Ischemic Skin Necrosis Research Articles

The “dark” side of terlipressin: a case report of ischemic skin necrosis and review of literature

BackgroundTerlipressin is a commonly used drug in cirrhotic patients with acute variceal bleed (AVB) due to its vasoconstrictor effects. Ischemic complications are uncommon adverse events associated with worse outcomes.Case presentationWe present a case of alcohol-related cirrhosis, who was started on terlipressin for AVB. However, he developed bilateral lower limb gangrene with ischemic skin necrosis and ultimately succumbed to death.ConclusionAlthough ischemic adverse events are uncommon with terlipressin, it is important to be aware of these complications as they may be severe and potentially life threatening.

Clinical Study of Liposuction Combined with Subareolar Incision Adenectomy for Gynecomastia

Objective: To investigate the clinical effect of liposuction combined with subareolar incision glandectomy in the treatment of Simon Grade Ⅲ adipo-glandular gynecomastia (GYN). Methods: From March 2021 to March 2022, the data of patients with Simon Grade Ⅲ adipo-glandular GYN treated by liposuction combined with glandectomy in the Department of Plastic Surgery, Zhongshan Hospital Affiliated to Dalian University and Henan Plastic Surgery and Aesthetic Hospital were retrospectively analyzed. Based on the medical records, color ultrasound was performed on the patient’s breast before surgery, which was determined to be GYN (more than 50% glandular tissue). A 3 mm long incision was made at the lower boundary of the surgical range, through which the adipose tissue in the hypertrophic region of the breast was repeatedly aspirated until a satisfactory thickness was achieved. The residual glandular tissue was removed by a semicircular arc incision under the areola, and then the areola incision was sutured in position. The blood flow, sensation, and wound healing of bilateral nipples and areola were observed after surgery, and the morphology of bilateral thorax and scar of incision were followed up. Results: A total of 15 GYN patients aged 18 to 35 years with body mass index of 23.8 to 26.5 kg/m2 (mean = 24.8 kg/m2) were included in this study. The average intraoperative liposuction volume of unilateral breast was 170 mL (150–200 mL), the average glandectomy volume was 115 g (95–125 g), and the average blood loss was about 40 mL (15–75 mL). Postoperative hypertrophic breast volume decreased significantly, and no complications such as hematoma, infection, skin ischemic necrosis, or sensory disturbance occurred in the nipple and areola, during the healing process. The patients were followed up for 3 to 6 months, and the bilateral thorax was smooth, symmetrical, and natural in contour. The incision was concealed, and the scar was not obvious. Conclusion: Liposuction combined with subareolar incision glandectomy in the treatment of Simon Grade Ⅲ adipo-glandular GYN is safe. The postoperative chest contour is smooth and natural, and the scar is small and invisible, which achieves good aesthetics.

Calciphylaxis and its co-occurrence with connective tissue diseases.

Calciphylaxis, also known as calcific uremic arteriopathy, is a rare calcification syndrome that presents as ischemic skin necrosis and severe pain. It has a high mortality rate and is characterised by calcification of the small and medium arteries and micro-thrombosis. Calciphylaxis mainly occurs in patients with end-stage renal disease. In recent years, there have been an increasing number of cases of calciphylaxis associated with connective tissue diseases. Given the absence of clear diagnostic criteria for calciphylaxis thus far, an early diagnosis is crucial for designing an effective multidisciplinary treatment plan. In this article, we review the research progress on calciphylaxis and describe its characteristics in the context of connective tissue diseases.

Complications of Totally Implantable Central Venous Catheters (Ports) Inserted via the Internal Jugular Vein Under Ultrasound and Fluoroscopy Guidance in Adult Oncology Patients: A Single-Center Experience.

IntroductionIn this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed.Material and methodsEight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted.ResultsA total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection.ConclusionPlacement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.

788 Baicalin accelerates wound healing in a murine model of ischemic pressure ulcer lesions

Pressure ulcers are a common skin disease that affects the elderly and patients with perceptual or mobility disorders. A pressure ulcer is an ischemic skin necrosis or ulcer that occurs when pressure is applied to a region of the body for an extended period of time, producing poor blood circulation and a lack of oxygen and nutrients. Natural origin pharmaceuticals account for more than half of all modern drugs, and they play an essential role in drug development programs. Baicalin is one of the most important flavonoids in plants, and it is responsible for their pharmacologic effects. This type of natural ingredients provide a wide range of pharmacologic benefits, including anti-inflammatory and anti-tumor properties. The two key processes linked with wound development and effecting the wound healing process with baicalin antioxidant in treating pressure ulcers are oxidative stress and inflammation. However, the effect of baicalin on wound healing in pressure ulcers has not been thoroughly investigated. The wound healing efficacy of baicalin in treating pressure ulcers in a murine pressure ulcer model is investigated in this study. First, the development of 1, 2, 3, 4 stage pressure ulcers after ischemia-reperfusion(I/R) cycle in a murine mouse model. In this model, we investigated the effectiveness of a baicalin in the wound healing of pressure ulcers. We found that baicalin promotes granulation tissue formation, accelerated wound closure, reduced proinflammatory cytokines production and inducing the differentiation of keratinocytes were observed. We expect that this study will contribute to the potential wound therapeutic agent for a pressure ulcer patient.

Clinical characteristics and treatment of terlipressin-induced ischemic skin necrosis: A synthesis of 35 literature reported cases.

The clinical features of terlipressin-induced ischemic skin necrosis are unknown. The purpose of this study is to explore the clinical features of terlipressin-induced skin necrosis. We searched Chinese and English databases to collect case reports of terlipressin-induced skin necrosis for retrospective analysis. A total of 42 patients (31 males and 11 females) from 35 studies were included, with a median age of 54 years (range 0.17-84). The onset of skin ischemia ranged from a few hours to 21 days. The most common clinical manifestations were bulla (15 cases, 35.7%), cyanosis (12 cases, 28.6%), necrosis (11 cases, 26.2%), and purpura (10 cases, 23.8%). The following were often affected: the legs (26 cases), 61.9%), abdomen (13, 31.0%), scrotum (10 cases, 23.8%), feet (10 cases, 23.8%), upper extremities (8 cases, 19.0%), and hands (7 cases, 16.7%). Skin biopsy showed fibrin thrombus (7 cases, 38.9%), nonspecific inflammation (6 cases, 33.3%), and necrosis (10 cases, 55.6%). After discontinuation of terlipressin, skin symptoms improved in most patients. Ischemic skin necrosis is a rare and serious adverse effect of terlipressin. Patients receiving terlipressin therapy should be monitored closely for terlipressin-related ischemic complications. Terlipressin should be discontinued immediately if ischemic complications occur.

Case Report: Idiopathic Subcutaneous Thrombotic Vasculopathy

Lower extremity ulcers have significant morbidity, with treatment determined by the underlying disorder. Reported is a 32-year-old female presenting with small skin nodules and bruises across her legs 4 weeks following her second COVID vaccination. These lesions progressed into large, necrotic ulcers over several months. Initial work-up showed widespread pannicular thrombotic vasculopathy with ischemic skin necrosis. The tissue was negative for calcification on Von Kossa histochemistry, and a working diagnosis of subcutaneous thrombotic vasculopathy was suggested. The ulcers progressed despite treatments with corticosteroids, therapeutic anticoagulation, intravenous immunoglobulin, plasmapheresis, sodium thiosulfate, wound care, and repeat debridement. Later debridement specimens demonstrated rare vascular and pannicular calcifications. This finding supports the hypothesis that subcutaneous thrombotic vasculopathy is a precursor to calciphylaxis, the patient’s current working diagnosis. However, based on the patient’s entire clinical picture, a definitive diagnosis has yet to be found. This report highlights the challenges of working with rare diseases and the importance of multidisciplinary cooperation.

Penile calciphylaxis in a patient with end-stage renal disease and chronic hemodialysis: a case report

Penile calciphylaxis is a rare and highly morbid condition mainly affecting diabetic patients with chronic renal failure (CRF). It is characterized by ischemic skin ulceration and necrosis secondary to dystrophic calcification of the subcutaneous penile tissue and penile arterioles. We report a 52-year-old male with a 6-year history of diabetes mellitus and CRF on hemodialysis, who presented with a painful penile necrotic lesion in the last three weeks. He firstly treated with medical treatment, which was failed. Then underwent total penectomy. The histopathology result confirmed the diagnosis of penile calciphylaxis. Unfortunately, he passed away due to septic shock and multisystem organ failure ten days after surgery. In conclusion, the diagnosis of penile calciphylaxis must be evoked in the presence of any minimal necrotic penile lesion in a patient with CRF; this will initiate quick medical and/or minimally invasive surgical treatment to improve the patient's prognosis and avoid serious complications.

Bullous skin lesions in cirrhotic patients receiving combination of terlipressin and noradrenaline: a case series

Background and Aim: Effect of terlipressin on systemic circulation causing severe ischemic events like myocardial ischemia, ischemic colitis and skin necrosis are rare. We present a case series of four patients, who developed blistering skin disease after administration of combination of Terlipressin and noraenalin both. We aimed to look for risk factors, onset, progress and outcome of bullous skin lesions in cirrhotic patients receiving combination of Terlipressin and Noradrenaline. Methods: We have included patients of liver cirrhosis who were started on Terlipressin for hepato-renal syndrome or variceal bleeding with Noradrenaline for shock and developed skin blisters. Results: Series includes four middle aged male patients of cirrhosis of liver with three patients had alcohol and one patient had NASH as etiology. Three patients had septic shock with HRS, while one had massive variceal bleed with hypotension. All four developed blistering within 2-4 days of starting vasopressors. Terlipressin was given in intravenous bolus doses (1 mg thrice to four times a day) while noradrenaline was given as infusion. Blisters were common in extremities, were extensive, and one even progressed to ischemic necrosis of skin. Blistering was more extensive with higher doses of terlipressin and noradrenaline. Sepsis as etiology for blisters was excluded in all by testing the fluid within the bullous lesion and negative blood cultures. Terlipressin was stopped in all, after which eruption of new lesions halted and skin lesions healed completely. Conclusions: Risk of bullous skin lesion increases when terlipressin is given as bolus doses as compared to infusion , when used in higher doses and in combination with noraenalin. In addition to the obesity, NAFLD, and ischemic heart disease, it was important to think that alcohol use was a possible risk factor for progressive ischemic necrosis due to terlipressin. Majority of patient’s skin lesions recovers after stopping terlipressin.

375 Baicalin accelerates wound healing in a mouse model of pressure ulcer

Pressure ulcers are one of the common skin diseases which usually occur in older people and patients with perceptual or movement disorder. A pressure ulcer is ischemic skin necrosis or ulcers that occur when pressure is continuously applied to a part of the body, causing impaired blood circulation in that part, resulting in a lack of oxygen and nutrient supply. Over 50% of all modern drugs have a natural origin, and they play an essential role in drug development programs. Baicalin is one of the significant flavonoids responsible for the pharmacologic actions of antioxidants such as anti-inflammation, anti-tumour.

Clinical effects of anterograde sural neurovascular flap in repairing skin and soft tissue defect around the knee

Objective: To explore the clinical effects of anterograde sural neurovascular flap in repairing skin and soft tissue defect around the knee. Methods: Nine patients with skin and soft tissue defect around the knee admitted to Beijing Fengtai YouAnMen Hospital from May 2011 to December 2018, were included in this retrospective descriptive study, including 8 males and 1 female, aged 16 to 65 years. The wound area after debridement ranged from 8 cm×5 cm to 18 cm×10 cm. Anterograde sural neurovascular flap was used to repair the wounds in 9 patients, with the area ranging from 9 cm×6 cm to 20 cm×12 cm. The donor sits of flaps in 2 patients were closed and sutured directly, and the donor sits of flaps in 7 patients were repaired with medial split-thickness skin graft of the ipsilateral thigh. The flap survival, complications, and follow-up after operation were recorded. Results: The flaps survived and the blood supply was good in 8 patients and the wounds were closed. One patient developed skin ischemic necrosis which was cured after three weeks of dressing change. All the skin grafts in the donor site of flap in 7 patients survived. In 6 months to 5 years of follow-up after surgery, the skin flap had good texture, color, and shape, and normal sensation. Except for one patient whose knee had poor recovery of function, the knee joint function of the other patients recovered well. Conclusions: The anterograde sural neurovascular flap has the advantages of high survival rate, satisfactory appearance and functional recovery post surgery, and is an ideal flap for repairing the skin and soft tissue defect around the knee.

Nicolau Syndrome Following Intralesional Sclerotherapy: A Dreaded Complication of a Simple Office Procedure

Introduction: Nicolau syndrome is an iatrogenic dreaded adverse skin reaction leading to ischemic necrosis of skin and underlying tissue after parenteral drug injection. The etiopathogenesis is poorly understood. However, inflammation, reflex vasospasm, and thrombo-embolic occlusion of blood vessels, including arterioles and arteries, are suggested as the cause of ischemia. Case Presentation: We report a 12-year-old girl who developed Nicolau syndrome after a simple office procedure of intralesional sclera therapy with sodium tetradecyl sulfate for a apyogenic granuloma on her right index finger. Three days later, she reported complaints of excruciatingly painful swelling with bluish discoloration of the right hand involving the palm, entire index, middle, and ring fingers, and distal part of the little finger. Nicolau syndrome was documented after intramuscular injections of drugs. Nevertheless, there are very few reports of Nicolau syndrome following post intralesional sclerotherapy. Conclusions: Sclerotherapy is a simple office procedure routinely performed by health care professionals (e.g., dermatologists and surgeons), and awareness about its dreaded entity is key. Stringent precautions and prompt management can prevent unfavorable complications. Additionally, prudent patient selection and detailed counseling with explicit informed consent regarding Nicolau syndrome are imperative while planning any parenteral drug injection or intralesional sclerotherapy to avoid litigation.

Treatment of diabetic foot with vaccum sealing drainage combined with transverse tibial bone transport

To summarize the effectiveness and experience of Wanger grade 3-5 diabetic foot treated with vacuum sealing drainage (VSD) combined with transverse tibial bone transport. Between March 2015 and January 2018, 21 patients with refractory diabetic foot who failed conservative treatment were treated with VSD combined with transverse tibial bone transport. There were 15 males and 6 females, aged 55-88 years (mean, 65 years). The diabetes history was 8-15 years (mean, 12.2 years). The duration of diabetic foot ranged from 7 to 84 days (mean, 35.3 days). The size of diabetic foot ulcer before operation ranged from 2 cm×2 cm to 8 cm×5 cm. According to Wanger classification, 8 cases were rated as grade 3, 11 cases as grade 4, and 2 cases as grade 5. Among the 21 cases, angiography of lower extremity before operation was performed in 5 cases, CT angiography of lower extremity in 16 cases, all of which indicated that the arteries below the knee were narrowed to varying degrees and not completely blocked. Preoperative foot skin temperature was (29.28±0.77)℃, C-reactive protein was (38.03±31.23) mg/L, leukocyte count was (9.44±2.21)×10 9/L, and the visual analogue scale (VAS) score was 6.8±1.5, and ability of daily living (Barthel index) was 54.3±10.3. After operation, 2 patients with Wanger grade 4 and smoking history failed treatment and had an major amputation (amputation above ankle joint) at 30 days and 45 days after operation, respectively. One patient with Wanger grade 5 and chronic heart failure died of cardiac arrest at 60 days after operation. The remaining 18 patients were followed up 6-24 months (mean, 9.2 months). The external fixator was removed at 40-62 days after operation, with an average of 46 days. All the wounds healed, with a healing time of 50-120 days (mean, 62.5 days). The pain of 18 patients' feet was relieved obviously, and there was no recurrence of ulcer in situ or other parts. There was no complication such as tibial fracture and ischemic necrosis of lower leg skin after operation. After ulcer healing, the foot skin temperature was (30.86±0.80)℃, C-reactive protein was (22.90±18.42) mg/L, VAS score was 2.4±1.2, and Barthel index was 77.3±4.6, all showing significant differences when compared with preoperative ones ( P<0.05); the leukocyte count was (8.91±1.72)×10 9/L, showing no significant difference ( t=1.090, P=0.291). VSD combined with transverse tibial bone transport can effectively promote the healing of Wanger grade 3-5 diabetic foot wounds, but smokers, unstable blood glucose control, and chronic heart failure patients have the risk of failure.

Analysis of clinical features of ophthalmic and cerebral artery occlusion after facial cosmetic injection

Objective To observe the clinical characteristics of ophthalmic and cerebral artery occlusion after facial cosmetic injection. Methods A retrospective case study. Twenty patients (20 eyes) with ophthalmic and cerebral artery occlusion in Department of Ophtalmology, The Fourth Hospital of Xi’an from February 2014 to December 2016 were enrolled in this study. There were 2 males (2 eyes) and 18 females (18 eyes). They aged from 21 to 41 years, with the mean age of 29.8±1.4 years. The disease courses was ranged from 3.5 hours to 21 days, with the mean of 40 hours. Facial cosmetic injections of all patients were performed at out-of-hospital beauty institutions. The visual impairment was associated with eyelid pain 1 to 10 minutes after injection.There were 12 right eyes and 8 left eyes.The injection materials, 18 patients were hyaluronic acid and 2 patients were autologous fat, respectively. At the injection site, 13 patients were sacral, 4 patients were nasal, and 3 patients were frontal. The concentration and dose of the injected filler were not known. All patients underwent vision, slit lamp microscope, fundus color photography, visual field, FFA, OCT, and brain CT, magnetic resonance angiography (MRA) examination. Results The visual acuity was ranged from no light perception to 1.0. Among the 20 eyes, 3 eyes (15%) were obstructed by simple ophthalmic artery; 5 eyes (25%) were obstructed by ophthalmic artery combined with cerebral artery; 7 eyes (35%) were obstructed by simple retinal artery occlusion (RAO) alone, which including central RAO (CRAO, 4 eyes), hemi-lateral artery obstruction (1 eye) and branch RAO (2 eyes); 1 eye (5%) was CRAO with ciliary artery branch obstruction; 1 eye (5%) was branch artery occlusion with ischemic optic neuropathy; 2 eyes (10%) were CRAO with nasal dorsal artery occlusion; 1 eye (5%) was CRAO, posterior ciliary artery obstruction and right middle cerebral artery occlusion. Among 20 patients, 4 patients (20%) had eye movement disorder and eyelid skin bun; 2 patients (10%) had facial pain and nasal skin ischemic necrosis. MRA revealed 6 patients (30%) of new intracranial ischemic lesions. Among them, 5 patients of hyaluronic acid injection showed asymptomatic small blood vessel embolization; 1 patient of autologous fat injection showed ophthalmary artery occlusion, cerebral artery occlusion, ipsilateral eye blindness, eye movement disorder and contralateral limb hemiplegia. Conclusion Facial cosmetic injection can cause severe iatrogenic complications such as RAO, ciliary artery occlusion, ischemic optic neuropathy, ophthalmic artery occlusion, and cerebral artery occlusion. Key words: Retinal artery occlusion; Ciliary arteries occlusion; Cerebral artery occlusion; Facial cosmetic injection

Síndrome de Nicolau. Manejo conservador. Caso clínico

Introducción: el síndrome de Nicolau, embolia cutis o dermatitis livedoide, es una reacción adversa poco frecuente a la administración de inyección intramuscular, subcutánea o intraarticular de medicamentos, inicia con dolor intenso y eritema que evoluciona a lesión livedoide que se torna hemorrágica, progresa a necrosis isquémica de piel y tejidos más profundos.&#x0D; Caso clínico: niño de 7 meses de edad, luego de inyección intramuscular de metamizol sódico presenta llanto continuo, seguido de lesión purpúrica afectando espalda, glúteo, muslo y pierna derechos, evolucionando hasta cicatrización total en 18 semanas.&#x0D; Conclusión: el síndrome de Nicolau, condición iatrogénica por inyección de múltiples medicamentos, produce lesión necrótica en área de irrigación de vasos afectados. El conocimiento de este síndrome facilitaría su prevención, al igual que su diagnóstico y manejo tempranos.

Treatment of skin soft tissue embolism after hyaluronic acid injection for injection rhinoplasty in Asian patients.

The purpose of this manuscript is to investigate the treatment of skin soft tissue embolization or vascular occlusion after the injection of hyaluronic acid (HA) for Injection Rhinoplasty (IR) in Asians with a special interest in the time occurrence of the occlusion. A total of 35 cases were evaluated after receiving HA injections for IR who presented with a vascular occlusive event. They were divided into three stages based on the time to embolization. Immediate, ≤5hours; early, ≤3days; and late, >3days. There were two cases of immediate, 28 deemed early, and five late. Methods to prevent tissue necrosis are reviewed in the manuscript based on these stages. Skin color gradually recovered to normal after 11 treatments in 11 patients with mild embolization. No ischemic aggravation or skin necrosis was observed in 19 patients with moderate embolization; red scarring was seen in two and hypertrophic scar with uneven skin color in one patient. The five patients in the severe category had longer healing, more red scars, and more hypertrophic scarring. The treatment of skin soft tissue embolization or vascular occlusion after HA IR in Asians can be effected by identifying the stage and degree of embolization and treating appropriately with the outlines presented in this manuscript.

Silver Sulfadiazine and Cerium Nitrate in Ischemic Skin Necrosis of the Leg and Foot: Results of a Prospective Randomized Controlled Study.

Flammacerium is a topical treatment composed of silver sulfadiazine and cerium nitrate initially used in burns. The objective was to assess the effectiveness of silver sulfadiazine and cerium nitrate on ischemic necrosis wounds of the lower limb as an alternative to amputation for a period of 12 weeks. Patients were prospectively randomized to receive silver sulfadiazine and cerium nitrate or standard care. Patients included adults with an ischemic wound of the lower limb, with necrosis covering over at least 50%. Critical ischemia limb was confirmed by an ankle-brachial index <0.7 or >1.3 with radiological confirmation. Patient demographic data, amputations procedures, wound area, Visual Analogue Scale pain rating, clinical infection, and adverse events were recorded. Fifty patients, 34 males and 16 females, were recruited between January 2010 and April 2014, 25 in each group. The mean age was 75.14 years (±11.64). Nine amputations (36%) occurred in each group. Amputation-free survival was superior in the active treatment group versus the standard group (169 393 days, 95% confidence interval = 134.926-203.861, vs 169 393 days, 95% confidence interval = 134.926-203.861). It was not statistically significant (log-rank, P = .958). Wound area reduction between both groups was not statistically different ( P = .651). Less adverse events of the lower limb occurred in the active treatment group ( P = .001). Our study showed that silver sulfadiazine and cerium nitrate is not inferior to standardized care on ischemic necrotic wounds of the lower extremity. Further studies are still needed to confirm its effectiveness.

Comparison of selective and non‐selective internal iliac artery embolization for abnormal placentation with major postpartum hemorrhage

Non‐selective internal iliac artery embolization for abnormal placentation and postpartum hemorrhage resulted in ischemic skin necrosis whereas selective embolization did not; unilateral embolization was ineffective.

Abstract: Topical Application of Nitrosonifedipine, a Novel Free Radical Scavenger, Ameliorate the Ischemic Skin Flap Necrosis

INTRODUCTION: Ischemic flap necrosis is often occurred by insufficient blood supply, which prolongs the treatment period and occasionally requires an additional surgery. Ischemic flaps generate an excess amount of free radicals which is regarded as a major factor of ischemic skin necrosis. Thus free-radical scavengers would be an effective drugs in improvement of flap survival. In our previous studies, we have reported nitrosonifedipine (NO-NIF), which is a photolytic compound of nifedipine, possesses a potent radical scavenging activity, and shows the favorable effects against vascular endothelial dysfunction and type 2 diabetic nephropathy. In this study, we evaluated the ameliorating effect of NO-NIF on the ischemic flap model mice. MATERIAL AND METHODS: 9–10 weeks old Male C57BL/6 mice were divided into 2 groups, NO-NIF or control (n=6 in each group), respectively. A 1.0 × 3.0 cm cranially based random pattern flap was elevated on the dorsum of mice. NO-NIF 30 mg/kg or vehicle was injected subcutaneously immediate after the operation and once a day until evaluation. Seven days after surgery, the survival area was calculated as a percentage of the total flap area. To detect the oxidative stress, malondialdehyde (MDA) in the distal part of the flap at post-operative day 1 and 3 was measured by thiobarbituric acid reactive substances assay. Protein expression of p22phox, an essential component of NADPH-oxidase, in the flap was measured by western blotting. RESULTS: At post-operative day 7, the flap survival area was significantly larger in the NO-NIF-treated mice than controls (78.29 ± 7.04% vs. 51.81 ± 6.85%, p=0.021). The amount of MDA significantly decreased in the NO-NIF-treated mice at post-operative day 3 (2.31 ± 0.28µmol/g protein vs. 4.21 ± 0.32µmol/g protein, p=0.001), whereas MDA was same level in the both groups at the post-operative day 1 (2.77 ± 0.61µmol/g protein vs. 2.96 ± 0.51µmol/g protein). In a manner consistent with MDA levels, protein expression level of p22phox was decreased in the NO-NIF-treated mice at post-operative day 3 (p=0.002). CONCLUSIONS: We present the ameliorating effect of NO-NIF on ischemic flap survival. MDA and p22phox protein was decreased by NO-NIF treatment, which suggests the ameliorating effect was exerted via free radical scavenging. This investigation indicates that free-radical scavengers including NO-NIF are effective drugs in improvement of flap survival. DISCLOSURE/FINANCIAL SUPPORT:None.

Short-term effectiveness of hypospadias repair with free inner prepuce tube

?To explore the short-term effectiveness of hypospadias repairs with free inner prepuce tube. ?Forty-two males with hypospadias were repaired with free inner prepuce tube between May and October 2015. The age ranged from 1 year and 1 month to 28 years and 2 months with a median of 2 years and 9 months. Initial operation for hypospadias was performed in 41 cases and re-operation in 1 case of chordee after 16 months of hypospadias repair. There were 36 cases of hypospadias ( 6 cases of proximal penile type, 1 case of penile scrotal type, 26 cases of scrotal type, and 3 cases of perineal type) and 6 cases of type Ⅳ chordee according to Donnahoo classification criteria. ?The length of reconstructed urethra was 2.0-5.5 cm (mean, 3.6 cm). The patients were followed up 6-10 months (mean, 8 months). Urinary fistulae was noted in 10 patients, which healed spontaneously in 5 cases within 3 months after surgery, and was cured after repair in 5 cases. Urethral stenosis occurred in 4 cases (2 external orifice stricture and 2 distal urethral stricture) and urethral incision was performed. Wound infection was noted in 3 cases, 2 of them needed further surgery for a permanent fistula. Skin ischemic necrosis was found in 3 cases, 1 of them had infection and fistula, and needed further surgical repair. Diverticulum of scrotum developed in 1 case. Ten patients need re-operation, and the success rate was 76.2% (32/42). At 3 months after surgery, the HOSE score ranged from 11 to 16 (mean, 14.7). The maximum urinary flow rate was 1.9-28.4 mL/s (mean, 10.5 mL/s) in 22 cases of outpatient at 3 months after surgery. ?Free inner prepuce tube can survive and play a role of normal neourethra. The short-term effectiveness has shown a relatively high complication rate and suggests this procedure should be carefully applied.