Publications by authors named "Yur-Ren Kuo"

166 Publications

Progress in Microdermal Grafting for Color Regeneration of White Scars.

Aesthet Surg J 2021 Jul 31. Epub 2021 Jul 31.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Background: Microdermal grafting is used to regenerate color in white (hypopigmented) scars using knife cutting partially de-epithelialized skin for grafting. However, the scalp has more melanocytes, and dermabrasion can preserve more melanocytes than knife cutting during partial de-epithelialization. Our clinics refined the two procedures that we originally reported using dermabrasion, not knife cutting, to partially de-epithelialize skin, and harvesting melanocyte donor sites from the scalp, not the skin.

Objectives: To evaluate the color regeneration results and complications of various microdermal grafting procedures for white scar color regeneration.

Methods: We described our use of the two technique refinements of microdermal grafting for white scars and reviewed 65 cases in which different variations of these procedures were used to treat scars on the face and forearms.

Results: Sixty-five patients (36 forearms; 29 faces) were treated, 40 receiving one session, 23 receiving two sessions and 2 receiving three session treatments. The follow up was 6.5 months (range, 4-16). The use of both technical refinements of the procedures produced approximately 15% better color generation than the original procedures after one session of treatment and approximately 20% better than the original procedures after two sessions. The use of histological immunostaining examination showed that the dermabrasion method could preserve more melanocytes around the epidermal-dermal region. The complication rate was reduced.

Conclusions: The use of the scalp as the donor site and partial de-epithelialization by dermabrasion can be safely incorporated into this microdermal grafting procedure for better color regeneration of white scars.
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http://dx.doi.org/10.1093/asj/sjab301DOI Listing
July 2021

Attitudes toward face transplantation in Asia: A survey of Taiwanese population.

Microsurgery 2021 Sep 21;41(6):599-602. Epub 2021 May 21.

Division of Plastic & Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

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http://dx.doi.org/10.1002/micr.30755DOI Listing
September 2021

The Effects of Silver-Releasing Foam Dressings on Diabetic Foot Ulcer Healing.

J Clin Med 2021 Apr 3;10(7). Epub 2021 Apr 3.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan.

Diabetic foot ulcers (DFUs) are a serious complication in diabetic patients and lead to high morbidity and mortality. Numerous dressings have been developed to facilitate wound healing of DFUs. This study investigated the wound healing efficacy of silver-releasing foam dressings versus silver-containing cream in managing outpatients with DFUs. Sixty patients with Wagner Grade 1 to 2 DFUs were recruited. The treatment group received silver-releasing foam dressing (Biatain Ag Non-Adhesive Foam dressing; Coloplast, Humlebaek, Denmark). The control group received 1% silver sulfadiazine (SSD) cream. The ulcer area in the silver foam group was significantly reduced compared with that in the SSD group after four weeks of treatment (silver foam group: 76.43 ± 7.41%, SSD group: 27.00 ± 4.95%, < 0.001). The weekly wound healing rate in the silver foam group was superior to the SSD group during the first three weeks of treatment ( < 0.05). The silver-releasing foam dressing is more effective than SSD in promoting wound healing of DFUs. The effect is more pronounced in the initial three weeks of the treatment. Thus, silver-releasing foam could be an effective wound dressing for DFUs, mainly in the early period of wound management.
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http://dx.doi.org/10.3390/jcm10071495DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8038333PMC
April 2021

The Acceleration of Diabetic Wound Healing by Low-Intensity Extracorporeal Shockwave Involves in the GSK-3β Pathway.

Biomedicines 2020 Dec 30;9(1). Epub 2020 Dec 30.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan.

Previous studies have demonstrated that extracorporeal shock wave therapy (ESWT) could accelerate diabetic wound healing and that the inhibition of glycogen synthase kinase-3β (GSK-3β) is involved in epithelial differentiation during wound healing. This study investigated whether the enhancement of diabetic wound healing by ESWT is associated with the GSK-3β-mediated Wnt/β-catenin signaling pathway. A dorsal skin wounding defect model using streptozotocin-induced diabetic rodents was established. Rats were divided into 4 groups: group 1, normal controls without diabetes; group 2, diabetic controls without treatment; group 3, diabetic rats receiving ESWT; and group 4, rats receiving 6-bromoindirubin-3'oxime (BIO), a GSK-3β inhibitor, to trigger Wnt/β-catenin signaling. Tissue samples were collected and analyzed by immunohistochemical (IHC) staining and quantitative RT-PCR. The ESWT and BIO-treated groups both exhibited significant promotion of wound healing compared to the healing in controls without treatment. RT-PCR analysis of Wnt-1, -3a, -4, -5a, and -10 and β-catenin expression showed significantly increased expression in the ESWT group. The IHC staining showed that Wnt-3a and -5a and β-catenin levels were significantly increased in the ESWT and BIO treatment groups compared to the control groups. ESWT enhancement of diabetic wound healing is associated with modulation of the GSK-3β-mediated Wnt/β-catenin signaling pathway.
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http://dx.doi.org/10.3390/biomedicines9010021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7824083PMC
December 2020

Adipose-derived stromal cells modulating composite allotransplant survival is correlated with B cell regulation in a rodent hind-limb allotransplantation model.

Stem Cell Res Ther 2020 11 11;11(1):478. Epub 2020 Nov 11.

Division of Plastic & Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, 100 Tzyou 1st Rd., Kaohsiung, 80756, Taiwan.

Background: Our previous studies demonstrated that adipose-derived mesenchymal stromal cells (ASCs) have immunomodulatory effects that prolong allograft survival in a rodent hind-limb allotransplant model. In this study, we investigated whether the effects of immunomodulation by ASCs on allograft survival are correlated with B cell regulation.

Methods: B cells isolated from splenocytes were cocultured with ASCs harvested from adipose tissue from rodent groin areas for in vitro experiments. In an in vivo study, hind-limb allotransplantation from Brown-Norway to Lewis rats was performed, and rats were treated with ASCs combined with short-term treatment with anti-lymphocyte serum (ALS)/cyclosporine (CsA) as immunosuppressants. Peripheral blood and transplanted tissue were collected for further analysis.

Result: An in vitro study revealed that ASCs significantly suppressed lipopolysaccharide-activated B cell proliferation and increased the percentage of Bregs. The levels of immunoregulatory cytokines, such as TGF-β1 and IL-10, were significantly increased in supernatants of stimulated B cells cocultured with ASCs. The in vivo study showed that treatment with ASCs combined with short-term ALS/CsA significantly reduced the B cell population in alloskin tissue, increased the proportion of circulating CD45Ra/Foxp3 B cells, and decreased C4d expression in alloskin.

Conclusion: ASCs combined with short-term immunosuppressant treatment prolong allograft survival and are correlated with B cell regulation, C4d expression and the modulation of immunoregulatory cytokines.
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http://dx.doi.org/10.1186/s13287-020-01961-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657354PMC
November 2020

Combination of a CD26 Inhibitor, G-CSF, and Short-term Immunosuppressants Modulates Allotransplant Survival and Immunoregulation in a Rodent Hindlimb Allotransplant Model.

Transplantation 2021 06;105(6):1250-1260

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Background: Recent studies have demonstrated that inhibition of CD26 potentiates stromal cell-derived factor-1α (SDF-1α), promotes tissue regeneration, and suppresses the rejection of organ transplants. This study investigated whether the combination of a CD26 inhibitor (CD26i) with granulocyte colony-stimulating factor (G-CSF) and short-term immunosuppressants modulates vascularized composite tissue allotransplant survival in a rodent orthotopic hindlimb allotransplant model.

Methods: The hindlimb allotransplantation from Brown-Norway to Lewis rats was divided into 4 groups. Group 1 (controls) did not receive any treatment. Group 2 was treated with short-term antilymphocyte serum (ALS) and cyclosporine-A (CsA). Group 3 was administrated CD26i and G-CSF. Group 4 received a combination of CD26i/G-CSF/ALS/CsA. Each subgroup comprised 10 rats. Peripheral blood and sampling of transplanted tissues were collected for immunological and histological analysis.

Results: The results revealed that allotransplant survival was found to be significantly prolonged in group 4 with CD26i/G-CSF/ALS/CsA treatment compared with those in the other groups. The interleukin-10 and transforming growth factor-βl levels, the percentage of CD4+/CD25+/FoxP3+ T cells, as well as the levels of SDF-1α expressions were significantly increased in group 4 compared with those in the other groups. Group 4 revealed a statistical increase in the percentage of donor cells (RT1n) expression in the recipient peripheral blood, and the mixed lymphocyte reaction showed hyporesponsiveness of the T cells to donor alloantigens.

Conclusion: The combination of CD26i/G-CSF and short-term immunosuppressants prolongs allotransplant survival by inducing immunoregulatory effects and enhancing the percentage of SDF-1α expression. This immunomodulatory approach has great potential as a strategy to increase vascularized composite allotransplantation survival.
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http://dx.doi.org/10.1097/TP.0000000000003504DOI Listing
June 2021

Current operative management and therapeutic algorithm of lymphedema in the lower extremities.

Asian J Surg 2021 Jan 17;44(1):46-53. Epub 2020 Sep 17.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore. Electronic address:

Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.
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http://dx.doi.org/10.1016/j.asjsur.2020.08.010DOI Listing
January 2021

Proteomic Analysis of Peri-Wounding Tissue Expressions in Extracorporeal Shock Wave Enhanced Diabetic Wound Healing in a Streptozotocin-Induced Diabetes Model.

Int J Mol Sci 2020 Jul 30;21(15). Epub 2020 Jul 30.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan..

Our former studies have demonstrated that extracorporeal shock wave therapy (ESWT) could enhance diabetic wound healing but the bio-mechanisms remain elusive. This study investigated the changes of topical peri-wounding tissue expressions after ESWT in a rodent streptozotocin-induced diabetic wounding model by using the proteomic analysis and elucidated the molecular mechanism. Diabetic rats receiving ESWT, normal control, and diabetic rats receiving no therapy were analyzed. The spots of interest in proteome analysis were subjected to mass spectrometry to elucidate the peptide mass fingerprints. Protein expression was validated using immunohistochemical staining and related expression of genes were analyzed using real-time RT-PCR. The proteomic data showed a significantly higher abundance of hemopexin at day 3 of therapy but down-regulation at day 10 as compared to diabetic control. In contrast, the level of serine proteinase inhibitor (serpin) A3N expression was significantly decreased at day 3 therapy but expression was upregulated at day 10. Using real-time RT-PCR revealed that serpin-related EGFR-MAPK pathway was involved in ESWT enhanced diabetic wound healing. In summary, proteome analyses demonstrated the expression change of hemopexin and serpin with related MAPK signaling involved in ESWT-enhanced diabetic wound healing. Modulation of hemopexin and serpin related pathways are good strategies to promote wound healing.
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http://dx.doi.org/10.3390/ijms21155445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7432617PMC
July 2020

The application and value of continuous nursing in patients after coronary artery bypass grafting.

J Cardiothorac Surg 2020 Jul 10;15(1):168. Epub 2020 Jul 10.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, 100 TzYou 1st Rd, Kaohsiung City, 80756, Taiwan.

Objective: To investigate the application and value of continuous nursing after coronary artery bypass grafting.

Methods: The clinical data of 62 patients after coronary artery bypass grafting from January 2016 to January 2018 were analyzed retrospectively. According to the nursing mode, the patients were divided into two groups: the continuous nursing group (n = 30) and the conventional nursing group (n = 32). All patients completed Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) at admission and 1 year after operation. All patients completed Seattle Angina Pectoris Questionnaire (SAQ) at discharge and 1 year after operation.

Results: All patients were followed up for more than one year. One year after operation, SAQ score in five items in continuous nursing group was significantly better than that in conventional nursing group.(P < 0.05) The continuous nursing group exhibited significantly decreased SAS and SDS scores 1 year after surgery compared to the preoperative SAS and SDS scores.(P < 0.05) The SAS and SDS scores of the continuous nursing group were significantly better than those of the conventional nursing group 1 year after surgery.(P < 0.05) Then incidence rate of chest tightness or chest pain and coronary restenosis in continuous nursing group were significantly less than that in conventional nursing group.(P < 0.05).

Conclusion: Continuous nursing improved patient compliance with treatment and reduces the occurrence of complications. The patient also receives proper psychological evaluations, which relieve patient anxiety and depression and improve the quality of life.
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http://dx.doi.org/10.1186/s13019-020-01210-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350717PMC
July 2020

Low-Grade Myofibroblastic Sarcoma Arising From Keloid Scar on the Chest Wall After Thoracic Surgery.

Ann Thorac Surg 2020 12 4;110(6):e469-e471. Epub 2020 Jun 4.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

Keloids are considered as benign fibroproliferative skin tumors, and rare cases of malignancies have been reported. We present a case of low-grade myofibroblastic sarcoma arising from a recurrent painful keloid scar on the right chest wall after video-assisted thoracic surgery for pneumothorax in a 77-year-old man. Wide composite excision of the keloid, surrounding ribs, and partial diaphragm were performed. The chest wall pleural defect was reconstructed with Teflon (Chemours, Wilmington, DE), and soft tissue was reconstructed with a transverse rectus abdominis myocutaneous flap. This case highlights that refractory keloids may be considered a harbinger of malignancy.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.063DOI Listing
December 2020

Telemedicine algorithm for chronic wound care during COVID-19.

Int Wound J 2020 Oct 3;17(5):1535-1537. Epub 2020 Jun 3.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

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http://dx.doi.org/10.1111/iwj.13409DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300820PMC
October 2020

Covid-19 guidance algorithm for advanced head and neck cancer reconstruction.

Microsurgery 2020 09 22;40(6):724-725. Epub 2020 May 22.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Chung Ho Memorial Hospital, Kaohsiung, Taiwan.

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http://dx.doi.org/10.1002/micr.30603DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280603PMC
September 2020

Decision algorithm and surgical strategies for managing tracheocutaneous fistula.

J Thorac Dis 2020 Mar;12(3):457-465

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung.

Background: Persistent tracheocutaneous fistula (TCF) is a complication of prolonged use of tracheostomy tube. Although many procedures exist to correct this issue, there is no consensus regarding its optimal management. We constructed a decision algorithm to determine appropriate surgical strategies for TCF repair.

Methods: Retrospectively reviewing our hospital's records, we found fourteen consecutive patients who had received surgical repair of tracheocutaneous fistula (primary closure or advanced local flap) between February 2013 and December 2018 and collected data relevant to their cases.

Results: We identified 11 male and 3 female patients. Duration of tracheostomy dependence was 8.1±4.7 months, and timespan from decannulation to surgical closure 7.4±6.5 months. Seven patients received primary closures, six received hinged turnover flaps, and one received random and perforator flap reconstruction. There was no perioperative mortality or morbidity except for one patient requiring a repeat tracheostomy 11 months after TCF repair due to pneumonia and subsequent respiratory failure. We used our findings and those reported in the literature to construct a modified risk factor scoring system based on patient's physical status, major comorbidities, perifistular soft tissue condition, and nutritional status and an algorithm for managing TCF based on the patients' fistula size and modified risk factor scores.

Conclusions: In conclusion, we were able to review our cases and those of other studies to create a risk scoring system and a decision algorithm that we believe will help optimize patient-directed surgical management of TCF repair.
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http://dx.doi.org/10.21037/jtd.2020.01.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138993PMC
March 2020

A meta-analysis of perventricular device closure of doubly committed subarterial ventricular septal defects.

J Cardiothorac Surg 2020 Jan 28;15(1):28. Epub 2020 Jan 28.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, 100 TzYou 1st Rd, Kaohsiung City, 80756, Taiwan.

Background: To investigate the safety and efficacy of perventricular device closure of doubly committed subarterial ventricular septal defects (dcsVSDs).

Methods: PubMed and Scopus were searched for studies in English that focused on perventricular device closure of dcsVSDs and were published up to the end of September 2019. We used a random-effects model to obtain pooled estimates of the success and complication rates.

Results: A total of 9 publications including 459 patients with dcsVSDs were included. The median follow-up duration ranged from 2 months to 5 years, with the mean age of patients ranging from 6.1 months to 4.5 years. The pooled estimate of the overall success rate of device closure in the 9 studies was 0.89 (95% CI: 0.86-0.93, I = 26.5%, P = 0.208). Further meta-regression analysis indicated no significant correlation between the success rate and the following factors: publication year, sample size, study type, mean age, mean weight, mean VSD size, and ratio of device size/weight. The pooled rate of postoperative aortic regurgitation was 0.045 (95% CI: 0.018-0.071, I = 50.96%, P = 0.000). The pooled rate of follow-up aortic regurgitation (AR) was 0.001 (95% CI, - 0.003-0.004, I = 63.00%, P = 0.009.) The pooled estimated rate of severe intraoperative complications was 0.106 (0.073-0.140, I = 70.7%, P = 0.208). Postoperative and follow-up complications were rare. No occurrence of a complete atrioventricular block was reported up to the last follow-up visit.

Conclusions: Perventricular device closure may be an alternative to conventional surgical repair in selected patients with dcsVSDs. The success rate was stable regarding the publication year and sample size, suggesting a relatively short learning curve and the technique's potential for application.
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http://dx.doi.org/10.1186/s13019-020-1062-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986052PMC
January 2020

Reply: Hyaluronic Acid-Povidone-Iodine Compound Facilitates Diabetic Wound Healing in a Streptozotocin-Induced Diabetes Rodent Model.

Plast Reconstr Surg 2020 02;145(2):455e-456e

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Faculty of Medicine, College of Medicine, Regeneration Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan.

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http://dx.doi.org/10.1097/PRS.0000000000006450DOI Listing
February 2020

Effects of the Sounds of Different Mechanical Mitral Valves on Quality of Life at Different Follow-Up Times: A Single-Center Study.

Ann Thorac Cardiovasc Surg 2020 Aug 10;26(4):209-215. Epub 2020 Jan 10.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Objective: To compare the effects of the sounds of different types of mechanical mitral valves on the quality of life (QoL) of patients at different follow-up times.

Methods: We collected data from 150 patients who underwent mechanical mitral valve replacement. Three time points were assessed, including at discharge, the third postoperative month (POM3), and the twelfth postoperative month (POM12). The SF-36 and a self-questionnaire were used to assess the QoL.

Results: Regarding the SF-36 scores, the ATS valve was superior to the Sorin and SJM valves in terms of some items. Moreover, the scores at discharge of all three mechanical valve groups were lower than those at POM3 and POM12. For the self-questionnaire scores, with the increase in postoperative time, the number of patients affected by the mechanical valve sounds decreased gradually. Considering the relevant influencing factors, older women were more likely to be affected by the valve sounds than were younger individuals and men.

Conclusion: The overall postoperative QoL improved for patients who underwent mechanical mitral valve replacement. In the comparative study, the impact of the ATS valve was better than those of the Sorin and SJM valves, but this difference gradually disappeared over time.
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http://dx.doi.org/10.5761/atcs.oa.19-00281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7435132PMC
August 2020

Comparison of quality of life in patients who underwent mechanical mitral valve replacement: star GK vs SJM.

J Cardiothorac Surg 2020 Jan 7;15(1). Epub 2020 Jan 7.

Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China.

Background: We want to compare the impact on health-related quality of life (HRQoL) between the Star GK and the SJM valve in the Chinese population.

Methods: We retrospectively enrolled a total of 172 patients who had undergone mechanical mitral valve replacement (MVR) (SJM valve in 87 patients and Star GK valve in 85 patients) at our institution from January 2013 to December 2015. We measured the sound pressure level, and used 2 self-administered questionnaires and the Chinese version of SF-36 to measure the HRQoL and valve-specific questions to evaluate patient anxiety.

Results: The Star GK group and the SJM group were similar in age, gender, body surface area, diameter of the implanted valve, underlying disease and current median NYHA class. Regarding the valve sound pressure perceived 1 year after operation, the SJM valve was slightly quieter than the Star GK valve, but the sound pressures of the two valves showed no significant differences. No significant differences in any of the eight subscales of the SF-36 were found between the two groups.

Conclusions: The present study suggests that the Star GK valve is similar to the SJM valve in its impact on HRQoL and audibility of mechanical sound in the Chinese population.
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http://dx.doi.org/10.1186/s13019-020-1045-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947926PMC
January 2020

Health-related quality of life in children and adolescents undergoing intraoperative device closure of isolated perimembranous ventricular septal defects in southeastern China.

J Cardiothorac Surg 2019 Dec 16;14(1):218. Epub 2019 Dec 16.

Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China.

Objectives: To investigate the health-related quality of life (HRQOL) in children and adolescents who underwent intraoperative device closure of perimembranous ventricular septal defects (pmVSDs).

Methods: From October 2017 to January 2018, a total of 126 children and adolescents with isolated pmVSDs who underwent intraoperative device closure were enrolled in this study. We used the Pediatric Quality of Life Inventory Measurement Models 4.0 generic core scales to measure HRQOL 24 h before the operation and three months and one year after surgery.

Results: A total of 126 patients were successfully occluded. No severe complications occurred during the operative time, and 1 case of Mobitz type I atrioventricular block (AVB) and 1 case of complete cAVB occurred during the postoperative period. Compared with the data before the operation, the total score and five domain scores, including physical, psychosocial, emotional, social and psychological functioning, were significantly higher at three months after the operation. In addition, the total score, physical functioning score, and the psychosocial functioning score at the 1-year follow-up were even higher than those at 3 months after the operation.

Conclusions: The present study suggests that intraoperative device closure of pmVSD could improve health-related quality of life in children/adolescents and that the improvement may progress as the time after the operation increases. Further studies should concentrate on comparisons with other medical methods, larger samples, and longer follow-up periods.
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http://dx.doi.org/10.1186/s13019-019-1040-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916053PMC
December 2019

Use of Extended Pedicled Transverse Rectus Abdominis Myocutaneous Flap for Extensive Chest Wall Defect Reconstruction After Mastectomy for Locally Advanced Breast Cancer.

Ann Plast Surg 2020 01;84(1S Suppl 1):S34-S39

Division of Breast Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University.

Background: The reconstruction of a large postmastectomy chest wall defect for patients with stage III/IV breast cancer is a challenge for plastic surgeons. In this study, we present the application of an extended transverse rectus abdominis myocutaneous (TRAM) flap to easily and safely reconstruct these defects.

Patients And Methods: A retrospective review from November 1997 to November 2016 revealed that 65 patients with stage III/IV breast cancer immediately underwent postmastectomy TRAM flap reconstruction. In total, 16 patients were enrolled in this study based on the inclusion criteria of a postmastectomy chest skin defect size of greater than or equal to 100 cm and a TRAM flap size of greater than or equal to 80% of the lower abdominal area for reconstruction.

Results: Eleven (68.9%) and 5 patients (31.3%) were diagnosed with stage III and stage IV breast cancer, respectively. The chest wall skin defects ranged from 135 to 440 cm. All flap areas exceeded 80% of the lower abdominal area. Overall, 100% of the harvested flaps were used in 3 patients, and only 1 patient had marginal necrosis in zone IV. No total flap loss was observed. The average length of hospital stay was 5.8 days, and the mean follow-up duration was 46.6 months (range, 4.5-117.7 months). On a Likert scale, the mean follow-up satisfaction score of 10 patients was 4.7.

Conclusions: Even when the flap area exceeded 80% of the lower abdominal area, the extended TRAM flap proved an effective and viable method for the immediate reconstruction of extensive postmastectomy chest wall skin defects, resulting in few minor complications and high follow-up satisfaction scores.
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http://dx.doi.org/10.1097/SAP.0000000000002188DOI Listing
January 2020

Fat Grafting for Facial Contouring (Nose and Chin).

Clin Plast Surg 2020 Jan 21;47(1):91-98. Epub 2019 Oct 21.

Department of Surgery, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung City 807, Taiwan, Taiwan.

The concept of microautologous fat transplantation (MAFT), proposed by Lin and colleagues in 2007, emphasized that the volume of each delivered parcel should be less than 0.01 mL to avoid potential fat grafting morbidities. The MAFT-GUN facilitates control of the parcel volume and therefore substantially avoids central necrosis and associated complications. In this article, the authors present a simple, reliable, and consistent procedure based on MAFT for profiloplasty. Favorable outcomes with sustainable long-term effectiveness were obtained, further confirming that the MAFT technique is an alternative for facial contouring in the nose and chin.
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http://dx.doi.org/10.1016/j.cps.2019.08.009DOI Listing
January 2020

Triamcinolone Acetonide Suppresses Keloid Formation Through Enhancing Apoptosis in a Nude Mouse Model.

Ann Plast Surg 2019 10;83(4S Suppl 1):S50-S54

From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital.

Background: Current understanding of steroid treatments for keloids is in regards to modulation of inflammation, proliferation, and apoptosis, with no in vivo study on the latter. Using a nude mouse model, we investigated whether triamcinolone acetonide (TA) injections induce keloids regression through enhancing apoptosis.

Materials And Methods: Thirty-six keloid specimens (1 × 1 cm) were harvested from 6 patients and separated into sets of 2 from the same patient: no treatment and intralesional TA injection (0.4 mg/mL/kg) at 8 weeks of postimplantation. One set was implanted in each of 18 randomly selected nude mice, which were separated into 3 groups based on time of keloid harvesting after treatment: group A, 2 weeks; group B, 8 weeks; and group C, 14 weeks. Each group had 1 set of specimen from each patient. Histological staining was performed with hematoxylin and eosin stain. Immunohistochemistry staining was performed for human-prolyl 4-hydroxylase (hPH4) and caspase 3 protein, along with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay.

Results: All keloid specimens survived, with no noted overgrowth. Hematoxylin and eosin staining revealed dense extracellular matrix and viable fibroblasts, and hPH4 immunohistochemistry revealed strong expression, demonstrating keloid viability. Caspase 3 protein and TUNEL expressions were significantly increased in the treatment versus control groups, demonstrating that TA injections induced apoptosis.

Conclusions: Triamcinolone acetonide intralesional injections significantly increased apoptosis in keloids, represented by increased caspase 3 protein and TUNEL expressions, supporting that steroids suppress keloids in part owing to enhancement of apoptosis.
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http://dx.doi.org/10.1097/SAP.0000000000002090DOI Listing
October 2019

Fluorescent Nanodiamonds Enable Long-Term Detection of Human Adipose-Derived Stem/Stromal Cells in an In Vivo Chondrogenesis Model Using Decellularized Extracellular Matrices and Fibrin Glue Polymer.

Polymers (Basel) 2019 Aug 23;11(9). Epub 2019 Aug 23.

Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linko, Taoyuan 333, Taiwan.

Clinically available materials, including allogeneic irradiated costal cartilage and fibrin glue polymer, were used as scaffolds for in vivo chondrogenic differentiation of human adipose-derived stem/stromal cells (hASCs) in the attempt to develop a more efficient treatment over current methods. Current studies include the use of growth-factor stimulation, tissue engineering, and biocompatible materials; however, most methods involve complicated processes and pose clinical limitations. In this report, the xenografts in the experimental group composed of a diced decellularized cartilage extracellular matrix (ECM), hASCs, and fibrin glue polymer were implanted into the subcutaneous layer of nude mice, and the results were compared with two groups of controls; one control group received implantation of decellularized cartilage ECM and fibrin glue polymer, and the other control group received implantation of hASCs mixed with fibrin glue polymer. To evaluate whether hASCs had in vivo chondrogenesis in the xenografts, hASCs were labeled with fluorescent nanodiamonds (FNDs), a biocompatible and photostable nanomaterial, to allow for long-term detection and histological analysis. Increased cellularity, glycosaminoglycan, and collagen deposition were found by the histological examination in the experimental group compared with control groups. With the background-free detection technique and time-gated fluorescence imaging, the numbers and locations of the FND-labeled hASCs could be detected by confocal microscopy. The chondrocyte-specific markers, such as aggrecan and type II collagen, were colocalized with cells containing signals of FNDs which indicated in vivo chondrogenesis of hASCs. Taken together, functional in vivo chondrogenesis of the hASCs could be achieved by clinically available decellularized cartilage ECM and fibrin glue polymer in the nude mice model without in vitro chondrogenic induction. The fluorescent signals of FNDs in hASCs can be detected in histological analysis, such as hematoxylin and eosin staining (H&E staining) without the interference of the autofluorescence. Our study may warrant future clinical applications of the combination of decellular cartilage ECM, fibrin glue polymer, and hASCs for cartilage repair.
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http://dx.doi.org/10.3390/polym11091391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780225PMC
August 2019

Differential Response of Non-cancerous and Malignant Breast Cancer Cells to Conditioned Medium of Adipose tissue-derived Stromal Cells (ASCs).

Int J Med Sci 2019 2;16(6):893-901. Epub 2019 Jun 2.

Institute of Stem Cell and Translational Cancer Research, Chang Gung Memorial Hospital at Linko, Taoyuan, Taiwan.

: The application of adipose tissue-derived stromal cells (ASCs) in regenerative medicine has become a growing trend due to its abundance and differentiation potentials. However, several breast cancer studies indicated that ASCs promote tumor progression, therefore, the use of ASCs for reconstruction after oncological surgery poses potential risks. In this study, we aimed to examine whether cancerous or non-cancerous breast cells will exhibit different responses to ASC-derived CM. : ASCs were isolated from residuals of subcutaneous adipose tissue obtained from patients undergoing surgery. Cancerous MCF-7, MDA-MB231, and MDA-MB468 cell lines and one non-cancerous M10/H184B5F5 cell line were cultured with variant concentrations of ASC-derived conditioned medium (CM) for analysis. : ASC-derived CM significantly reduced cell viability by triggering apoptosis in MCF-7, MDA-MB231, and MDA-MB468 cell lines. ATM-Chk2-dependent DNA damage response was activated early in cancer cells when exposed to ASC-derived CM. By contrast, prompted cell proliferation instead of cell death was detected in M10/H184B5F5 cells under the treatment of lower CM concentration. Even when exposed to the highest concentration of CM, only cell cycle arrest accompanied by a weak DNA damage response were detected in M10/H184B5F5 cells, no cell deaths were observed. : Overall, this study demonstrated that cancerous and non-cancerous breast cells respond differently to ASC-derived CM. ASC-derived CM triggered significant cell death in breast cancer cell lines, however non-cancerous breast cells exhibited dissimilar response to ASC-derived CM.
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http://dx.doi.org/10.7150/ijms.27125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6643111PMC
February 2020

Glucagon-Like Peptide-1 Receptor Agonist Attenuates Autophagy to Ameliorate Pulmonary Arterial Hypertension through Drp1/NOX- and Atg-5/Atg-7/Beclin-1/LC3β Pathways.

Int J Mol Sci 2019 Jul 12;20(14). Epub 2019 Jul 12.

Department of Pharmacology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan.

Mitochondrial dysfunction is associated with cardiovascular diseases and diabetes. Pulmonary arterial hypertension (PAH) is characterized by pulmonary vascular remodeling, and the abnormal proliferation, apoptosis and migration of pulmonary arterial smooth muscle cells (PASMCs). The glucagon-like peptide-1 (GLP-1) receptor agonist, liraglutide, has been shown to prevent pulmonary hypertension in monocrotaline-exposed rats. The aim of this study was to investigate the effect of liraglutide on autophagy, mitochondrial stress and apoptosis induced by platelet-derived growth factor BB (PDGF-BB). PASMCs were exposed to PDGF-BB, and changes in mitochondrial morphology, fusion-associated protein markers, and reactive oxygen species (ROS) production were examined. Autophagy was assessed according to the expressions of microtubule-associated protein light chain 3 (LC3)-II, LC3 puncta and Beclin-1. Western blot analysis was used to assess apoptosis, mitochondrial stress and autophagy markers. Liraglutide significantly inhibited PDGF-BB proliferation, migration and motility in PASMCs. PDGF-BB-induced ROS production was mitigated by liraglutide. Liraglutide increased the expression of α-smooth muscle actin (α-SMA) and decreased the expression of p-Yes-associated protein (p-YAP), inhibited autophagy-related protein (Atg)-5, Atg-7, Beclin-1 and the formation of LC3-β and mitochondrial fusion protein dynamin-related (Drp)1. Therefore, liraglutide can mitigate the proliferation of PASMCs via inhibiting cellular Drp1/nicotinamide adenine dinucleotide phosphate (NADPH) oxidases (NOX) pathways and Atg-5/Atg-7/Beclin-1/LC3β-dependent pathways of autophagy in PAH.
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http://dx.doi.org/10.3390/ijms20143435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6678531PMC
July 2019

Widespread dystrophic calcinosis cutis in both thighs associated with Sjögren's syndrome: A case of 20-year follow-up.

Kaohsiung J Med Sci 2019 Oct 27;35(10):648-650. Epub 2019 Jun 27.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

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http://dx.doi.org/10.1002/kjm2.12103DOI Listing
October 2019

Extended Extracorporeal Shockwave Therapy for Chronic Diabetic Foot Ulcers: A Case Series.

Wounds 2019 May 15;31(5):132-136. Epub 2019 Mar 15.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; and Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

Introduction: It is hypothesized that cumulative extended application of extracorporeal shockwave therapy (ESWT) can be beneficial to sustain the effect of ESWT and improve the long-term outcome in chronic diabetic foot ulcers (DFUs).

Objective: The purpose of this study is to investigate the effectiveness of multiple extended booster ESWT to maintain the effects of ESWT on the outcomes of chronic DFUs.

Materials And Methods: Four patients with a DFU were treated with ESWT, including 1 patient with 12 treatments and 3 patients with 6 treatments. Evaluations included clinical assessment, blood flow perfusion, and biopsy of the ulcers.

Results: At 48 weeks, the results showed completely healed ulcers in 2 patients and improved ulcers in the other 2 patients. In the DFU Scale Short-Form, the score decreased in 1 patient and remained unchanged in 3 at 48 weeks. Blood perfusion increased in 1 patient but remained unchanged in 3. In immunohistochemical analysis, the angiogenic, anti-inflammatory, proliferative, and tissue repair biomarkers were elevated in 1 patient and decreased in 3.

Conclusions: The effects of ESWT appear to maintain certain levels for an extended period of time at 1 year but start to show deterioration on tissue viability. Therefore, it is speculated that intermittent booster ESWT may maintain the effects of ESWT and sustain the tissue viability and repairing. The use of ESWT appeared to be effective for DFU treatment, and extended ESWT showed a tendency of sustaining ESWT effects when multiple booster treatments are utilized in patients with a DFU.
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May 2019

Changes in the levels of inflammatory markers after transthoracic device closure of ventricular septal defects in pediatric patients.

J Cardiothorac Surg 2019 Apr 8;14(1):70. Epub 2019 Apr 8.

Department of Cardiac Surgery, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, the Daoshan road 18, Gulou District, Fuzhou, 350001, People's Republic of China.

Background: Transthoracic device closure of ventricular septal defect (VSD) is widely used in the clinic, especially in China. Changes in inflammatory marker levels after transthoracic device closure of VSD in pediatric patients have not been reported.

Methods: We retrospectively collected clinical data for 85 pediatric patients in our hospital from September 2017 to January 2018. The patients were divided into two groups according to treatment (device group vs. surgical group). The clinical and experimental data from the two groups were statistically analyzed.

Results: Clinical outcomes were good in all patients without any fatal complications. Similar increasing trends in inflammatory markers (white blood cell (WBC) count, procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6)) were found in the two groups, both of which showed noticeable systemic inflammatory responses. In addition, no significant difference in the postoperative levels of inflammatory markers was observed between these two groups.

Conclusions: Although transthoracic device closure of VSD seems to be less traumatic and involves a quicker recovery, it also induces a systemic inflammatory response as measured by WBC count and PCT, CRP and IL-6 levels, and the altered trends in inflammatory markers were similar to those of conventional surgery under CPB.
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http://dx.doi.org/10.1186/s13019-019-0900-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454635PMC
April 2019

The Epidemiology and Clinical Features of Blepharoptosis in Taiwanese Population.

Aesthetic Plast Surg 2019 08 14;43(4):964-972. Epub 2019 Mar 14.

Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, No.100, Tzyou 1st Rd, Kaohsiung, 807, Taiwan.

Background: Blepharoptosis describes a condition of low-lying upper eyelid that may affect individuals of all ages under various etiologies. It may be of congenital or acquired form by the timing of onset or be divided into myogenic, neurogenic, aponeurotic, or mechanical types according to the mechanism. Our goal was to report the characteristics of age-specific blepharoptosis and to analyze the association between levator function (LF) and ptosis severity of each ptosis subtype.

Materials And Methods: The retrospective, single-center, cross-sectional study consisted of patients diagnosed with blepharoptosis in the plastic surgery practice at a medical center between September 2009 and May 2017. We reported patients' age at presentation, sex, laterality of ptosis, etiology, classification, and evaluation of ptosis including levator function and ptosis severity.

Results: During a nine-year span of study, a total of 1975 eyelids of 1164 Taiwanese patients aged between 2 and 88 years were enrolled in the research (mean = 57.73 ± 13.41 years). The female-to-male ratio was 2.72 (95% confidence interval [CI]: p < 0.0001). Acquired blepharoptosis and bilateral blepharoptosis were more frequently observed (55.85%, p < 0.0001 and 69.67%, p < 0.0001, respectively). In age-specific relative incidence of blepharoptosis, myogenic ptosis was the majority in patients younger than 40 years. Early onset of aponeurotic ptosis was observed in young contact lenses wearers. Aponeurotic blepharoptosis was the predominant type of ptosis in the senior population older than 40 years (p < 0.0001). Among the subtypes, mechanical ptosis had the most preserved LF (p < 0.0001). LF and MRD1 had statistically positive correlations in all subtypes of blepharoptosis, in which neurogenic ptosis demonstrated the severest levator dysfunction for each millimeter in MRD1 reduction.

Conclusions: Of the 1164 Taiwanese patients, blepharoptosis had a higher propensity for female gender and the age between the second to fourth decades. Bilateral involvement of blepharoptosis with acquired type was frequently diagnosed. Myogenic ptosis had a preponderance in age younger than 40 years, while aponeurotic ptosis usually affects senile population. Many mild degree myogenic ptosis was simultaneously recognized in young-aged adults seeking aesthetic double eyelid surgery. Early onset of acquired aponeurotic ptosis was also observed in contact lens wearers given the trend of decorative contact lens use. Levator dysfunction was implicated in the pathology of not only myogenic ptosis but aponeurotic, mechanical, and neurogenic ptosis. Moreover, levator function of neurogenic ptosis was most severely impacted in each MRD reduction among all subtypes of blepharoptosis.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-019-01344-2DOI Listing
August 2019

Hyaluronic Acid-Povidone-Iodine Compound Facilitates Diabetic Wound Healing in a Streptozotocin-Induced Diabetes Rodent Model.

Plast Reconstr Surg 2019 05;143(5):1371-1382

From the Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital; the Department of Healthcare Materials, Material and Chemical Research Laboratories, Industrial Technology Research Institute; the Department of Orthopaedics, Kaohsiung Chang Gung Memorial Hospital; the Faculty of Medicine, College of Medicine, Orthopaedic Research Center, Kaohsiung Medical University; and the Department of Biological Sciences, National Sun Yat-sen University.

Background: This study investigated whether a hyaluronic acid-povidone-iodine compound can enhance diabetic wound healing.

Methods: A dorsal skin defect (6 × 5 cm) in a streptozotocin-induced diabetes rodent model was used. Seventy male Wistar rats were divided into seven groups: I, normal control; II, diabetic control, no treatment; III, diabetic rats, lower molecular weight (100 kDa) hyaluronic acid; IV, rats, higher molecular weight (1000 kDa) hyaluronic acid; V, rats, 0.1% povidone-iodine; VI, rats, lower molecular weight hyaluronic acid plus povidone-iodine; and VII, rats, higher molecular weight hyaluronic acid plus povidone-iodine. Histologic examination was performed with hematoxylin and eosin staining. CD45, Ki-67, prolyl 4-hydroxylase, and vascular endothelial growth factor were evaluated with immunohistochemical staining.

Results: Compared with the control, higher molecular weight hyaluronic acid plus povidone-iodine-treated rats had significantly reduced wound area (p < 0.001). Higher molecular weight hyaluronic acid plus povidone-iodine increased wound healing time when compared with higher molecular weight hyaluronic acid, povidone-iodine, or lower molecular weight hyaluronic acid plus povidone-iodine. Histology revealed significantly increased neovessels and suppressed inflammatory response in the higher molecular weight hyaluronic acid plus povidone-iodine group when compared with the control group. Immunohistochemical staining revealed significantly increased Ki67, prolyl 4-hydroxylase, and vascular endothelial growth factor expression, and suppressed CD45 expression in the higher molecular weight hyaluronic acid plus povidone-iodine group when compared with the other groups.

Conclusion: Higher molecular weight hyaluronic acid plus povidone-iodine complex dressing significantly facilitated diabetic wound healing via increasing neovascularization and tissue regeneration and suppressing a proinflammatory response.
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http://dx.doi.org/10.1097/PRS.0000000000005504DOI Listing
May 2019
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