Mithun Sinha

Lymphedema is chronic swelling from lymphatic dysfunction. The vascular delay phenomenon is used in flap reconstruction to increase flap viability through staged selective partial disruption of blood supply to enhance flap survival, followed by flap transfer 7–10 days later. A similar corollary for lymphatics remains unknown. The purpose of this study was to evaluate whether lymphatic preconditioning with staged disruption of lymphatics in the murine hindlimb lymphedema model can be protective against lymphedema. C57BL/6 mice underwent 20 Gy hindlimb irradiation. Group 1 (immediate lymphatic disruption) underwent a circumferential skin incision, complete lymphatic disruption, and popliteal lymph node excision in a single-stage operation. Group 2 (delayed lymphatic disruption) underwent a semi-circumferential inguinal skin incision and dominant lymphatic transection and, 7 days later, received a circumferential skin incision, complete lymphatic transection, and popliteal lymphadenectomy. Paw thickness was measured weekly. Near-infrared laser lymphangiography and immunohistochemistry were performed on D35. Group 2 had a lower average paw thickness (p = 0.0008) and greater lymphatic clearance signal intensity at 24 h (p = 0.0035). Immunohistochemistry indicated an abundance of the lymphatic endothelial-specific marker podoplanin in Group 2 compared to Group 1 (p = 0.03). This study demonstrates evidence for a novel concept of a lymphatic delay phenomenon parallel to the well-known vascular delay phenomenon.

Introduction: Lymphedema is limb swelling secondary to lymphatic injury. Utilization of negative pressure therapy (NPT) has been shown to stimulate lymphatic vessel density, but the effect of NPT on secondary lymphedema is unknown. The purpose of this study was to evaluate the role of prophylactic NPT in murine hindlimb lymphedema model. Methods: The murine hindlimb model of lymphedema was used. Mice underwent 20-Gy irradiation of one hindlimb. One-week post-radiation, an incision in the proximal hindlimb was created to disrupt lymphatic vessels and remove popliteal lymph nodes. Mice were divided into two groups: group 1 (NPT) and group 2 (no NPT). Group 1 received a negative pressure of 75 mm Hg on the lymphedema-induced hindlimb for 12 consecutive hours in the first 5 postoperative days (PODs). Group 2 did not receive NPT. Paw thickness measurements and near-infrared laser lymphangiography were measured. Results: The study included 16 mice (group 1 n = 6, group 2 n = 10). Paw thickness on POD 21 in group 1 was 2.9 ± 0.3 mm compared to 3.3 ± 0.3 mm in group 2 (p = 0.02). On POD 35, the average paw thickness was 2.4 ± 0.1 mm in group 1 compared to 3.2 ± 0.2 mm (p = 0.001). Lymphangiography dye clearance was greater in group 1 compared to group 2 (p = 0.008). Conclusions: Mice in the hindlimb lymphedema model that underwent NPT in the early postoperative period had less paw thickness swelling and better lymphatic function than mice that did not have NPT. NPT decreased lymphedema when used prophylactically following lymphatic injury.

Objective: To investigate the prevalence of infection in diabetic foot ulcers (DFUs) and its association with lower limb major and minor amputations, examining demographic and socioeconomic factors influencing DFU outcomes. Research design and methods: This retrospective study analyzed data from the Indiana Network for Patient Care (INPC) from January 2019 to May 2024. A total of 27,078 patients with DFUs were included, aged 9 to 103 years. Data included demographics, clinical encounters, ICD-10, CPT codes, laboratory values, and microbiological assessments. Analyses included Pearson correlation, logistic regression, and one-sample proportion tests. Results: Patients were predominately male (64.3%) and female (35.7%) with a mean age of 63.8 years. DFU prevalence showed significant inverse correlation with median income (r=0.2108, p=0.0016); lower-income areas (median income < $64,200) had DFU rates > 5.0 per 1,000 population. Of cultured specimens, 33.79% showed infections, primarily Staphylococcus spp. (22.52%) and Streptococcus spp. (11.27%). In major and minor amputation cases with microbial data available, Staphylococcus spp. (22.75%), Enterococcus spp. (11.86%) and Streptococcus spp. (10.42%) genera were most common. Osteomyelitis increased amputation odds by 7.83 times (pStaphylococcus , Enterococcus and Streptococcus genera were strongly associated with amputation risk. These findings have important clinical implications: early identification of these specific bacterial pathogens could guide targeted antibiotic therapy and inform risk stratification for amputation prevention. Improved bacterial identification could enhance DFU management and reduce complications such as amputation.

Bacterial biofilms are structured microbial communities enclosed within a self-produced extracellular polymeric substance matrix composed of polysaccharides, proteins, extracellular DNA, and lipids. This matrix promotes adhesion, structural stability, and the development of heterogeneous microenvironments that restrict antimicrobial penetration and shield bacteria from host immune responses. As a result, biofilms are major contributors to chronic, recurrent, device-related, and difficult-to-treat infections, posing a major challenge for clinical management and antimicrobial stewardship. This review summarizes current understandings of biofilm biology, its clinical relevance, including the stages of biofilm development, the composition and protective roles of the matrix, and the physiological heterogeneity that arises during maturation. It also examines key mechanisms underlying biofilm tolerance and resistance, such as limited antibiotic diffusion, and sequestration, enzymatic inactivation, efflux pump upregulation, persister cell formation, and horizontal gene transfer. In addition, it highlights important clinical settings in which biofilms are implicated, including cystic fibrosis, chronic wounds, osteomyelitis, implant- or device-associated infections, and breast implant illness, in which persistent implant-associated biofilms and the resulting chronic inflammatory milieu have been hypothesized to contribute to local and systemic manifestations in a subset of patients. The review further discusses conventional and emerging approaches for biofilm detection alongwith real-time monitoring. Biofilm-associated infections remain difficult to eradicate because persistence is driven by multiple interconnected protective mechanisms. Effective management therefore requires integrated strategies that combine accurate detection with multifaceted therapies, including antibiotics alongside matrix-disrupting enzymes, quorum-sensing inhibitors, bacteriophages, metabolic reactivators, and nanotechnology-based delivery systems. Advances in multi-omics and system-level modeling will be essential for developing next-generation strategies to prevent, monitor, and treat biofilm-associated disease.

Background: A subset of females with breast implants have reported a myriad of nonspecific systemic symptoms collectively termed systemic symptoms associated with breast implants (SSBI). SSBI symptoms are similar to manifestations associated with autoimmune and connective tissue disorders. Breast tissue is rich in adipose cells, comprised of lipids. Insertion of an implant creates an oxidative environment leading to lipid oxidation. Oxylipins can influence immune responses and inflammatory processes. Objectives: In this study we explored the abundance of a spectrum of oxylipins in the periprosthetic tissue surrounding the breast implant. Because oxylipins are immunogenic, we sought to determine if they were associated with the SSBI patients. We have also attempted to determine if the common manifestations exhibited by such patients have any association with oxylipin abundance. Methods: The study included 120 patients divided into 3 cohorts. We analyzed 46 patients with breast implants exhibiting manifestations associated with SSBI; 29 patients with breast implants not exhibiting manifestations associated with SSBI (control cohort I, non-SSBI); and 45 patients without implants (control cohort II, no-implant tissue). Lipid extraction and oxylipin quantification were performed with liquid chromatography mass spectrometry (LC-MS/MS). LC-MS/MS targeted analysis of the breast adipose tissue was performed. Results: Of the 15 oxylipins analyzed, 5 exhibited increased abundance in the SSBI cohort when compared to the non-SSBI and no-implant cohorts. Conclusions: The study documents the association of the oxylipins with each manifestation reported by the patient. This study provides an objective assessment of the subjective questionnaire, highlighting which symptoms may be more relevant than the others. Level of Evidence: 4:

This study investigates a mechanistic link of bacterial biofilm–mediated host-pathogen interaction leading to immunological complications associated with breast implant illness (BII). Over 10 million women worldwide have breast implants. In recent years, women have described a constellation of immunological symptoms believed to be related to their breast implants. We report that periprosthetic breast tissue of participants with symptoms associated with BII had increased abundance of biofilm and biofilm-derived oxylipin 10-HOME compared with participants with implants who are without symptoms (non-BII) and participants without implants. S. epidermidis biofilm was observed to be higher in the BII group compared with the non-BII group and the normal tissue group. Oxylipin 10-HOME was found to be immunogenically capable of polarizing naive CD4⁺ T cells with a resulting Th1 subtype in vitro and in vivo. Consistently, an abundance of CD4⁺Th1 subtype was observed in the periprosthetic breast tissue and blood of people in the BII group. Mice injected with 10-HOME also had increased Th1 subtype in their blood, akin to patients with BII, and demonstrated fatigue-like symptoms. The identification of an oxylipin-mediated mechanism of immune activation induced by local bacterial biofilm provides insight into the possible pathogenesis of the implant-associated immune symptoms of BII.

Introduction: Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) commonly presents as a peri-implant effusion (seroma). CD30 (TNFRSF8) is a consistent marker of tumor cells but also can be expressed by activated lymphocytes in benign seromas. Diagnosis of BIA-ALCL currently includes cytology and detection of CD30 by immunohistochemistry or flow cytometry, but these studies require specialized equipment and pathologists’ interpretation. We hypothesized that a CD30 lateral flow assay (LFA) could provide a less costly rapid test for soluble CD30 that eventually could be used by non-specialized personnel for point-of-care diagnosis of BIA-ALCL. Methods: We performed LFA for CD30 and enzyme-linked immunosorbent assay (ELISA) for 15 patients with pathologically confirmed BIA-ALCL and 10 patients with benign seromas. To determine the dynamic range of CD30 detection by LFA, we added recombinant CD30 protein to universal buffer at seven different concentrations ranging from 125 pg/mL to 10,000 pg/mL. We then performed LFA for CD30 on cryopreserved seromas of 10 patients with pathologically confirmed BIA-ALCL and 10 patients with benign seromas. Results: Recombinant CD30 protein added to universal buffer produced a distinct test line at concentrations higher than 1000 pg/mL and faint test lines at 250–500 pg/mL. LFA produced a positive test line for all BIA-ALCL seromas undiluted and for 8 of 10 malignant seromas at 1:10 dilution, whereas 3 of 10 benign seromas were positive undiluted but all were negative at 1:10 dilution. Undiluted CD30 LFA had a sensitivity of 100.00%, specificity of 70.00%, positive predictive value of 76.92%, and negative predictive value of 100.00% for BIA-ALCL. When specimens were diluted 1:10, sensitivity was reduced to 80.00% but specificity and positive predictive values increased to 100.00%, while negative predictive value was reduced to 88.33%. When measured by ELISA, CD30 was below 1200 pg/mL in each of six benign seromas, whereas seven BIA-ALCL seromas contained CD30 levels > 2300 pg/mL, in all but one case calculated from dilutions of 1:10 or 1:50. Conclusions: BIA-ALCL seromas can be distinguished from benign seromas by CD30 ELISA and LFA, but LFA requires less time (<20 min) and can be performed without special equipment by non-specialized personnel, suggesting future point-of-care testing for BIA-ALCL may be feasible.

Background. Breast implants are commonly placed postbreast cancer reconstruction, cosmetic augmentation, and gender-affirming surgery. Breast implant illness (BII) is a systemic complication associated with breast implants. Patients with BII may experience autoimmune symptoms including fatigue, difficulty concentrating, hair loss, weight change, and depression. BII is poorly understood, and the etiology is unknown. The purpose of this literature review is to characterize BII autoimmune disorders and determine possible causes for its etiology. Methods. The PubMed, Google Scholar, Embase, Web of Science, and OVID databases were interrogated from 2010 to 2020 using a query strategy including search term combinations of implants, breast implant illness, autoimmune, and systemic illness. Results. BII includes a spectrum of autoimmune symptoms such as fatigue, myalgias/arthralgias, dry eyes/mouth, and rash. A review of epidemiological studies in the past ten years exhibited evidence affirming an association between breast implants and autoimmune diseases. The most commonly recognized were Sjogrens syndrome, rheumatoid arthritis, systemic sclerosis, chronic fatigue syndrome, and Raynauds syndrome. Explantation resulted in alleviation of symptoms in over 50 of patients, strengthening the hypothesis linking breast implants to BII. Studies have shown that silicone is a biologically inert material and unlikely to be the cause of these symptoms. This is supported by the fact that increased risk of autoimmune disease was also reported in patients with other implantable biomaterials such as orthopedic implants. Recent studies shed light on a possible role of bacterial biofilm and subsequent host-pathogen interactions as a confounding factor to this problem. Conclusion. BII could be dependent on biofilm infection and the microenvironment around the implants. The true pathophysiology behind these complaints must be further investigated so that alternative treatment regimens other than explantation can be developed. Translational significance of these studies is not limited to breast implants but extends to other implants as well.