPCR) and protein was detected by immunohistochemistry (IHC).

Results

The COX4I2 expression level in PCC group is significantly higher than that in ACA group (P<0.01). The expression of angiogenesis-related genes EPAS1, VEGFA and KDR mRNA in PCC group is higher than that of ACA group (P<0.05). Correlation analysis shows COX4I2 expression level is correlated with CT values (P<0.001), intraoperative blood loss (P<0.05) and operation time (P<0.05), and the expression of COX4I2 mRNA is correlated with EPAS1, VEGFA and KDR mRNA (P<0.01).

Conclusions

The results displayed a distinct expression level of COX4I2 between ACA and PCC, suggesting that COX4I2 is a novel biomarker of blood supply in adrenal tumors. This research also opens the possibility for further research on COX4I2 as a novel target for anti-tumor angiogenesis.

Improved access to the bone marrow space by multiple perforations of the alveolar bundle bone after tooth extraction-A case report

Objectives

The dental alveolus is lined by a thin cortical layer (“bundle bone”, “alveolar bone proper”, “cribriform plate”, “lamina dura”), that can impede access to the bone marrow and its vasculature. During unassisted socket healing, the alveolar bundle bone is gradually resorbed allowing tissue resources from the bone marrow to enter into the socket space. An optimized wound healing process, either during unassisted socket healing or during ridge preservation procedures, with autogenous bone and/or any bone/collagen substitute material, depends at least partly on an adequate vascularization of the socket space. This ensures sufficient recruitment of osteoblast and osteoclast precursor cells and facilitates fast bone regeneration and/or uneventful integration of the augmentation material.

Methods

The present technical note describes an easy treatment step after tooth extraction aiming to improve socket healing with or without any ridge preservation procedure, by facilitating an increased blood inflow into the dental alveolus. Specifically, after tooth extraction the alveolar bundle bone is perforated several times – mainly in a palatally/lingually – by a small round bur (diameter < 1 mm) extending into the trabecular bone.

Results and conclusions

By means of this relatively simple treatment step, an increased blood inflow into the alveolus is achieved after tooth extraction, which might enhance socket healing and corticalization of the entrance, and in turn result in a lower complication rate (e.g., dry socket), in an enhanced graft incorporation, and/or in a reduced loss of alveolar ridge volume.

Duplicated Anterior Choroidal Arteries: Literature Review and Clinical Implications

The anterior choroidal artery supplies important cerebral structures. One important variation of this vessel is duplication. However, little is reported on this anatomical variant and moreover, the prevalence of such a finding varies widely. Therefore, here, we review the literature regarding duplicated anterior choroidal arteries. Clinicians reviewing imaging of the brain, interventionalists, or neurosurgerons should be knowledgeable of variations of the anterior choroidal artery, including its duplication. A better understanding of this anatomy and embryology can improve diagnoses and patient outcomes following interventional or open neurosurgical techniques.

Revascularized Pyelo-Uretero-Cystoplasty in Patients with Chronic Bladder Outlet Obstruction Due to Ectopic Ureterocele: A Safe Surgical Technique with Superior Continence Outcomes

PURPOSE

To present the outcomes of revascularized pyeloureterocystoplasty with ureterocele unroofing in end stage bladder patients with duplex system and ureterocele.

METHODS

Thirteen patients with obstruction of intrauterine outlet from an ectopic obstructive ureterocele were included. Fourteen units of duplex systems underwent upper pole partial nephrectomy in conjunction with augmentation revascularized pyeloureterocystoplaty and ureterocele unroofing. The anterior and lateral walls of the ureterocele were excised before cystoplasty, and the resultant edges of the posterior wall were sutured to the bladder epithelium. Anastomosis of the upper pole vein and artery to the inferior iliac artery and the common iliac vein was performed. Detubularization of the whole ureter was performed with exception of the intramural ureteric part that kept tubularized for 'jet/turbulent' occurrence. Five patients (control group) underwent pyeloureterocystoplasty without revascularization. Patients underwent several evaluations in long-term follow-up.

RESULTS

Patients were all dry by day and night in our long-term follow-up. Urinary incontinence improved in patients with no need for re-augmentation technique. Vesicoureteral reflux subsided in all patients postoperatively except one, who was asymptomatic. After five years, median bladder capacity rose from 128.5 ml to 395 ml and bladder compliance showed significant improvement from 15 ml/cm H₂O to 29 ml/cm H₂O, in experimental group and remained stable for 24-36 months. Median bladder capacity did not rise significantly in control group.

CONCLUSION

Pyeloureterocystoplasty is an efficient choice in this type of patients, which may prevent the recurrence of hypocompliant bladders and prevent ischemia and subsequent fibrosis.

Quantitative analysis of distal femoral epiphysis blood supply in healthy newborns and infants with superb microvascular imaging

BACKGROUND/AIM

To determine the blood supply of the distal femoral epiphysis (DFE) using superb microvascular imaging in newborns and infants, and to investigate the correlation with ossification center (OC) length, gender and age.

MATERIALS AND METHODS

A total of 140 cases were evaluated in this study. The cases were divided into 2 groups of less than 90 days and over than 90 days. Cartilage blood supply was measured with vascularity index (%) (VI).

RESULTS

The mean OC length and median VI values were measured as 10.20±3.72 mm and 0.80% (0.58-1.50) for boys and 10.03±3.36 mm and 0.70 % (0.30-1.40) for girls, respectively. There was no significant difference in OC length and VI between genders. The mean OC length in Group II was significantly higher than in Group I (12.14±3.14 vs 8.09± 2.64) (p < 0.001). The median VI in Group I was higher than the cases in Group II (1.40% vs 0.40%) (p<0.001). There were positive correlations between age and OC length (r=0.716), negative correlations between age and VI (r=-0.822), and between VI and OC length (r=-0.657).

CONCLUSION

Quantitative reference values for DFE blood supply and OC length can guide the diagnosis and follow-up of many skeletal diseases.

OPTIMIZATION OF RED BLOOD CELL UNIT STORAGE DURING SARS-COV-2 PANDEMIC: ADOPTING NEW STRATEGIES TO ENSURE SUPPLY IN A DECENTRALIZED BLOOD BANK IN BRAZIL

Introduction

As coronavirus disease-2019 (COVID-19) spread worldwide and social restrictions were intensified, difficulties in blood supply were expected to result in a shortage of blood donors, logistic issues and a change in blood consumption. Consequences could be detrimental to the meeting of the blood supply demand, especially in a decentralized blood bank in the State of São Paulo responsible for providing blood to more than 100 hospitals, mostly of the public health system. Aiming to minimize negative effects and focusing on maintenance of the blood supply, a different approach was discussed and adopted.

Materials and Methods

Briefly, strategies were related to monitoring and promoting measures to achieve a positive RBC unit balance. Thus, the number of donors, transfusions, RBC unit inventory, RBC unit loss and RBC units within up to 5 days from the expiration date were evaluated.

Results

Several strategies were adopted to ensure sufficient availability of RBC units: blood donation was improved with social media and extra blood collections, a restrictive transfusion protocol was implemented, a new logistic process to use RBC units closer to the expiration date was established and non-isogroup transfusions were avoided.

Conclusion

Altogether, described strategies were crucial to optimize blood storage during the pandemic. Investing in monitoring and logistics contributed to a positive RBC unit balance and conserving these strategies could be useful.

Ultrasonographic tissue perfusion analysis at implant and palatal donor sites following soft tissue augmentation: A clinical pilot study

AIM

To describe the application of power Doppler Ultrasonography (US) for evaluating blood flow at implant and palatal donor sites following soft tissue augmentation with the connective tissue graft (CTG).

MATERIALS AND METHODS

Five patients exhibiting a peri-implant soft tissue dehiscence received treatment with a coronally advanced flap and corresponding CTG. Power Doppler US was used for assessing blood volume at baseline, 1 week, 1 month, 6 months and 12 months post-surgery for assessing blood-flow dynamics at the implant and palatal donor sites. The speed-weighted and power-weighted colour pixel density (CPPD) were computed from colour velocity (CV) and colour power (CP), respectively.

RESULTS

A mean increase in CV of 199.25% was observed at the midfacial region of the implant sites after 1 week compared to baseline. CV and CP were increased in all sites at 1 week and 1 month. At 6 and 12 months, the mean CV appeared lower than baseline at the implant sites. CCPD was increased at the palatal donor sites and at the great palatine foramen areas at the 1-week and 1-month post-operative evaluations.

CONCLUSIONS

Power Doppler US is a non-invasive and valuable tool for estimating tissue perfusion and CPPD variation during different phases of intra-oral soft tissue graft healing.

Impact of the COVID-19 pandemic on blood supply and demand in the WHO African Region

Background and Objectives

The coronavirus disease 2019 (COVID‐19) affected millions of people worldwide and caused disruptions at the global level including in healthcare provision. Countries of the WHO African region have put in place measures for the COVID‐19 pandemic containment that may adversely affect blood system activities and subsequently reduce the supply and demand of blood and blood components. This study aims to assess the impact of the COVID‐19 pandemic on blood supply and demand in the WHO African Region and propose measures to address the challenges faced by countries.

Materials and Methods

A survey questionnaire was sent to all 47 countries in the WHO African Region to collect information on blood supply and demand for the first 5 months of 2019 and 2020, respectively, and on COVID‐19 Convalescent Plasma therapy in September 2020.

Results

Thirty‐seven countries provided responses. The total number of blood donations dropped in 32 countries while it increased in five countries. The proportion of blood drives also decreased in 21 countries and increased in nine countries. The blood requested and issued for transfusion decreased for blood demand and for blood issued for transfusion in 30 countries. Ten countries reported some activities of convalescent plasma. However, very few units of this product collected have been transfused to COVID‐19 patients.

Conclusion

The COVID‐19 pandemic has led to a reduction of blood related activities in the region, including the supply and demand. Countries preparedness plans for health emergencies need more emphasis to maintaining blood stock.

A novel transverse talar tunnel achieved less vessel damage and better drilling safety for ATFL reconstruction: a cadaveric study with three-dimensional microCT

PURPOSE

To introduce a novel transverse tunnel (TT) in anterior talofibular ligament (ATFL) reconstruction, and assess whether it was superior to the tunnels currently used.

METHODS

Thirteen fresh cadaveric lower extremities were perfused with lead-based contrast. Talar tunnels were drilled from the ATFL insertion in the following directions: transversely towards the medial side (TT), towards the talar neck (TNT), and towards the anterior, distal, and posterior points of the medial malleolus (AMMT, DMMT, and PMMT, respectively). MicroCT was used to reconstruct the tali, and virtual transosseous and 20-mm blind-ended tunnels were generated. The graft bending angle, vascular compromise caused by the tunnels, and the minimum distances from the tunnels to the chondral surfaces were evaluated.

RESULTS

The bending angles between the ATFL and the TT, TNT, AMMT, DMMT, and PMMT were 47.3±7.9°, 41.5±7.7°, 57.0±6.0°, 63.9±11.7°, and 87.9±6.2°, respectively. The proportion of damaged intraosseous vessels was significantly less for the TT (7.8±2.7%) compared with the AMMT (10.0±5.2%), DMMT (15.5±6.5%), and PMMT (16.9±3.9%). Both the TNT and the AMMT carried a high risk of joint penetration, with respective minimum distances of 2.2±1.7 mm and 1.4±1.0 mm from the tunnel to the cartilage; in contrast, the TT, DMMT, and PMMT had larger safety margins, with minimum distances of 5.4±0.8 mm, 8.9+2.7 mm, and 6.0±1.2 mm. The blind-ended tunnels caused less vascular compromise and had larger minimum distances to the cartilage (better drilling safety) than the transosseous tunnels for all tunnel directions.

CONCLUSION

The TT achieves a superior graft bending angle and intraosseous blood supply protection than the AMMT, DMMT, and PMMT, and is less likely to result in cartilage damage than the TNT. The 20-mm blind-ended tunnels achieve less vessel damage and better drilling safety than transosseous tunnels.

Vascularization of the human intervertebral disc: A scoping review

Intervertebral discs (IVDs) are often referred to as the largest avascular structures of the human body, yet a collective resource characterizing the vascularization of the IVD does not exist. To address this gap, the objective of this study was to conduct a comprehensive search of the literature to review and summarize current knowledge of the prevalence and localization of blood supply in human IVDs, with a scoping review. A comprehensive search of peer-reviewed publications on the topic of IVD vascularization in humans was conducted across six electronic databases: PubMed, EMBASE, MEDLINE, Scopus, Web of Science, and BIOSIS Previews. Studies of humans were included regardless of age, sex, ethnicity, and health status, with the exception of IVD herniation. Two independent reviewers screened titles and abstracts and full-texts according to eligibility criteria. The review was conducted and reported according to Preferred Reporting Items for Systematic Reviews Extension for Scoping Reviews guidelines. Our search yielded 3122 articles, with 22 articles meeting the inclusion criteria. The study samples ranged in age from fetal to >90 years and included both sexes, various health statuses, and used different methodologies (eg, histology, medical imaging, and gross dissection) to assess vasculature. Overall, consistent observations were that (a) the nucleus pulposus of the IVD is avascular throughout life, (b) both the cartilage endplates and annulus fibrosus receive considerable blood supply early in life that diminishes over the lifespan, and (c) vascular ingrowth into the cartilage endplates and inner layers of the annulus fibrosus is commonly associated with damaged or disrupted tissue, irrespective of age. Histology and immunohistochemistry are often used to report vascularization of the IVD. The body of the current literature suggests that the IVD should not be generalized as an avascular tissue. Instead, vascularization of the IVD differs based on the constituent tissues, their age, and state of degeneration or damage.

Experimental Study on Evaluation of Blood Supply Level and Embolization Ratio of Liver Cancer Based on I-Flow Software

Objective:

To confirm the feasibility and accuracy of the method for evaluating blood supply and embolization rate of liver cancer based on I-flow software through animal experiments and clinical study.

Methods:

Rabbits underwent selective angiography under different perfusion conditions in the same kidney. The blood supply level was evaluated by I-flow software method. The results were analyzed for coefficient of variation. Thirty patients with liver cancer who underwent selective hepatic artery embolization were enrolled. The mathematical methods and 3 diagnostic specialists were used to evaluate the preoperative blood supply level and embolization rate. The results were recorded and the results were tested for consistency.

Results:

Animal experiments confirmed that the blood supply level analysis method designed by the research team was consistent under different contrast conditions (including total contrast agent, contrast medium perfusion rate, and limiting pressure) (coefficient of variation: 8.55%). The mathematical calculation results of preoperative blood supply level and embolization ratio of liver cancer are consistent with the average value of visual judgment results of diagnostic experts. (Preoperative blood supply level: concordance coefficient = 0.284, P = 0.003; embolization ratio: concordance coefficient = 0.218, P = 0.011).

Conclusion:

Based on I-flow software, the mathematical calculation method designed by this research group can effectively estimate the preoperative blood supply level of liver cancer and the embolization rate of single vascular embolization treatment, which can provide reliable data support for embolization treatment of liver cancer.

Methylene blue usage for determining accessory artery ligation in donor kidneys

Objectives. We present a technique for determining whether to ligate or preserve accessory arteries in donor kidneys before implantation. Methods. Forty-three living-related donor kidneys in patients from January 2014 to February 2018 at our institution were included, all of which had dual arteries without the same stem. Among them, 19 cases of accessory arterial blood supply were evaluated using methylene blue (MB) perfusion, and accessory arteries supplying less than 10% of the total MB perfusion volume were ligated. The other 24 cases were assessed using a conventional method in which arteries with diameters less than 2 mm were ligated. The back-table surgical time, Doppler ultrasonography index, renal function and complications were compared between the 2 groups. Results. All patients underwent successful kidney transplantation. The back-table surgical time in the MB group was longer than that in the conventional group (42.70 ± 4.70 min vs 34.64 ± 5.30 min, P < .05). The serum creatinine level in the MB group was significantly lower than that in the conventional group 1 month after the operation (103.15 ± 19.26 μmol/L vs 119.17 ± 28.32 μmol/L, P < .05). No differences in the Doppler ultrasonography index or postoperative complications were noted. Conclusions. MB perfusion provides an easy and effective method to make decisions regarding arterial ligation and helps preserve renal function without increasing the number of complications after transplantation.

Hepatocellular Carcinoma With Different Areas of Right Retroperitoneal Space Invasion: Evaluation of Transcatheter Arterial Chemoembolization Efficacy and Blood Supply Characteristics

Purpose

To evaluate the therapeutic efficacy of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with different areas of right retroperitoneal space (rRPS) invasion and analyze the blood supply.

Methods

This retrospective study enrolled 41 patients with HCC with different areas of rRPS invasion treated with TACE, including 22 HCCs with superior aspect of the right perirenal space (SARPS) invasion and 19 HCCs with right anterior pararenal space (RAPS) invasion. The overall response rate (ORR) and disease control rate (DCR) were analyzed. The prognostic factors for overall survival (OS) after TACE were determined. The blood supply characteristics of HCC with different areas of rRPS invasion were analyzed with arteriograms.

Results

All patients underwent 2.8 ± 1.8 TACE sessions over 25.0 ± 21.9 months. The median OS was 29.0 months for patients with SARPS invasion and 12.0 months for patients with RAPS invasion (P = 0.004). Only the invaded area of the rRPS was an independent prognostic factor for OS [hazard ratio (HR), 2.833; 95% CI, 1.297–6.188; and P = 0.009). The ORR and DCR were significantly higher in the group with SARPS invasion than in the group with RAPS invasion (ORR: 63.6% vs 31.6%, P = 0.041; DCR: 77.3% vs 47.4%, P = 0.047). Initially, HCC with SARPS invasion were supplied by the hepatic artery (HA; n = 8) and both the HA and extrahepatic collateral vessels (EHCs; n = 14); HCC with RAPS invasion were supplied by the HA (n = 10) and both the HA and EHCs (n = 9); as the TACE sessions increased, the tumor-feeding vessels shifted from the HA to both the HA and EHCs, and even EHCs could be the only blood supply. Rare EHCs appeared earlier and more frequently in the RAPS group than in the SARPS group.

Conclusion

The efficacy of TACE differed for HCC with different areas of rRPS invasion, and the median OS, ORR and DCR were significantly better in the SARPS group than in the RAPS group. Different common EHCs supplied HCCs with different areas of rRPS invasion, while other rare EHCs appeared more frequently in the RAPS group.

Anatomy of Ankle Syndesmotic Ligaments: A Systematic Review of Cadaveric Studies

Diagnosis and management of isolated syndesmotic injuries are controversial and highly debated. Hence, the aim of this study is to explore and gain the current understanding pertaining to detailed anatomy of syndesmotic ligaments through a systematic review of published cadaveric studies. A systematic review was conducted online for literature published in English using PubMed and Google Scholar, as per PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, up to April 30, 2019. Predefined eligibility criteria were applied, and the data thus compiled was analyzed. Study quality was assessed based on Quality Appraisal for Cadaveric Studies (QUACS) scale. A total of 12 studies reporting 365 ankles were included in this review. Considerable inconsistency in the naming and description of syndesmotic ligaments was observed, with only 2 studies reporting the vasculature of the ligaments. Hence further investigation of the anatomy of the syndesmotic ligaments is recommended so as to better inform clinical practice, as awareness of anatomy is critical for assessment, healing, and successful surgical management.Levels of Evidence: Level III: Systematic review of anatomical dissections.

[Effect of vascularized peroneus longus tendon graft reconstruction on anterior cruciate ligament insertion in rabbits]

OBJECTIVE

To investigate the effect of vascularized peroneus longus tendon graft reconstruction on anterior cruciate ligament (ACL) insertion in rabbits.

METHODS

Eighty healthy New Zealand white rabbits were harvested to prepare ACL injury models and randomly divided into two groups ( n=40). The ACL was reconstructed with vascularized peroneus longus tendon graft in group A and peroneus longus tendon graft without blood supply in group B. The survival of animals and the healing of incision were observed after operation; the grafts were taken for gross and histological observations at 4, 8, and 16 weeks; the biomechanical test of the grafts was carried out to record the maximum tensile strength and incidence of ACL insertion rupture at 8 and 16 weeks.

RESULTS

All animals survived until the experiment completed. General observation showed that the tunnel was combined with grafts, the vascular infiltration was abundant, and no obvious boundary between the tunnel and grafts existed at 16 weeks in group A; there was still an obvious boundary between the tunnel and graft in group B. Histological observation showed that the collagen fibers between tendon and bone in group A increased gradually, the dense fiber connection was formed, and the "tidal-line" like structure similar to the normal ACL insertion was formed at 16 weeks; but the"tidal-line" like structure was not obvious in group B. Biomechanical test showed that there was no significant difference in the incidence of ACL insertion rupture at 8 and 16 weeks between group A and group B ( P=0.680; P=0.590), but the maximum tensile strength at 8 and 16 weeks were higher in group A than in group B ( t=18.503, P=0.001; t=25.391, P=0.001).

CONCLUSION

The vascularized peroneus longus tendon graft for ACL reconstruction can obviously promote the outcome of the ACL insertion.

Vascular Anatomy of the Inferior Turbinate and Its Clinical Implications

BACKGROUND

Published reports on the vascular anatomy of the inferior turbinate (IT) are limited. Historical papers report the IT artery as a tributary off the posterior lateral nasal artery (PLNA), but this has not been our clinical experience.

OBJECTIVE

The purpose of this study was to examine the arterial blood supply to and the branching pattern within the IT. We discuss this is the context of IT surgery and relate it to postoperative bleeding complication rates.

METHODS

Endoscopic dissection was performed on 16 cadaver heads (24 sides) to determine the origin of the IT artery. Intraoperative surgical videos were analyzed in 50 patients to uncover the vascular branching pattern within the IT. A retrospective review of bleeding complications in patients undergoing IT reduction surgery was also conducted.

RESULTS

In 17 of 24 sides (70.8%), the IT artery arose either exclusively (54.2%) or partly (16.6%) off the descending palatine artery (DPA). As a branch off the DPA, the IT artery exited the pterygopalatine fossa through a foramen located 7.7 ± 3.0 mm from posterior edge of the IT, 8.4 ± 3.1 mm above the nasal floor and 1.6 ± 2.1 mm below the insertion of the IT bone onto the lateral nasal wall. The mean number of arteries cascading within the IT was 2.7 ± 0.5. Moreover, 112 patients underwent IT reduction surgery and 2 (1.8%) experienced postoperative epistaxis.

CONCLUSION

The IT artery has major contributions from the DPA. Most commonly 3 arteries branch within the IT. Knowledge of this vascular anatomy may minimize bleeding associated with IT reduction surgery.

A Case of Subclavian Artery Thrombosis

Subclavian artery thrombosis is a rare cause of upper limb ischemia resulting from occlusion of the upper extremity blood supply. Symptomatic presentation is quite rare and therefore remains underdiagnosed by physicians. Possible catastrophic clinical consequences necessitate prompt rectification of the underlying disease and risk factors. Treatment modalities are often selected depending on the severity of clinical presentation. Herein, we present a case of a 52-year-old man who presented to the outpatient department with a one-month history of pain and blackish discoloration of the right-hand digits, palm, and wrist. His social history also revealed a chronic 30-year history of smoking. At the time of consultation, his past medical history was insignificant for chronic medical disease and hospitalizations. However, inpatient investigations diagnosed him with diabetes. Physical examination revealed a bad odor emanating from the devitalized affected right hand. Neurological examination was significant for the loss of pain sensation in the right hand. Furthermore, the right radial and brachial pulses were also absent (grade 0). Right upper extremity angiography revealed the occlusion of the right subclavian artery and right brachial artery. Above elbow amputation was advised and performed based on angiogram scans and physical examination findings. We report a case of subclavian artery thrombosis in an undiagnosed diabetic with a chronic history of smoking. Our report details the common etiology, clinical presentation, and management options feasible for this clinical entity. Furthermore, it reiterates the importance of counseling patients to attend annual healthcare doctor visits.