[Gluteal artery based perforator flaps for sacral pressure sore reconstruction in children]

INTRODUCTION

Children have much lower incidence of pressure sores (PS) than adults and furthermore, they are diagnosed in earlier stages. Therefore, the reported experience with surgical treatment of advanced pediatric PS is scarce.

MATERIAL AND METHODS

We present the surgical treatment of 2 chronic PS stage IV in children aged 11 and 14 years, by means of perforator flaps based on the gluteal arteries: in the first case we used a free-style flap based on a left medial gluteal perforator and in the second a large reusable rotation-advancement flap based on both right superior and inferior gluteal artery perforators.

RESULTS

In both patients we achieved a rapid cure with 100% survival of the flaps and a stable cover over a 6 month and 1 year follow-up respectively.

CONCLUSIONS

Gluteal artery perforator flaps can produce excellent and durable results in the reconstructive treatment of sacral pressure sores in children. These flaps carry lower morbidity than musculocutaneous flaps and are more reliable than traditional fasciocutaneous flaps. Furthermore they preserve more reconstructive options in case of recurrence during the children's lifetime.

Maxillary growth in a congenital cleft palate canine model for surgical research

We have recently presented the Old Spanish Pointer dog, with a 15-20% spontaneous congenital cleft palate rate, as a unique experimental model of this disease. This study aimed to describe the cleft palate of these dogs for surgical research purposes and to determine whether congenital cleft palate influences maxillofacial growth. Seven newborn Old Spanish Pointer dogs of both sexes, comprising a cleft palate group (n = 4) and a normal palate group (n = 3), were fed using the same technique. Macroscopic photographs and plaster casts from the palate, lateral radiographs and computer tomograms of the skull were taken sequentially over 41 weeks, starting at week 5. The cleft morphology, the size and the tissue characteristics in these dogs resembled the human cleft better than current available animal models. During growth, the cleft width varies. Most of the transverse and longitudinal measures of the palate were statistically lower in the cleft palate group. The cleft palate group showed hypoplasia of the naso-maxillary complex. This model of congenital cleft palate seems suitable for surgical research purposes. A reduced maxillofacial pre- and post-natal development is associated to the congenital cleft palate in the Old Spanish Pointer dog.

[Extruded cochlear implant magnet covered with a temporoparietal fascial flap. A case report]

Complications are infrequent after cochlear implant surgery but they might occur despite careful preoperative planning and meticulous surgical technique. Among the most commonly encountered problems are those associated with the postauricular flap. An exposed, and therefore contaminated, device requires immediate attention and intervention. Cochlear implantation revision surgery is justified by two main reasons, the high price of these devices and the difficulty of reimplantation, due to cochlear fibrosis and ossification after its removal. There are multiple options in cochlear implantation revision surgery with infected device. However, the temporoparietal fascia flap is highly vascularized and provides some advantages over other alternatives. We report a case of a 5 year old boy with bilateral sensor neural hearing loss, who suffered a device extrusion three years after its implantation.

[Intraparotid first branchial arch cyst: complex diagnostic and therapeutic process]

First branchial arch cysts are uncommon. Therefore, together with its variable clinical and age presentation they are often misdiagnosed at first. The treatment is surgical, requiring a correct procedure to avoid future recurrences. In this paper we describe a typical case of first branchial arch cyst in which as described in other reports, we first made several misdiagnoses and therefore an inadequate treatment and lastly, with the correct diagnosis, we performed a meticulous complete excision under facial nerve monitoring.

Anti-secretory, anti-inflammatory and anti-Helicobacter pylori activities of several fractions isolated from Piper carpunya Ruiz & Pav

ETHNOPHARMACOLOGICAL RELEVANCE

The leaves of Piper carpunya Ruiz & Pav. (syn Piper lenticellosum C.D.C.) (Piperaceae), are widely used in folk medicine in tropical and subtropical countries of South America as an anti-inflammatory, anti-ulcer, anti-diarrheal and anti-parasitical remedy as well as an ailment for skin irritations.

AIMS OF THE STUDY

To study the anti-inflammatory, anti-secretory and anti-Helicobacter pylori activities of different fractions isolated from an ethanolic extract of the leaves of Piper carpunya, in order to provide evidence for the use of this plant as an anti-ulcer remedy. Moreover, to isolate the main compounds of the extract and relate their biological activity to the experimental results obtained with the fractions.

MATERIALS AND METHODS

Sixteen fractions were obtained from the ethanolic extract (F I-XVI) and 16 pure compounds were isolated and identified from these fractions. We studied the effects of the fractions (0.1-400microg/mL) on the release of myeloperoxidase (MPO) enzyme from rat peritoneal leukocytes, on rabbit gastric microsomal H(+), K(+)-ATPase activity and anti-Helicobacter pylori anti-microbial activity using the microdilution method (MM). The main compounds contained in the fractions were isolated and identified by (1)H- and (13)C NMR spectra analysis and comparison with the literature data.

RESULTS

Eight fractions showed inhibition of MPO enzyme (F I-IV, X, XII, XIV and XV). The highest inhibition was observed with F XIV (50microg/mL, 60.9%, p<0.001). F X and XII were the most active ones, inhibiting the gastric H(+), K(+)-ATPase activity with IC(50) values equal to 22.3microg/mL and 28.1microg/mL, respectively. All fractions, except F XV, presented detectable anti-Helicobacter pylori activity, with a diameter of inhibition zones ranging from 11mm up to 50mm. The best anti-Helicobacter pylori activity was obtained with F III and V. Both fractions killed Helicobacter pylori with lowest concentration values, about 6.25mug/mL. Sixteen pure compounds were isolated, five of them are flavonoids that possess strong anti-oxidant and free radical scavenging activity, e.g. vitexin, isovitexin, and rhamnopyranosylvitexin. Terpenoids like sitosterol, stigmasterol and phytol, which have shown gastroprotective activity, and dihydrochalcones, like asebogenin, with anti-bacterial activity, were also isolated. Furthermore, the rare neolignan 1, that is a DNA polymerase beta lyase inhibitor, and (6S, 9S)-roseoside, that shows strong anti-bacterial activity, were isolated, for the first time, from the genus Piper.

CONCLUSIONS

We suggest that the flavonoids isolated from F I and II (vitexin, isovitexin, rhamnopyranosylvitexin and isoembigenin) contribute to the anti-MPO activity, as well as to their anti-Helicobacter pylori activity. These flavonoids may also be responsible for the important inhibition of H(+), K(+)-ATPase activity. Also the phytosterols and phytol obtained from F XIV and XV could be involved in these gastroprotective activities. These results encourage us to continue phytochemical studies on these fractions in order to obtain full scientific validation for this species.

[Rapidly involuting congenital hemangioma (RICH) that simulates a minimal cleft lip]

Hemangiomas are frequent tumors that manifest in variable forms. Rapidly Involuting Congenital Hemangiomas (RICH) are a rare subtype, only recently described, which, in contrast to the typical infantile hemangioma, undergo accelerated involution, sometimes within days. Their different initial appearance and posterior evolution may cause confusion with other tumors of infancy or even with congenital malformations. We present a case of RICH in the upper lip that after rapid involution produced a morphologic sequel that resembled a microform cleft lip. The authors review the specific characteristics of this rare tumor and describe the technical detail of surgical correction in this patient.

Correction of nasojugal groove with tunnelled fat graft

BACKGROUND

Pronounced nasojugal sulcus (tear trough deformity) is a frequent and distressing symptom in aesthetic palpebral surgery. The sliding fat technique using the transcutaneous or transconjunctival approach has proven to be considerably useful in patients with clinically evident fat bags. In the absence of fat bags, commonly used techniques can lead to unpredictable (and frequently less than optimal) results.

OBJECTIVE

The authors report their experience with correcting the nasojugal groove in the absence of palpebral fat bags by use of a one-piece, free fat graft as an alternative to autologous fat injections or the placement of alloplastic materials.

METHODS

The authors conducted a retrospective study of a consecutive series of 34 patients (33 women and one man) between 42 and 57 years of age. In all cases, small, free fat grafts harvested from the medial fat compartment of the upper eyelid were placed precisely under the depression through two stab incisions in the suborbicularis plane, filling in the groove.

RESULTS

Results were considered excellent in 24 out of the 34 patients. Results in the remaining 10 patients were rated as good, in most cases because of mild undercorrection. All patients expressed a high degree of satisfaction. Recovery time was very short and no eye or eyelid complications were observed.

CONCLUSIONS

Correction of the nasojugal groove with a tunnelled fat graft causes minimal tissue trauma and allows exact placement of the graft. The upper palpebral fat has unique characteristics that render it an ideal graft material for correction of the nasojugal groove in patients with no concomitant lower fat bags. This procedure offers more predictable results and a lower incidence of adverse effects than more commonly used techniques.

[Mammary reconstruction in Poland's syndrome]

Poland's syndrome is considered to be a polimalformative entity with different degrees of severity. We retrospectively reviewed our patients with Poland's syndrome diagnosis, treated between 2000 and 2006. The aim of our study is to assess the different choices of surgical treatment for mammary reconstruction according to the importance of malformation and taking into account our own experience and literature references. A total o f 13 patients (5 males and 8 females) were studied and only 6 of them (1 male and 5 females) underwent surgery. Surgical indication was based on Foucras's classification, considering 3 grades of severity. We propose a surgical approach adapted to each stage, as well as surgical refinements to improve the aesthetic aspect. Most of our patients were very satisfied with final results even though they underwent complex procedures with a considerable rate of complications.

The aerial parts of Guazuma ulmifolia Lam. protect against NSAID-induced gastric lesions

Guazuma ulmifolia Lam., a member of the Sterculiaceae family, is used in folk medicine because of its antioxidant, antimicrobial and antihypertensive properties. Most of the research work carried out on this plant has focused on the bark because of its high concentration of antioxidant proanthocyanidins. The flowers and leaves of Guazuma ulmifolia, though less studied, are also used as a remedy for different conditions, such as kidney and gastrointestinal diseases, fever and diabetes. The aim of this study was to assess the gastroprotective effects of an aqueous suspension of the ethanolic extract from leaves and flowers of Guazuma ulmifolia in a model of acute gastric ulcer induced by diclofenac as ulcerogenic agent, using the proton pump inhibitor omeprazole as a protection reference. Therefore, the extract was administered two times orally to three groups of Wistar rats at doses of 500, 250 and 125mg/kg, with a 24-h interval between doses. Diclofenac (100mg/kg) was given 1h after the last administration of the extract. Pretreatment with Guazuma ulmifolia or omeprazole decreased the ulcerated area in a dose-dependent way. Myeloperoxidase activity as a marker of neutrophil infiltration was slightly reduced in vivo, whereas in vitro, anti-inflammatory activity was clearly inhibited in a dose-dependent way. The lowest doses of the extract significantly decreased the levels of lipoperoxides, and superoxide dismuthase activity increased to a similar extent as with omeprazole (P<0.001). Examination of glutathione metabolism reflected a significant rise in glutathione peroxidase activity at the highest dose of Guazuma ulmifolia. Finally, there was a faint elevation in prostaglandin E(2) levels with all doses, though the depletion induced by diclofenac could not be reverted. We conclude that the aerial parts of Guazuma ulmifolia protect gastric mucosa against the injurious effect of NSAIDs mainly by anti-inflammatory and radical-scavenging mechanisms.

[Complications and sequelae after nasal trauma]

Septal haematoma after nasal trauma is a complication that can lead to septal abscess if unrecognized or early intervention is not performed. It can cause compression and thereby necrosis that evolve to a septal abscess in which cultures reveal saprophyte bacteria. Cartilage necrosis and destruction can produce impaired breathing and aesthetic deformities with collapse of the dorsum and the tip of the nose. We present a 10 year old masculine infant, that suffered a nasal fracture with a septal haematoma that remained undiagnosed. The patient developed a septal abscess that required drainage and resulted in nasal sequelae with collapse of dorsum and cranial displacement of tip and columella. Functional and aesthetic reconstruction was performed using rib cartilage grafts. No complications occurred. Functional and aesthetic improvement was observed. Result after 2 months of follow-up is considered favourable.

Protective and antioxidant effects of Rhizophora mangle L. against NSAID-induced gastric ulcers

The bark of Rhizophora mangle, the red mangrove, has been used traditionally in folk medicine of Caribbean countries due to its antiseptic, astringent, haemostatic and antifungal properties. Aqueous extracts are rich in tannins and have been proven experimentally to possess antibacterial, wound healing and antiulcerogenic effects. This work was designed to determine the gastroprotective effect of Rhizophora mangle in a model of diclofenac-induced ulcers in rats and to study the mechanisms involved, using the proton pump inhibitor omeprazole as a comparison. The lyophilized extract was given by oral gavage (125 and 62.5mg/kg) three times at 12h intervals before administering diclofenac 100mg/kg. Pretreatment with the extract resulted in a significant decrease of the ulcerated area (P<0.01). Rhizophora mangle induced a recovery of PGE(2) levels, which had been depleted by diclofenac. No anti-inflammatory effect was observed ex vivo or in vitro. The highest dose of the extract provoked a marked increase in glutathione peroxidase and superoxide dismutase activity, which was comparable to omeprazole. Furthermore, lipid peroxidation levels were inhibited in a dose-dependent manner. These results suggest that the gastroprotective effect of Rhizophora mangle in this experimental model appears through an antioxidant and prostaglandin-dependent way.

[Liposuction in children: clinical utility]

Liposuction has become one of the most frequent aesthetic procedures. The "typical" patient is a young female with fat deposits in the trochanteric region. Gradually the safety of the technique together with the high satisfaction rate of the patients have contributed to the widening of its indications to other pathologies of the adipose tissue in different age populations. However, there is scarce literature regarding liposuction in childhood. The authors present their experience with liposuction as the treatment of congenital as well as acquired lipodystrophies in the paediatric age. Some particular details of the technique are described and the advantages of liposuction versus open surgery in these cases are analyzed.

Pharmaceutical care: past, present and future

Since the concept of Pharmaceutical Care was introduced from United States about twenty years ago, this initiative has become a dominant form of practice for thousands of pharmacists around the world. Currently, pharmaceutical care is understood as the pharmacists' compromise to obtain the maximum benefit from the pharmacological treatments of the patients, being therefore responsible of monitoring their pharmacotherapy. As the profession has moved from a product orientation (dispensing medications) to a patient focus, clinical training requirements have expanded. This is a slow but ongoing process, which started from a philosophical point of view, in order to transform the concept of Pharmacy from commodity-based, mercantile operations into a clinical profession in the community pharmacies. Since its introduction, there has been an ample debate on the definition of pharmaceutical care due to differences in Pharmacy systems and in health care structure among the different countries. Moreover, several implementation barriers exist, which are attributable to problems in education, skills, resources and environment. Indeed, an awareness of the problem resulting from the use of medicines exists and numerous studies reflect that drug use control is necessary since there is an important relationship between morbidity / mortality and pharmacotherapy. Thus, it is possible to evaluate the benefits of pharmaceutical care on patients' health and ultimately on society. Many studies have been conducted, which show that the provision of pharmaceutical care has its value in common pathologies such as diabetes, hypertension, asthma, hyperlipidemia, chronic pain, rheumatic diseases or psychiatric disorders, as well as in polymedicated patients. A large amount of data is currently being published in biomedical journals, in an effort to establish the clinical, economic and humanistic viability of pharmaceutical care. Thus, the aim of this review is to study the evolution of this practice from its beginning until nowadays. Furthermore, we have analyzed a number of implementation programs performed in countries of Europe, the United States and Latin America, focusing on clinical, economical and humanistic outcomes, and also, on the current concept of drug therapy problems (DTP) considered as failures in drug therapy. We conclude that the positive outcomes obtained with different programs of pharmaceutical care are making a beneficial change in patients' health but still more research projects should be conducted to support this change.

Basal cell carcinoma in childhood after radiation therapy: case report and review

We describe 2 patients who received ionizing radiation as part of a curative regimen for childhood malignancy which later developed basal cell carcinoma at an early age. They do not occur within the context of well-defined syndromes, such like basal cell nevus syndrome, albinism, or xeroderma pigmentosum. Basal cell carcinomas appears on radiated areas in older individuals, less often in younger patients, in which the period of latency between exposure to radiation and the appearance of basal cell carcinomas is shorter than in older patients. Our 2 cases presented a period of latency of 11 and 10 years. Radiated skin areas must be explored as part of the follow-up in children who received radiotherapy and should probably be maintained for life. The basal cell carcinoma in childhood is best treated by excision.

[Free fat flap for the treatment of Parry-Romberg disease in children]

Progressive hemifacial Atrophy (PHA) or Romberg's Disease is a rare entity of unknown etiology, which most often affects only one side of the face and can include all tissue planes in different grades of severity. Of the several treatments proposed, pedicled or free flaps seem to achieve the best cosmetic results in severe cases. In mild to moderate cases, free autologous fat transplant may obtain optimal results with lower complexity, cost and morbidity. The presence of multiple adipoblasts might increase the possibilities of graft take, particularly in children. Furthermore, refinements in the processes of extraction, preparation and reintroduction of the fat have contributed to improve the results that may be long lasting. We present 2 cases of PHA in 2 girls (11 and 13 years old), that were treated by lipofilling. No complications occurred. In both cases we observed a small reduction in the volume of the initial graft. Thus the procedure was repeated 6 months later to improve facial symmetry. Results have been excellent in one year follow-up.

[Intramuscular juvenile xantogranuloma]

Deep or intramuscular juvenile xanthogranuloma (JXG) is very rare. There are, however, some clinical and histological similarities between the case we present and the few cases that have been published in the literature. Although most of them will need histologic confirmation to establish the final diagnosis, surgeons who are operating tumors of infancy should consider it in the differential diagnosis of well circumscribed, rapidly growing dorsal masses in children under 3 years of age. Macroscopic appearance upon excision can help to support the diagnosis. Knowledge of this variant of JXG may avoid aggressive diagnostic or therapeutic procedures.

Rapidly involuting congenital hemangioma: clinical and histopathologic features

We define the histopathologic findings and review the clinical and radiologic characteristics of rapidly involuting congenital hemangioma (RICH). The features of RICH are compared to the equally uncommon noninvoluting congenital hemangioma (NICH) and common infantile hemangioma. RICH and NICH had many similarities, such as appearance, location, size, and sex distribution. The obvious differences in behavior served to differentiate RICH, NICH, and common infantile hemangioma. Magnetic resonance imaging (MRI) of the three tumors is quite similar, but some RICH also had areas of inhomogeneity and larger flow voids on MRI and arterial aneurysms on angiography. The histologic appearance of RICH differed from NICH and common infantile hemangioma, but some overlap was noted among the three lesions. RICH was composed of small-to-large lobules of capillaries with moderately plump endothelial cells and pericytes; the lobules were surrounded by abundant fibrous tissue. One-half of the specimens had a central involuting zone(s) characterized by lobular loss, fibrous tissue, and draining channels that were often large and abnormal. Ancillary features commonly found were hemosiderin, thrombosis, cyst formation, focal calcification, and extramedullary hematopoiesis. With one exception, endothelial cells in RICH (as in NICH) did not express glucose transporter-1 protein, as does common infantile hemangioma. One RICH exhibited 50% postnatal involution during the 1st year, stopped regressing, was resected at 18 months, and was histologically indistinguishable from NICH. In addition, several RICH, resected in early infancy, also had some histologic features suggestive of NICH. Furthermore, NICH removed early (2-4 years), showed some histologic findings of RICH or were indistinguishable from RICH. We conclude that RICH, NICH, and common infantile hemangioma have overlapping clinical and pathologic features. These observations support the hypothesis that these vascular tumors may be variations of a single entity ab initio. It is unknown whether the progenitor cell for these uncommon congenital vascular tumors is the same as for common infantile hemangioma.

Liposuction in atypical cases

Liposuction has become the most frequent aesthetic procedure, and its indications continue to expand to different areas of plastic surgery. In this article the authors present their experience with liposuction in the treatment of nine cases termed "atypical," for not being purely aesthetic. Included are four congenital lipodystrophies-occult spinal disraphism, osteogenesis imperfecta, congenital lipomatosis difusa, and Klinefelter syndrome-and five acquired ones-posttraumatic lipoma, posttraumatic asymmetry, insulinic hypertrophic lipodystrophy, adiposis dolorosa, and TRAM flap. Particular features of each lipodystrophy are reviewed and details of fat distribution and density are described. We also review some specific details of the technique. On the other hand, we wish to point out the importance of recognizing and correctly diagnosing some specific lipodystrophies that are part of defined clinical patterns and that require an integral therapeutic approach.

The role of lipoaspiration in defeminization of Klinefelter syndrome: a case report

Klinefelter syndrome is the most frequent sex chromosome anomaly. Affected men characteristically present a tall stature, eunuchoid contours with feminine fat distribution, gynecomastia, hypogonadism, infertility, and behavioral and psychiatric disorders. Diagnosis is confirmed by karyotype, which demonstrates an extra X chromosome. Treatment is mainly directed toward appropriate defeminization. Current treatment consists of testosterone replacement therapy and surgical correction of gynecomastia.

Sclerotherapy of craniofacial venous malformations: complications and results

Of all vascular anomalies, venous malformations are the most common, and they have a propensity for the head and neck. The authors retrospectively analyzed 40 patients with craniofacial venous malformations who underwent sclerotherapy between October of 1994 and June of 1996 to determine (1) the results of sclerotherapy with ethanol and/or sodium tetradecyl sulfate, (2) the types and rate of complications, and (3) whether outcome correlated with age, sex, location, size, tissues involved, morphology (lobular or varicose), venous outflow, or number of sclerotherapy sessions. The authors also reviewed the results after sclerotherapy and contour resection (n = 18). Comparisons between the results with ethanol and sodium tetradecyl sulfate and between sclerotherapy alone and sclerotherapy and resection combined were not done. The study was composed of three parts. They were (1) a review of records and imaging studies, (2) a panel evaluation of pretreatment and posttreatment photographs, and (3) a questionnaire that determined the patient's (or parent of the patient's) impression of therapy. Interrater and intrarater agreement were analyzed. Sclerotherapy was performed in an angiographic suite, under general anesthesia, using absolute ethanol and/or sodium tetradecyl sulfate. Complications of the treatment included acute blistering (50 percent), hemoglobinuria (28 percent), deep ulceration (13 percent), and nerve injury (7.5 percent). Two patients suffered transient facial paresis, and one had permanent unilateral vocal cord paralysis. Thirty patients (75 percent) were rated as having marked improvement or as being cured by all three members of the panel; 10 patients (25 percent) were rated as having no change or only slight improvement by one or more members of the panel. Interrater reliability was moderately positive, and intrarater reliability was highly positive. Thirty-seven patients or parents of patients (93 percent) responded to the questionnaire. The outcome was considered to be marked improvement or cured in 28 patients (76 percent), and nine respondents (24 percent) described only minor improvement or no change. Logistic regression analysis revealed that only male sex and number of sclerotherapeutic procedures were significant multivariate predictors of outcome. Size, location, tissues involved, morphology, or venous outflow were not determinant. In conclusion, sclerotherapy with ethanol or sodium tetradecyl sulfate is an effective and safe treatment for craniofacial venous malformations. Often, sclerotherapy has to be repeated. For extensive perioral malformations, combined sclerotherapy and resection give the best result.