Conventional pressure-based assessments (e.g., skin perfusion pressure) of Hemodialysis Access-Induced Distal Ischemia (HAIDI) are often limited by pain or ulcer location. We report the utility of transcutaneous oxygen pressure (TcPO2) for objective clinical decision-making in this setting. An 84-year-old man developed ischemic necrosis of the left index, middle, and ring fingers secondary to HAIDI after arteriovenous graft creation. Angiography confirmed hemodynamic steal, which was treated with collateral vein coil embolization to restore perfusion while preserving access. TcPO2 improved markedly from 29 to 73 mmHg (palm) and 6 to 64 mmHg (dorsum) post-intervention. These values exceeded the 40-mmHg healing threshold typically used for lower-extremity ischemia. Supported by these objective findings and favorable clinical progression, limited amputation was successfully performed instead of major amputation, resulting in complete healing. TcPO2 provides a practical, noninvasive complementary means to confirm microcirculatory recovery, supporting decisions on the timing and feasibility of limited amputation in HAIDI when conventional methods are impractical.

Background:Reconstructive plates used in mandibular reconstruction may lead to complications such as plate fracture or exposure, and their management is often difficult. In this study, we investigated complications associated with mandibular reconstruction plates in patients who underwent resection of oral squamous cell carcinoma in our department. Methods:Twenty-five patients who received mandibular reconstruction plates during oral squamous cell carcinoma resection at our department over approximately the past 10 years were reviewed. Parameters examined included age, sex, tumor location, stage, type and timing of complication, possible causes, and treatments. Results:Plate exposure occurred in 4 patients, and plate fracture occurred in 4 patients. All exposures were on the cutaneous side. Additional findings included screw fractures and bone resorption around screws. Plate fractures tended to occur more often in patients with strong occlusal support. Patients without reconstruction showed a significantly higher incidence of fracture. Plate fracture was also influenced by plate configuration and bending, while plate exposure was attributed mainly to insufficient soft tissue volume. Conclusion:Although plate reconstruction is useful, the relatively high frequency of complications requires careful consideration of multiple factors when determining its application.

Quantitative assessment of the pressure injury size (S) and pocket (P, undermining) is essential for evaluating wound healing. Conventional LabelMe annotations often lead to oversegmentation, whereas object detection with You Only Look Once (YOLO) enables accurate wound localization. Here, we developed a hybrid AI model that combines LabelMe segmentation with YOLO gating. This single-centre retrospective study compared two models: LabelMe-Seeded Auto-Recognition (LSAR) and YOLO-gated LSAR (YGL). Model performance was evaluated by concordance rate and weighted Cohen's κ for DESIGN-R staging and by mean absolute error (MAE) and median (interquartile range) for area error. Overall, 1017 wound images (training: 979; testing: 38) were analysed. For S, the YGL model achieved higher concordance (85.7%, κ = 0.969) and smaller area errors than did the LSAR. For P, the YGL model demonstrated higher concordance and smaller area errors than did the LSAR model. The YOLO-LabelMe hybrid model improved the stage concordance and size accuracy compared with LabelMe alone. Despite the residual outliers in P assessment, this approach represents a promising step towards automated, clinically adaptable wound measurements.

Background:Accurate assessment of pressure injuries is critical in clinical settings, especially when evaluating necrotic tissue using the DESIGN-R® scale widely adopted in Japan. This study aimed to integrate artificial intelligence (AI) into the evaluation process to enhance diagnostic consistency and accuracy. By leveraging deep learning and convolutional neural networks, we explored the potential of AI models in classifying necrotic tissue from wound images. Methods:A retrospective observational study was conducted using electronic medical records and wound photographs from patients treated at Tottori University Hospital between 2014 and 2022. Two supervised learning models were developed: a Categorical Classification Model (CCM) for multi-class prediction, and a Binary Classification Model (BCM) implementing a two-step binary classification. Necrotic tissue was categorized based on the DESIGN-R® scale into three classes: n0 (no necrosis), N3 (soft necrosis), and N6 (hard, adherent necrosis). The models' performance was evaluated using standard classification metrics. Results:The CCM showed recall rates of 0.7824 for n0, 0.6620 for N3, and 1.0000 for N6. In contrast, the BCM achieved higher recall rates: 0.9074 for n0, 0.9884 for N3, and 1.0000 for N6. Overall metrics for CCM were: accuracy 0.8148, precision 0.8166, and F-1 score 0.8089. The BCM surpassed these with an accuracy of 0.8711, precision 0.8418, and F-1 score 0.8508. Across all performance indicators, the BCM demonstrated superior classification capability. Conclusion:The study demonstrated that AI, particularly the binary classification approach, can enhance necrotic tissue assessment in pressure injury evaluation. The BCM consistently outperformed the CCM, supporting its potential as a reliable tool to assist clinicians in objective and standardized pressure injury evaluation using the DESIGN-R® framework.

Background: The development of models using deep learning (DL) to assess pressure injuries from wound images has recently gained attention. Creating enough supervised data is important for improving performance but is time-consuming. Therefore, the development of models that can achieve high performance with limited supervised data is desirable. Materials and methods: This retrospective observational study utilized DL and included patients who received medical examinations for sacral pressure injuries between February 2017 and December 2021. Images were labeled according to the DESIGN-R (R) classification. Three artificial intelligence (AI) models for assessing pressure injury depth were created with a convolutional neural network (Categorical, Binary, and Combined classification models) and performance was compared among the models. Results: A set of 414 pressure injury images in five depth stages (d0 to D4) were analyzed. The Combined classification model showed superior performance (F1-score, 0.868). The Categorical classification model frequently misclassified d1 and d2 as d0 (d0 Precision, 0.503), but showed high performance for D3 and D4 (F1score, 0.986 and 0.966, respectively). The Binary classification model showed high performance in differentiating between d0 and d1-D4 (F1-score, 0.895); however, performance decreased with increasing number of evaluation steps. Conclusion: The Combined classification model displayed superior performance without increasing the supervised data, which can be attributed to use of the high-performance Binary classification model for initial d0 evaluation and subsequent use of the Categorical classification model with fewer evaluation steps. Understanding the unique characteristics of classification methods and deploying them appropriately can enhance AI model performance.

The keystone flap has become an established option that has been utilized recently to close significant myelomeningocele defects. Although the keystone flaps can be adapted to repair myelomeningocele defects of different sizes, the shape of the defect is also an essential factor to consider. In this study, the authors proposed an algorithmic approach for reconstructing significant meningomyelocele defects utilizing different types of keystone flaps based on the shape of the resulting defect. From September 2016 to March 2022, the authors retrospectively reviewed the medical records of 28 patients with meningomyelocele who underwent repair with the keystone flaps. The mean age was 28 days (3 days to 4.5 months). Twenty-one meningomyelocele defects were in the lumbosacral (75%) and 7 in the thoracolumbar regions (25%). The defect sizes ranged from 3.5×5 cm (area, 13.4 cm 2 ) to 9×7 cm (area, 49.5 cm 2 ), with an average of 26.2 cm 2 . Ten meningomyelocele defects were a vertically oriented oval shape, 16 defects were a transversely oriented oval shape, and 2 defects were circular. In addition, unilateral keystone flap was used in 7.1% of the patients (2 patients), bilateral keystone flap in 28.6% (8 patients), and rotation advancement keystone flaps in 64.3% (18 patients). According to these findings, an algorithm was created based on the defect shape. This algorithmic approach is used as a decision-making guide to select the correct type of keystone flaps to repair myelomeningocele according to the defect shape.

In lateral skull base reconstruction, it is necessary to seal the defect in the lateral skull base, fill the dead space, and, sometimes, reconstruct the facial nerve. However, this procedure is difficult to perform with a standard musculocutaneous flap. Therefore, for such cases, an omental flap is used in our hospital because of its flexibility. In this study, we report our experience with the procedure (lateral skull base reconstruction with a free omental flap) and its long-term outcome and facial nerve reconstruction, with special focus on facial nerve recovery. This study is a technical note and a retrospective review. It was conducted in Nagoya University Hospital. Overall, 16 patients (12 women and 4 men; mean age: 55.1 years) underwent lateral skull base reconstruction with a free omental flap after subtotal temporal bone resection or lateral temporal bone resection during 2005-2017. The main outcome measures were postoperative complications and facial nerve recovery: Yanagihara score and House-Brackmann grading system. Complications included partial necrosis and minor cerebrospinal fluid leakage in 2 patients. Facial nerve recovery could be observed more than 12 months after surgery, with a mean Yanagihara score of 19.6 and House-Brackmann grade of 3.60. The free omental flap is a reliable method for lateral skull base reconstruction, especially in cases where facial nerve reconstruction is needed. To the best of our knowledge, this is the first report on facial nerve recovery after lateral skull base reconstruction.

Digital images of the skin play an important role in the clinical evaluation of skin diseases. Improvements in image recognition technology have enabled evaluation of digital images using deep learning. Such technology requires digital images that can be evaluated under appropriate conditions,1 but it is difficult to capture digital images that meet these conditions. It is preferred to use image correction color charts to adjust color, size, brightness, and color temperature when taking case photographs. CasMatch (Bear Medic, Tokyo, Japan) is an image correction color chart commonly used in Japan. It is supplied as a 10 × 10 mm adhesive sticker with nine colors, marked with a 1 mm scale. The color tones can be adjusted to more closely resemble the subject using image processing software, and the 1 mm scale can be used for size measurements. Color correction and size measurements play an important role in image recognition. CasMatch is generally affixed to healthy skin around an area of skin disease (Fig. 1A). It is not suitable for use on uneven surfaces, such as the toes, because misalignment between the CasMatch and the lesion may affect size measurement by image recognition. In addition, when used with elderly patients or patients with skin diseases, the adhesive nature of this product could cause medical adhesive-related skin injury (MARSI).2 The prevalence of MARSI in acute care hospitals has been reported as 3.4%–25.0%, and is a problem in patient care.3 Until now, insufficient attention has been paid to the effective use of image correction color charts. We propose an alternative method in which the CasMatch sticker is attached to a ruler and held in position near the area of interest while the photograph is taken (Fig. 1B).Fig. 1.: Photographs showing the use of CasMatch. A, A CasMatch adhesive sticker is applied to the patient’s skin. B, If the sticker should not be applied to the skin due to skin disease, it can be attached to a ruler and positioned nearby.This method has two advantages. First, it can be positioned correctly even in areas where proper application is difficult (such as the toes), thus enabling image recognition to be performed. Second, there is no risk of MARSI. The difference in quality of photographs between the proposed and conventional methods has not yet been examined. However, in our experience, it was possible to take better quality and more suitable case photographs for image recognition than with conventional method, especially in areas with uneven surfaces. It is expected that research in the field of image recognition will continue to grow. The accuracy of deep learning improves with larger sample sizes.4 Awareness of the use of image correction color charts that are appropriate for image recognition will be effective in increasing the number of appropriate case photos. We consider that the present findings will lead to a more feasible environment for future image recognition research. Photographic standards applicable to image recognition will be expected. To summarize, the use of image correction color charts placed on a ruler allows for correct positioning even in areas where proper application is difficult and prevents skin damage. We believe that this report will assist in future research in image recognition technology.

AbstractPlatelet-rich plasma (PRP) and adipose-derived stem cells (ADSCs) are known to secrete angiogenic factors that contribute to the treatment of intractable ulcers. The combination of PRP and ADSCs may enhance their angiogenic effects. However, it remains unclear whether treatment of ADSCs with PRP influences angiogenesis. We studied whether the conditioned medium from PRP-treated ADSCs under hypoxic conditions exerts angiogenic effects. Although PRP stimulated the proliferation of ADSCs obtained from rats, it decreased the mRNA levels of vascular endothelial growth factor, hepatocyte growth factor, and TGF-β1, but not of basic fibroblast growth factor, under hypoxia. The conditioned medium of PRP-treated ADSCs inhibited endothelial nitric oxide synthase phosphorylation, decreased NO production, and suppressed tube formation in human umbilical vein endothelial cells. Transplantation of ADSCs alone increased both blood flow and capillary density of the ischemic limb; however, its combination with PRP did not further improve blood flow or capillary density. This suggests that both conditioned medium of ADSCs treated with PRP and combination of PRP with ADSCs transplantation may attenuate the phosphorylation of endothelial nitric oxide synthase and angiogenesis.

Background There is a need for quick skin blood flow tests that can be performed in the wound healing field. Antera 3D® is a compact scanner using multispectral imaging. It can perform quick assessment of skin conditions. The purpose of the present study was to investigate the ability of the Antera 3D® to assess skin blood flow in comparison with transcutaneous partial pressure of oxygen (TcPO2) measurements. Methods This study was conducted on 13 patients with a history of lower extremity ulcers. Measurements of hemoglobin average level (hereafter, Hb score) measured by Antera 3D® and TcPO2 measured by a transcutaneous blood gas monitor were obtained at the same sites on the dorsal foot and lower leg. Differences in Hb score and TcPO2 were analyzed by t-test for each measurement site and for the presence of peripheral arterial disease (PAD). The correlation between TcPO2 and Hb score was analyzed by Pearson's correlation coefficient. Results Twenty-four limbs were tested. Hb score was higher (P < 0.001) and TcPO2 was lower (P = 0.056) in the dorsal foot compared to the lower leg. In the dorsal foot, Hb score was higher (P = 0.023) and TcPO2 was lower (P = 0.046) in patients with PAD compared to those without PAD. A significant negative correlation (r = -0.68; 95% confidence interval -0.85 to -0.38, P < 0.001) between TcPO2 and Hb score was observed in the dorsal foot. Conclusion The negative correlation between TcPO2 and Hb score may reflect compensatory peripheral vasodilation due to occlusion or stenosis of central arteries. This study showed that Hb score measured by Antera 3D® may be related to skin blood flow.

When resecting the internal jugular veins bilaterally in surgery for head and neck cancer, it is necessary to perform neck dissection in two stages or to reconstruct the internal jugular veins in one stage. Reconstruction of the internal jugular vein using grafting or direct anastomosis to the external jugular vein have both been reported. We report the case of a 53-year-old man with accidental injury to the left internal jugular vein after resection of the right internal jugular vein for supraglottic cancer. The left internal jugular vein was damaged near the inflow of the subclavian vein, making vein grafting difficult. Therefore, internal jugular venous return was reestablished by end-to-side anastomosis of the left internal jugular vein to the left external jugular vein system. In this surgical procedure, by incising the internal jugular vein obliquely, it was not necessary to match the calibers of the internal jugular vein and the external jugular vein system, and a smooth hemodynamic body was reconstructed. In addition, we were able to reconstruct the internal jugular vein while preserving blood flow in the external jugular vein system. End-to-side anastomosis of the internal jugular vein to the external jugular system is an option for internal jugular vein reconstruction.

INTRODUCTION:Free jejunal flap (FJF) reconstruction is a standard procedure for pharyngeal and cervical esophageal defects resulting from head and neck cancer resection. However, improvements in patients' quality of life after surgery require a further statistical approach.METHODS:An observational, retrospective, multivariate analysis was designed to report the incidence of postoperative complications and their association with clinical factors in 101 patients who underwent total pharyngo-laryngo-esophagectomy and FJF reconstruction for head and neck cancer at a university hospital between January 2007 and December 2020.RESULTS:Postoperative complications were observed in 69% of patients. In the reconstructive site, anastomotic leak, observed in 8% of patients was associated with vascular anastomosis in the external jugular vein system (age-adjusted odds ratio [OR]: 9.05, p = 0.044) and anastomotic stricture, observed in 11% of patients was associated with postoperative radiotherapy (age-adjusted OR: 12.60, p = 0.02). Cervical skin flap necrosis was the most common complication (34%) and was associated with vascular anastomosis on the right cervical side (age- and sex-adjusted OR: 4.00, p = 0.005).CONCLUSION:Although FJF reconstruction is a useful procedure, 69% of patients suffer a postoperative complication. We suppose that anastomotic leak is related to the low blood flow resistance of the FJF and inadequate drainage of the external jugular venous system, and anastomotic stricture is related to the vulnerability of the intestinal tissue to radiation. Furthermore, we hypothesized that the location of the vascular anastomosis may affect the mesenteric location of the FJF and the dead space in the neck, leading to the development of cervical skin flap necrosis. These data contribute to increasing our knowledge about postoperative complications related to FJF reconstruction.

Introduction Myelomeningocele is the most common form of neural tube anomalies. Early reliable skin coverage should be achieved to reduce central nervous system infections. The keystone flaps are gaining popularity for myelomeningocele defect reconstruction. However, the use of a traditional keystone flap is limited in very wide or transversely oriented myleomeningocele defects with inadequate lateral tissue laxity. In this study, we present our successful experience using modified rotation advancement keystone flaps for closure of the transversely oriented myelomeningocele defects. Patients and Methods Between April 2019 and April 2020, the modified rotation advancement keystone flap was used for reconstruction of transversely oriented myelomeningocele defect in 7 patients (5 males and 2 females) with average age of 14 days. The localization of the lesions was lumbosacral in 5 patients and thoracolumbar in 2 patient. The average myelomeningocele defect width was 6.4 cm, whereas the average defect length was 5.7 cm. The following information was evaluated: the flap dimensions, operative time, and postoperative complications. Results All patients had uneventful operations, except for 1 case of superficial epidermolysis over flap tip, which settled with conservative wound management. Immediate venous congestion was detected in 2 patients that completely resolved. Otherwise, all wounds healed without any evidence of complications. The mean follow-up was 4 months. Conclusions Although the conventional keystone flap seems to have geometric constraints to close a transversally oriented myelomeningocele defect, the modified rotation advancement keystone flap serves as a superior alternative and effective option for closure transversally oriented defect.

Background Although head and neck reconstruction using free flaps has become a common procedure, flap complications remain a concern. This study aimed to analyze the risk factors of free flap complications and to identify the causes of these complications. Methods We studied 97 patients with head and neck cancer with intraoral defects who underwent reconstruction using free flaps at Tottori University Hospital between 2011 and 2020. We used a retrospective cohort study design to investigate whether flap complications, including flap necrosis (total and partial) and flap dehiscence, were related to various factors, including the underlying disease condition, treatment status, and surgical factors. Results Of the 97 patients analyzed, total flap necrosis was observed in one patient (1.0%). The incidence rate of flap complications, including flap necrosis and flap dehiscence, was 29.9%. When the time taken to perform one vascular anastomosis, including preparation of the recipient vessel and flap vessel, exceeded 30 min, the incidence rates of flap necrosis (total and partial) (odds ratio, 8.30; 95% confidence interval, 1.91-36.00; P = 0.005) and flap dehiscence (odds ratio, 3.46; 95% confidence interval, 1.05-11.36; P = 0.041) increased significantly. Conclusion The time taken to perform one vessel anastomosis was the factor that contributed the most to the incidence of flap complications. Reconstructive surgeons should reduce the incidence of flap complications by keeping the known risk factors of the surgery in mind and by aiming to complete a vascular anastomosis time, including the time taken for the preparation of vessels, of ≤ 30 min per vessel during surgery.

OBJECTIVE:Pressure injuries in people with spinal cord injury or dysfunction (SCI/D) are known to have a high recurrence rate. As a countermeasure, we perform surgery after adjusting the wheelchair and cushion with the intervention of a seating expert. The effectiveness of seating interventions in postsurgical recurrence prevention was examined. MATERIALS AND METHODS:In this retrospective analysis, the participants were 19 patients with SCI/D who underwent pressure injury surgical treatment in the gluteal region from 2005 to 2018. The patients with conventional rehabilitation were assigned to Group 1 (n = 8), and those with seating intervention by experts in addition to conventional rehabilitation were assigned to Group 2 (n = 11). The main outcome measure was the presence or absence of recurrence 3 years after the surgery. The recurrence rate was compared between the two groups. RESULTS:The recurrence rates were 18% with seating intervention and 75% without; there was a significant difference (p = 0.025). The recurrence odds ratio was 13.5. CONCLUSION:This study suggests that presurgical seating evaluation and assessment by experts, postsurgical rehabilitation based on presurgical evaluation and assessment, and routine follow-up and seating adjustment according to changes are efficacious for preventing postsurgical pressure injury recurrence in patients with SCI/D.

Background:In free flap transfer, size discrepancy between the vascular pedicle and recipient vessel can create a problem for microsurgeons and sometimes induces postoperative thrombus formation. When there is a major difference between the diameters of the vascular pedicle and the recipient vessel, the larger vessel is often tapered to perform the anastomosis properly. However, the decision on the tapering angle used depends mostly on the operator's experience. In this study, computational fluid dynamics (CFD) was used to investigate the optimum tapering angle.Methods:Using ANSYS ICEM 16.0 (ANSYS Japan, Tokyo, Japan), simulated vessels of diameters 1.5 mm and 3.0 mm were designed and then used to produce four anastomosis models with the 3.0-mm vessel tapered at angles of 15º, 30º, 60º, and 90º (no tapering). Venous perfusion with a mean value of 13.0 mL/min was simulated, and this was passed through the four anastomosis models in both the forward direction (F), from the smaller to the larger vessel, and the retrograde direction (R), from the larger to the smaller vessel. The velocity, wall shear stress (WSS), and oscillatory shear index (OSI) were measured in these eight patterns and then analyzed using OpenFOAM version 5.Results:The decrease in velocity was limiting. The WSS was greater in the R direction than the F direction at every tapering angle. The OSI also tended to be almost the same in the F direction, and lower at smaller tapering angles in the R direction. And, it was greater in the F direction than in the R direction at every tapering angle. The OSI values for 15º and 30º were almost identical in the R direction.Conclusion:The risk of thrombus formation is thought to be lower when tapering is used for anastomosis if the direction of flow is from the larger to the smaller vessel, rather than vice versa. These results also suggest that the optimum tapering angle is approximately 30º in both directions.

Background：The biological actions of fucoidan depend on its molecular weight. 20-30 kDa fucoidan has been reported to stimulate angiogenesis in ischemic limbs. We purified very high molecular weight fucoidan (HMWF) from mozuku (brown algae of the Okinawan coontail family) to assess its effect on angiogenesis. Methods and Results：We examined the angiogenic effects of mozuku HMWF (300 kDa) and akamoku (Sargassum seaweed) HMWF (80 kDa) in a mouse ischemic limb model by measuring laser Doppler blood flow (LDBF) and capillary density. We also studied the angiogenic actions of mozuku HMWF administered pre- and post-ischemia as compared to post-ischemia treatment. Mozuku HMWF increased both LDBF and capillary density in the ischemic leg, whereas akamoku HMWF did not. Treatment with mozuku HMWF pre- and post-ischemia increased both LDBF and capillary density, which was not seen in post-ischemia treatment alone. Conclusions：This study demonstrated the therapeutic effect of pre- and post-ischemia treatment with mozuku HMWF in ischemic limbs, and the timing of administration is important for its angiogenic activity.

The prognosis for carcinoma of the external auditory canal is good when the tumor can be removed en bloc, and the surgical procedure is often uniformly selected based on the T grade according to the Pittsburgh classification. However, since tumor localization differs despite the same T grade, uniformity in surgical procedures can cause excessive complications. In the case reported here, the tumor in a patient with left external auditory canal carcinoma extended from within the external auditory canal to the lateral wall of the attic, and was classified as T3 （Pittsburgh classification）. After neoadjuvant chemotherapy, we planned an atypical surgery to remove the attic lateral to the malleus head in a lump, as well as a lateral bone resection. The lesion was removed en bloc while confirming the margin intraoperatively using a navigation system, and no recurrence has been observed for nearly 4 years after surgery. We believe that advances in diagnostic imaging have made it possible to avoid relying on a single standard procedure and have helped us accurately determine tumor margins and use navigation systems to effectively resect tumors.

The tapering technique is one of the useful methods of anastomosing 2 vessels with large discrepancies during microanastomoses. When the tapering technique is used, a three-point suture is always present. The authors analyzed the most appropriate suture technique for this using computational fluid dynamics. This aspect has not previously been addressed. Three different suture techniques were simulated: (1) Three single-knot sutures (Type I); (2) Two single-knot sutures forming an X-shape (Type II); and (3) A single continuous ligature through the vascular wall (Type III). Vascular models of these 3 types were created. The streamline, wall shear stress, and oscillatory shear index at the anastomosis site were measured using a previously prepared venous model. Streamline disruption was most severe for Type II. In all 3 types, the highest wall shear stress was recorded at the suture peak protruding into the vessel. The maximum oscillatory shear index was highest in Type II, and lowest in Type III. The present results suggest that Type III is the best three-point suturing method for the tapering technique.