OBJECTIVETo explore the clinical effects of relaying reversed perforator flaps in repairing skin and soft tissue defects at distal end of finger and donor site.

METHODSSeventeen patients (17 fingers) with skin and soft tissue defects at distal end of finger were hospitalized from June 2011 to June 2013. The reversed digital artery perforator flap with branch of digital nerve was used to repair the defect. The first donor site was repaired by dorsal metacarpal artery perforator flap; the second donor site was closed by suturing. The area of skin defect at distal end of finger ranged from 2.0 cm x 1.5 cm to 3.0 cm x 2.0 cm, and the area of digital artery perforator flap and dorsal metacarpal artery perforator flap ranged from 2.2 cm x 1.5 cm to 3.6 cm x 2.5 cm and 2.5 cm x 2.0 cm to 4.2 cm x 3.0 cm, respectively.

RESULTSAll the 34 flaps survived completely. Cyanosis and partial necrosis of the epidermis appeared in 1 flap, which was healed after dressing change. All the patients were followed up for 1 to 18 months, with mean time of 8 months. The color, texture and appearance of flaps were satisfactory. There was no depression or breakdown in the first donor sites. Some linear scars appeared in the second donor sites, but they did not affect the general appearance. The donor sites at joint or tendon did not affect the joint activity after healing. The results of function evaluation of range of active movement of the fingers were excellent in 15 cases and good in 2 cases. The results of sensation of the flaps were S3 in 1 finger, S4 in 2 fingers, and S5 in 14 fingers. The distance of two-point discrimination of flaps ranged from 5 to 7 mm, with mean distance of 6 mm.

CONCLUSIONSRelaying reversed perforator flap, with reliable blood supply and both donor sites in the hand, can improve the appearance and function of the first donor site as well as repair skin and soft tissue defects at distal end of finger.

Cicatrix ; Depression ; Epidermis ; Extremities ; Finger Injuries ; surgery ; Humans ; Perforator Flap ; Reconstructive Surgical Procedures ; methods ; Skin ; Skin Transplantation ; methods ; Soft Tissue Injuries ; surgery ; Surgical Flaps ; blood supply ; Sutures ; Tendons ; Treatment Outcome ; Wound Healing

[ ABSTRACT] AIM:To investigate the effects of pathological products, urinary proteins and advanced glycosyla-tion end products ( AGE) produced in the progression of chronic kidney disease ( CKD) , on the structure and function of lysosomes in renal tubular epithelial cells ( TECs ) , and try to find a novel approach for preventing or delaying CKD. METHODS:The renal specimens of the untreated patients with minimal change nephrotic syndrome (MCNS), diabetic nephropathy (DN) or normal kidney were collected.The expression of lysosomal-associated membrane protein 1 (LAMP1) and cathepsin B ( CB) was studied in TECs by indirect immunofluorescent staining.Human renal tubular epithelial cell line HK-2 was incubated with 8 g/L urinary proteins or 100 mg/L AGE.The expression of LAMP1 and CB was investigated by indirect immunofluorescence and the activity of CB and cathepsin L ( CL) was measured by biochemical and enzymatic as-says.The degradation of DQ-ovalbumin was also determined.RESULTS: The lysosomal membrane permeabilization oc-curred in the TECs of MCNS and DN patients.After treatment with urinary proteins or AGE-BSA, the lysosomal membrane permeabilization of the HK-2 cells was increased.The activity of CB and CL and degradation of DQ-ovalbumin were de-creased as compared with normal control group.CONCLUSION:The digestive function of lysosome was decreased and ly-sosomal membrane permeabilization occurred in the TECs exposed to urinary proteins and AGE, which might be a key factor to induce the tubulointerstitial fibrosis.

Objective To evaluate effects of tea polyphenols on the mRNA and nucleoprotein expression of Nrf2/Bach1 in human skin fibroblasts (HSFs).Methods Some HSFs were incubated with tea polyphenols at different concentrations of 0,2.5,5,10,20 and 40 mg/L for 24 hours.Methyl thiazolyl tetrazolium (MTT) assay was conducted to evaluate the proliferative activity of HSFs to screen the optimal concentration of tea polyphenols.Then,some other HSFs were treated with tea polyphenols at this optimal concentration for 24 hours.Real-time quantitative PCR (RT-qPCR) was performed to determine mRNA expression of Nrf2 and Bach1,Western blot analysis to measure nuclear expression of Nrf2 and Bach1 proteins,and immunofluorescence assay to determine the distribution of Nrf2 and Bach1 protein in the cell nucleus.Results MTT assay showed that 5 mg/L tea polyphenols had no obvious effects on the proliferation of HSFs,so 5 mg/L was chosen as the optimal concentration of tea polyphenols for subsequent experiments.HSFs cultured without tea polyphenols served as control group.After the treatment,the 5-mg/L tea polyphenol group showed significantly decreased mRNA and nuclear protein expression of Bach 1 (mRNA:0.629 ± 0.077 vs.0.940 ± 0.033,t =6.397,P ＜ 0.05;protein:1.424 ± 0.171 vs.16.966 ± 1.702,t =15.730,P ＜ 0.05),but significantly increased mRNA and nuclear protein expression of Nrf2 (mRNA:1.467 ± 0.076 vs.0.977 ± 0.091,t =7.133,P ＜ 0.05;protein:6.929 ± 0.121 vs.3.537 ± 0.126,t =33.636,P ＜ 0.05) compared with the control group.Immunofluorescence assay showed increased accumulation of Nrf2 protein,but decreased accumulation of Bach1 protein in the nucleus.Conclusion Tea polyphenols can promote the mRNA and nuclear protein expression as well as nuclear distribution of Nrf2,but suppress the mRNA and nuclear protein expression as well as nuclear distribution of Bach 1,finally exerting antioxidative effects.

Objective:To investigate the management of patients with intravenous misplacement of nephrostomy tube following percutaneous renal surgery.Methods:The data of 6 patients with intravenous misplacement of nephrostomy tube during percutaneous nephrolithotomy (PCNL) treated in the two hospitals of Chenzhou from January 2006 to December 2020 were retrospectively analyzed. The median age was 41.0(38.5, 53.0) years old. There were 4 males and 2 females. Three patients had undergone contralateral upper urinary tract operation. One patient had undergone ipsilateral upper urinary tract operation. Two patients had not undergone upper urinary tract operation. Two of the 6 patients had a solitary kidney. Two patients were diagnosed with staghorn calculi (combined with mild hydronephrosis in 1 patient, moderate hydronephrosis in 1 patient). Four patients were diagnosed with ureteral calculus (combined with mild hydronephrosis in 2 patients, moderate hydronephrosis in 1 patient, severe hydronephrosis in 1 patient). In all 6 patients, the tract was dilated with fascial dilators. Immediately after dilator removal, brisk venous bleeding was noted. A nephrostomy tube was inserted promptly through the sheath to tamponade the tract and was immediately closed. Five cases were diagnosed by CT after operation, and 1 case was early diagnosed by intraoperative injection of contrast medium through nephrostomy tube. The nephrostomy tube was misplaced in 5 patients with left upper urinary tract calculi, and in 1 patient with right upper urinary tract calculi. The tip of nephrostomy tube was located in ipsilateral renal vein in 3 patients with left upper urinary tract calculus, inferior vena cava in 2 patients with left upper urinary tract calculus, and contralateral renal vein in 1 patient with right upper urinary tract calculus. No venous thrombosis of renal vein or inferior vena cava was founded in the 6 patients. All 6 patients were managed with strict bed rest, intravenous antibiotics, and one-step or two-step tube withdrawal under close monitoring. One step method referred to total removal of nephrostomy tube under ultrasonic monitoring. Two step method referred to retracting the end of nephrostomy tube into the renal sinus under CT monitoring in the first step, then the nephrostomy tube was completely removed under ultrasound monitoring.Results:All 6 patients were successfully managed with strict bed rest, intravenous antibiotics, and one-step or two-step tube withdrawal under close monitoring. The tube was withdrew by one-step method in 1 patient, by two-step method in 5 patients. The original operations were performed successfully under close observation in 4 patients during the same hospitalization and in 1 patient during the next hospitalization. Other type of operation in 1 patient was performed during the next hospitalization. The all 6 patients were discharged uneventfully. The stone was cleared.Conclusions:Intravenous misplacement of a nephrostomy tube is mainly diagnosed by CT. The nephrostomy tube should be sealed immediately after diagnosis. The intravenously misplaced nephrostomy tube can be successfully removed by one-step or two-step withdrawing under close monitoring. Upper urinary tract stones can be successfully treated at the same time or by stages.

Objective: To investigate the feasibility and efficacy of free lobulated lateral circumflex femoral artery perforator flap for foot and ankle defect at non-weight bearing area. Methods: From January 2008 to June 2016, 28 cases with foot and ankle skin and soft tissue defects at non-weight bearing area were treated, including 16 cases with traffic accident, 8 cases with machine injury, and 4 cases with falling injury. There were 10 cases with Achilles tendon exposure, 16 cases with dorsalis pedis tendons exposure and 12 cases with bone exposure. The defect size ranged from 10 cm×8 cm to 16 cm×13 cm. Doppler ultrasound detector was used to select two perforators of lateral femoral circumflex artery. The lobulated perforator flap was designed and harvested as one flap. After clip test was performed to make sure the blood supply of flap, the flap was segmented and repositioned to cover the wound. The width of lobulated flaps was less than 8cm, in order to close the defect at donor sites directly. Postoperative rountine anti-inflammatory, anticoagulant, anticonvulsive treatment and function exercise were adopted. The patients were followed up for 6-28 months. Results: The flap size ranged from 9.0 cm×4.5 cm to 17.0 cm×7.0 cm. Partial necrosis happened at the end of one flap lobe due to pressure, which healed after dressing. All the other 27 flaps survived completely with satisfactory cosmetic and functional result. The wounds at donor sites all healed primarily. Conclusions Free lobulated lateral circumflex femoral artery perforator flap is one of the ideal flaps with high survival rate and low complication for foot and ankle defect at non-weight bearing area.

Objective: To investigate the therapeutic effect of propeller flap with low peroneal artery perforator for defects at ankle and heel. Methods: From January 2009 to March 2016, 28 cases with skin defects at ankle and heel were treated with propeller flap pedicled by low peroneal artery perforator, including 15 cases of car accidents, 8 cases of pressure injury, 3 cases of wring injury and 2 cases of electricity shock injury. Defects size ranged from 3 cm×3 cm to 4 cm×6 cm. The fibular was divided into 9 segments from head to external ankle. Doppler ultrasound was used to locate the low peroneal artery perforator from the lower 6-9 segments. The flap pivot point was at perforator point at skin surface, with the peroneal artery as flap axis. The length of big blade was the distance from rotate point to distal end of defects. The flap width was half of the length. The ratio of big blade length to width should not exceed 2∶1. The flaps size was from 3 cm×5 cm to 4 cm×10 cm, based on the defect size. The defects at donor site could be closed with small blade directly. Results: Partial necrosis happened in 1 case due to veneous crisis, which healed after dressing. All the other 27 flaps survived completely. During the follow-up period, the flaps had good match in color and thickness. No secondary operation was needed. Conclusions The optimization of propeller flap with low peroneal artery perforator is an idealmethod for defects at ankle and heel, which can avoid the necrosis at distal end of flap.

Based on the analysis of the existing problems and implementation dilemmas in family doctor contracting and first-return-visits faced by primary medical institutions in China, the authors propose countermeasures to provide reference for managers of primary health care institutions.

Objective To evaluate the protective effect of pterostilbene against ultraviolet B (UVB)-induced acute damage in HaCaT cells,and to explore related mechanisms.Methods The 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazo1ium (MTS) assay and flow cytometry were performed to estimate the proliferative activity and the apoptosis and necrosis rate of HaCaT cells treated with different concentrations of pterostilbene respectively,so as to screen the non-toxic concentration of pterostilbene.HaCaT cells were randomly divided into several groups:normal control group receiving no treatment,UVB group irradiated with 57 mJ/cm2 UVB,3 pterostilbene groups treated with 2.44,4.88 and 9.75 μmol/L pterostilbene respectively for 24 hours,3 pterostilbene + UVB groups treated with 2.44,4.88 and 9.75 μmol/L pterostilbene respectively for 24 hours followed by UVB radiation.Western blot analysis was conducted to detect changes of the transcription factor NF-E2-related factor 2 (Nrf2) expression in cell nuclei and cytoplasm before and after the treatment with pterostilbene and UVB,quantitative PCR to determine the mRNA expression of catalase and superoxide dismutase in the HaCaT cells,and enzyme-linked immunosorbent assay (ELISA) to evaluate the activity of catalase and superoxide dismutase.Results MTS assay and flow cytometry showed that 2.44,4.88 and 9.75 μmol/L pterostilbene had non-toxic effect on HaCaT cells.The protein expression of Nrf2 in the nuclei and cytoplasm in the normal control group was 1.03 ± 0.08 and 1.04 ± 0.11 respectively.Compared with the normal control group,the protein expression of Nrf2 in the nuclei and cytoplasm experienced no significant changes in the 2.44-,4.88-and 9.75-μmol/L pterostilbene groups,and the UVB group showed similar protein expression of Nrf2 in the cytoplasm,but significantly increased protein expression of Nrf2 in the nuclei (1.77 ± 0.08,q =17.24,P ＜ 0.01).Compared with the normal control group and UVB group,the 2.44-,4.88-and 9.75-μmol/L pterostilbene + UVB groups all showed significantly lower protein expression of Nrf2 in the cytoplasm (0.86 ± 0.10,0.87 ± 0.11 and 0.46 ± 0.11 respectively,all P ＜ 0.05),but significantly higher protein expression of Nrf2 in the nuclei (2.38 ± 0.11,2.57 ± 0.11 and 2.07 ± 0.13,all P ＜ 0.01).As qPCR showed,UVB radiation could significantly inhibit the mRNA expression of CAT (P ＜ 0.05),but had no obvious effect on the mRNA expression of SOD (P ＞ 0.05).The mRNA expression of CAT and SOD experienced no significant changes in the 2.44-,4.88-and 9.75-μmol/L pterostilbene groups compared with the normal control group (P ＞ 0.05).However,2.44,4.88 and 9.75 μmol/L pterostilbene could significantly reduce the inhibitory effect of UVB radiation on the mRNA expression of CAT (P ＜ 0.05) and up-regulate the mRNA expression of SOD in the pterostilbene + UVB groups (P ＜ 0.05).ELISA revealed that UVB radiation could inhibit the activity of CAT and SOD in the HaCaT cells (both P ＜ 0.001),while 2.44,4.88 and 9.75 μmol/L pterostilbene could reduce the inhibitory effect of UVB radiation on the activity of CAT and SOD (all P ＜ 0.05).However,the activity of CAT and SOD were still lower in the 2.44-,4.88-and 9.75-μmol/L pterostilbene + UVB groups than in the normal control group (P ＜ 0.05).Conclusion Pterostilbene can prevent UVB-induced acute damage in HaCaT cells by activating the Nrf2 pathway and up-regulating the expression of the downstream antioxidant enzymes CAT and SOD.

Objective To discuss the therapeutic effect of free perforator flap of the humeral back and the healing of the wound after the removal of the malignant tumor.Methods From January,2012 to June,2016,12 cases were treated as soft tissue tumors on shoulder,including 8 cases of skin juga fibrosarcoma,3 cases of basal cell carcinoma,squamous cell carcinoma of the skin in 1 case.Preoperative using doppler ultrasound probe design perforator flap to expand resection,intraoperative cut edge basal tag frozen pathological examination without taking skin flap after the tumor invasion,according to the wound and wear the appropriate adjustment design of perforator flap.Followed-up to observe recurrence,flaps or ulcers,and the texture of the flap and the feel of the flap.All patients were followed-up regularly.Results All 12 patients were followed-up for 6-48 months.The flaps were all alive.The tumor did not relapse,and the flap was not swollen.The texture was consistent with the surrounding tissue.There was no ulceration of the flap.No obvious depression deformity.The outlook of flaps was satisfied,but the feeling was not.The doror sites were closed directly.Conclusion Adjacent using humeral back free perforators flap to repair the defect after tumor resection on shoulder is an easy operation.It is one of the ideal flaps to repair a malignant tumor on the back of the shoulder.

Objective:To evaluate the effect of metformin on ultraviolet A (UVA) -induced photoaging of an immortalized human keratinocytes cell line (HaCaT), and to explore its potential mechanisms.Methods:Cell counting kit 8 (CCK8) assay was performed to evaluate the effect of metformin at different concentrations (0 - 100 mmol/L) on the viability of HaCaT cells, and 10 mmol/L metformin was selected for subsequent experiments. Cultured HaCaT cells were divided into a blank control group (conventional culture), a metformin group (treated with culture medium containing 10 mmol/L metformin), a UVA irradiation group (conventional culture for 24 hours followed by 10 J/cm 2 UVA irradiation) and a metformin + UVA group (treated with culture medium containing 10 mmol/L metformin for 24 hours followed by 10 J/cm 2 UVA irradiation) ; UVA irradiation was performed at a dose of 10 J/cm 2 once a day for 3 consecutive days. After 4-day treatment, cells were collected, the β-galactosidase assay was performed to determine the proportion of senescent cells in each group, 2′, 7′-dichlorodihydrofluorescein diacetate assay to detect levels of intracellular reactive oxygen species (ROS), and the comet assay to detect DNA damage levels. Additionally, some HaCaT cells were divided into the blank control group, metformin group, 1.25 μmol/L dorsomorphin (an adenosine monophosphate-activated protein kinase [AMPK] inhibitor) + metformin group, and 2.5 μmol/L dorsomorphin + metformin group, and cells in the latter two groups were treated with 1.25 and 2.5 μmol/L dorsomorphin respectively for 2 hours, followed by the treatment with 10 mmol/L metformin for 24 hours. Western blot analysis was performed to determine the cellular localization and phosphorylation levels of nuclear factor-erythroid 2-related factor 2 (Nrf2). By using the small-interfering RNA (siRNA) -mediated silencing method, siRNA-Nrf2 was transfected into HaCaT cells to knock down Nrf2 expression (siRNA-Nrf2 group) ; 2.5 μmol/L dorsomorphin-treated HaCaT cells or Nrf2-knockdown HaCaT cells were treated with metformin and UVA irradiation (dorsomorphin + metformin + UVA group, siRNA-Nrf2 + metformin + UVA group, respectively), and the proportions of senescent cells were further calculated in each group. Statistical analysis was carried out by using one-way analysis of variance and two-way analysis of variance, and least significant difference (LSD) - t test was used for multiple comparisons. Results:Treatment with different concentrations of metformin for 24 hours could affect the viability of HaCaT cells to varying degrees ( F = 5 206.31, P < 0.001) ; there were no significant differences in the relative survival rates of HaCaT cells between the 10 - 20 mmol/L metformin groups and the control group (0 mmol/L metformin group, all P > 0.05), while the relative cell survival rates were significantly lower in the 25 - 100 mmol/L metformin groups than in the control group (all P < 0.05). After UVA irradiation, HaCaT cells shrank significantly and became narrow and elongated, and the intercellular spaces increased; the relative cell survival rate was significantly lower in the UVA irradiation group (76.13% ± 1.03%) than in the blank control group (100.00% ± 1.24%, LSD- t = 14.86, P < 0.001), but significantly higher in the metformin + UVA group (106.69% ± 2.45%) than in the UVA irradiation group (LSD- t = 11.55, P < 0.001). Moreover, the UVA irradiation group showed significantly increased proportions of senescent cells (45.14% ± 4.98%), intracellular ROS levels (144.61% ± 4.91%), and percentages of DNA in the tail (75.33% ± 1.77%) compared with the blank control group (23.84% ± 1.89%, 55.49% ± 1.57%, 1.88% ± 0.29%, respectively, all P < 0.001), while the metformin + UVA group showed significantly decreased proportions of senescent cells (24.26% ± 1.34%), intracellular ROS levels (58.62% ± 2.17%), percentages of DNA in the tail (15.83% ± 1.23%) compared with the UVA irradiation group (all P < 0.001). Western blot analysis showed that the Nrf2 expression in the cytoplasm was lower in the 10 mmol/L metformin group than in the blank control group, while the phosphorylated Nrf2 expression in the nuclei was higher in the 10 mmol/L metformin group than in the blank control group, suggesting that metformin could effectively induce the phosphorylation of Nrf2 and its nuclear translocation; both the pretreatment with 1.25 and 2.5 μmol/L dorsomorphin could significantly reduce the phosphorylation levels of AMPKα and Nrf2 induced by 10 mmol/L metformin. The proportions of senescent cells in the dorsomorphin + metformin + UVA group and the siRNA-Nrf2 + metformin + UVA group were 67.84% ± 2.74% and 65.94% ± 1.33%, respectively, which were significantly higher than those in the metformin + UVA group (37.76% ± 1.64%, t = 14.45, 13.34, respectively, both P < 0.001) . Conclusion:Metformin may inhibit UVA-induced photoaging of HaCaT cells by activating the AMPK/Nrf2 signaling pathway, scavenging ROS and reducing DNA damage.