Informed consent in plastic surgery, evaluation of its effectiveness for mutual satisfaction of patient and doctor: Comparison of methods

BACKGROUND

The acquisition of signed informed consent is not always enough to ensure adequate medical protection. Particularly, in plastic surgery, improving the doctor-patient relationship by understanding the patient's emotions and expectations becomes a determining factor when choosing the best therapeutic strategy for the subject in question, which may also include nonsurgical eligibility.

METHODS

Ninety patients with various plastic surgery disabilities were recruited and randomly divided into three groups: Patients in the first group underwent the ``traditional'' clinical interview, those in the second underwent the clinical approach called Shared Decision Making (SDM), and those in the third group received both the SDM and a questionnaire evaluating patient expectations (Expectation Questionnaire-Pgm). At the end of each interview, a specialist physician in Plastic, Reconstructive and Aesthetic Surgery was asked to fill in a questionnaire regarding his/her satisfaction with the method used. Likewise, the patient filled in a questionnaire on his/her satisfaction with the interview.

RESULTS

For the doctors, the third method was superior in investigating patient expectations, emotions, and personal preferences. For the patients, the third method scored significantly higher than the first one for overall satisfaction and ability to evaluate personal preferences and needs and higher than the first and second methods in assessing expectations.

CONCLUSIONS

For doctors, the SDM coupled with the Expectation Questionnaire-Pgm proved to be the most useful tool to understand patient expectations and emotions and thus improve the medical-patient relationship through shared decision-making. The third method therefore aims for better patient coverage and improved informed consent, thereby reducing the likelihood of litigation and better assessing nonfitness for operation.

Podocyte GSK3 is an evolutionarily conserved critical regulator of kidney function

Albuminuria affects millions of people, and is an independent risk factor for kidney failure, cardiovascular morbidity and death. The key cell that prevents albuminuria is the terminally differentiated glomerular podocyte. Here we report the evolutionary importance of the enzyme Glycogen Synthase Kinase 3 (GSK3) for maintaining podocyte function in mice and the equivalent nephrocyte cell in Drosophila. Developmental deletion of both GSK3 isoforms (α and β) in murine podocytes causes late neonatal death associated with massive albuminuria and renal failure. Similarly, silencing GSK3 in nephrocytes is developmentally lethal for this cell. Mature genetic or pharmacological podocyte/nephrocyte GSK3 inhibition is also detrimental; producing albuminuric kidney disease in mice and nephrocyte depletion in Drosophila. Mechanistically, GSK3 loss causes differentiated podocytes to re-enter the cell cycle and undergo mitotic catastrophe, modulated via the Hippo pathway but independent of Wnt-β-catenin. This work clearly identifies GSK3 as a critical regulator of podocyte and hence kidney function.

Long Term Cosmetic and Functional Results of One Stage Reconstruction for Lower Eyelid Malignant Melanoma: A Single Centre Experience of Eleven Patients

Introduction

Eyelid malignant melanoma represents less than 1 % of all skin melanomas and approximately 1 % of all malignant neoplasms of the eyelid skin. Because of its relative rarity, there is a paucity of descriptive papers reporting only small series of reconstructed patients. The repair of eyelid defects represents a reconstructive challenge. Ideally, the reconstruction of the defect must guarantee function with tissue of the same color, texture, and thickness of that of the removed skin and at the same time avoid complications such as ectropion and lagophthalmos.

Materials and Methods

We describe a consecutive series of 11 patients affected by cutaneous melanoma of the lower lid who underwent full-thickness excision of the neoplasm and subsequent wide excision. All the patients were treated in one-stage reconstruction modality with a modified monopedicle myocutaneous flap, harvested from omolateral upper eyelid, tunneled under the lateral canthus skin and armed with a conchal auricular cartilage framework. Four patients underwent the sentinel lymph node biopsy during reconstructive procedure. No major complications were reported. In our experience, the proposed myocutaneous flap allows to obtain excellent results, both aesthetically and functionally.

Conclusions

This technique has the advantage of avoiding multi-staged procedures, with respect for the oncological excision indication for head and neck melanoma, decreasing the incidence of associated major complications.

Effect of early correction of nasal septal deformity in unilateral cleft lip and palate on inferior turbinate hypertrophy and nasal patency

OBJECTIVES

A relatively neglected aspect of cleft lip nasal deformity is the effect of septal deviation and inferior turbinate hypertrophy (ITH) on the functional airway. In particular, ITH in the noncleft side can be especially problematic, because it reduces the healthy nasal area, creating bilateral nasal obstruction that might affect the growth of the maxillofacial skeleton. Although these anatomic and functional changes are documented, few recommendations have been developed regarding the proper approach to ITH. The aim of the present study was to asses the ITH severity and determine the degree of nasal airway patency in patients who have undergone primary correction of the nasal septum during lip repair compared to patients operated on without primary septal correction.

METHODS

The study population included two groups. One group consisted of twenty unilateral cleft lip palate UCLP patients who have previously undergone primary rhinoseptoplasty as part of their treatment plan. The control group consisted of twenty UCLP patients operated on without rhinoseptal correction. The Nasal Obstructive Symptom Evaluation (NOSE) scale and nasal endoscopy were used to assess nasal obstruction.

RESULTS

The overall untreated group reported severe symptoms across all NOSE scale dimensions more frequently than children who have undergone primary rhinoseptoplasty. The difference was statistically significant for each dimensions (p < 0.05). The mean NOSE score for group A and group B was 21.4 ± 9.4 and 70.8 ± 17.2 respectively (p < 0.0001). In group A turbinate size decreased significantly (p < 0.05) compared to pre-operative data. Comparing the two groups a statistically significant difference in turbinate size was observed (p < 0.0001).

CONCLUSION

The results of the present study confirm that there is a significant degree of ITH and nasal airway dysfunction in patients with UCLP. Early septal repositioning during primary cleft lip repair results in a statistically significant reduction in IT size and improvement of nasal patency.

Preoperative Evaluation of Ferritinemia in Primary Epithelial Ovarian Cancer

Aims and background

High ferritin serum levels have been reported in patients suffering from various malignancies. The aim of this study was to evaluate the role of ferritinemia in the preoperative diagnosis of ovarian carcinoma.

Methods

Between March 1993 and September 1996, 60 patients suffering from ovarian carcinoma were surgically treated at our Department. Their ferritin serum levels were measured preoperatively by a solid-phase, two-site chemiluminescent immunometric assay and compared with those of a group of 60 healthy, age-matched, non pregnant controls.

Results

The mean serum concentration of ferritin was 54.7 ± 7.8 ng/ml (range, 14–135) in healthy controls and 112.3 ± 21.2 ng/ml (range, 9–947) in patients with ovarian carcinoma. The difference was statistically significant (P = 0.005, X2 test = 7.951). Serum ferritin was elevated preoperatively (cutoff ≥ 120 ng/ml) in 18/60 patients with malignancy (sensitivity 30%), whereas the CA 125 levels were above the cutoff in 53/60 patients (sensitivity 88.3%). Only 2/60 women of the control group had ferritin titers > 120 ng/ml (specificity 96.7%). The ferritin levels increased with advancing disease stage; no significant correlation was found between ferritin concentration and neoplastic histology and grading. The mean serum iron levels were also measured preoperatively in patients with ovarian carcinoma and healthy controls. They were 57.2 ± 3.8 and 66.3 ± 2.61 μg/dl, respectively, and the difference was not significant (P = 0.655, X2 test= 0.200).

Conclusions

The present study underlines that although ferritin shows an elevated specificity, its low sensitivity does not suggest any true usefulness as a tumor marker in epithelial ovarian cancer.

A field screening test for the assessment of concentrations and mobility of potentially toxic elements in soils: a case study on urban soils from Rome and Novi Sad

The increasing demand for environmental pollution control results in the development and use of new procedures for the determination of dangerous chemicals. Simple screening methods, which can be used directly in the field for a preliminary assessment of soil contamination, seem to be extremely advantageous. In our laboratory, we developed and optimized a rapid test for a preliminary evaluation of both the concentration and the mobility of some potentially toxic metals in soils. This screening test consists of a single extraction of the soil sample with a buffer solution, followed by the titration of the extracted solution with dithizone to determine the contents of bi-valent heavy metals (such as Pb, Cu, Zn, and Cd). This screening method was then directly applied in the field during the sampling campaign in the framework of an Italian-Serbian collaborative project, finalized in the study of metal availability in soils. The results obtained in the field with the rapid test were compared with those obtained in the laboratory following the conventional procedure commonly used to evaluate metal bioavailability (diethylenetriaminepentaacetic extraction). Moreover, selected samples were analyzed sequentially in the laboratory using the standardized BCR three-step sequential extraction procedure. The screening test gave results conceptually in good agreement with those obtained via the BCR procedure. These preliminary data show that the proposed screening test is a reliable method for the preliminary rapid evaluation of metal total concentrations and of potential metal mobility in soils, supporting sampling activities directly in the field.

Microfluidic immunosensor for rapid and highly-sensitive salivary cortisol quantification

This paper presents a novel poly(dimethylsiloxane) (PDMS) microfluidic immunosensor that integrates a complementary metal-oxide-semiconductor (CMOS) optical detection system for a rapid and highly-sensitive quantification of salivary cortisol. The simple and non-invasive method of saliva sampling provides an interesting alternative to the blood, allowing a fast sampling at short intervals, relevant for many clinical diagnostic applications. The developed approach is based on the covalent immobilization of a coating antibody (Ab), a polyclonal anti-IgG, onto a treated PDMS surface. The coating Ab binds the capture Ab, an IgG specific for cortisol, allowing its correct orientation. Horseradish peroxidase (HRP)-labelled cortisol is added to compete with the cortisol in the sample, for the capture Ab binding sites. The HRP-labelled cortisol, bonded to the capture Ab, is measured through the HRP enzyme and the tetramethylbenzidine (TMB) substrate reaction. The cortisol quantification is performed by colorimetric detection of HRP-labelled cortisol, through optical absorption at 450nm, using a CMOS silicon photodiode as the photodetector. Under the developed optimized conditions presented here, e.g., microfluidic channels geometry, immobilization method and immunoassay conditions, the immunosensor shows a linear range of detection between 0.01-20ng/mL, a limit of detection (LOD) of 18pg/mL and an analysis time of 35min, featuring a great potential for point-of-care applications requiring continuous monitoring of the salivary cortisol levels during a circadian cycle.

Mercury contamination of riverine sediments in the vicinity of a mercury cell chlor-alkali plant in Sagua River, Cuba

Sediment is a great indicator for assessing coastal mercury contamination. The objective of this study was to assess the magnitude of mercury pollution in the sediments of the Sagua River, Cuba, where a mercury-cell chlor-alkali plant has operated since the beginning of the 1980s. Surface sediments and a sediment core were collected in the Sagua River and analyzed for mercury using an Advanced Mercury Analyser (LECO AMA-254). Total mercury concentrations ranged from 0.165 to 97 μg g(-1) dry weight surface sediments. Enrichment Factor (EF), Index of Geoaccumulation (Igeo) and Sediment Quality Guidelines were applied to calculate the degrees of sediment contamination. The EF showed the significant role of anthropogenic mercury inputs in sediments of the Sagua River. The result also determined that in all stations downstream from the chlor-alkali plant effluents, the mercury concentrations in the sediments were higher than the Probable Effect Levels value, indicating a high potential for adverse biological effects. The Igeo index indicated that the sediments in the Sagua River are evaluated as heavily polluted to extremely contaminated and should be remediated as a hazardous material. This study could provide the latest benchmark of mercury pollution and prove beneficial to future pollution studies in relation to monitoring works in sediments from tropical rivers and estuaries.

Absence of IFNγ promotes hippocampal plasticity and enhances cognitive performance

Cognitive functioning can be differentially modulated by components of the immune system. Interferon-γ (IFNγ) is a pro-inflammatory cytokine whose production is altered in many conditions displaying some degree of cognitive deficits, although its role in cognitive functioning is still unclear. Here we show that the absence of IFNγ selectively enhances cognitive behaviours in tasks in which the hippocampus is implicated. Moreover, the absence of IFNγ leads to volumetric and cell density changes that are restricted to the dorsal part of the hippocampus. In the dorsal hippocampus, the absence of this pro-inflammatory cytokine leads to an increase in the numbers of newly born neurons in the subgranular zone of the dentate gyrus (DG), an adult neurogenic niche known to support learning and memory, and to an enlargement of the dendritic arborization of DG granule and cornu ammonis (CA)1 pyramidal neurons. Moreover, it also modestly impacts synaptic plasticity, by decreasing the paired-pulse facilitation in the Schaffer collateral to CA1 pyramidal cell synapses. Taken together, our results provide evidence that IFNγ is a negative regulator of hippocampal functioning, as its absence positively impacts on dorsal hippocampus structure, cell density, neuronal morphology and synaptic plasticity. Importantly, these neuroplastic changes are associated with improved performance in learning and memory tasks. Therefore, blockage of the IFNγ signalling may present as promising therapeutic targets for the treatment of inflammation-associated cognitive dysfunction.

Non-syndromic cleft lip with or without cleft palate in Asian populations: Association analysis on three gene polymorphisms of the folate pathway

OBJECTIVE

Orofacial clefts (OFCs) are one of the most common birth defects in humans. They are the subject of a number of investigations aimed at elucidating the bases of their complex mode of inheritance involving both genetic and environmental factors. Genes belonging to the folate pathway have been among the most studied. The aim of the investigation was to replicate previous studies reporting evidence of association between polymorphisms of folate related genes and the occurrence of non-syndromic cleft lip with or without cleft palate (NSCL/P), using three independent samples of different ancestry: from Tibet, Bangladesh and Iran, respectively.

DESIGN

Specifically, the polymorphisms rs1801133 of MTHFR, rs1801198 of TCN2, and rs4920037 of CBS, were tested.

RESULTS

A decreased risk of NSCL/P was observed in patients presenting the C677T variant at MTHFR gene (relative risk for heterozygotes=0.53; 95% confidence interval [C.I.]=0.32-0.87). The investigated polymorphisms mapping at TCN2 and CBS genes did not provide any evidence of association.

CONCLUSION

Overall, these results indicate that NSCL/P risk factors differ among populations and confirm the importance of testing putative susceptibility variants in different genetic backgrounds.

Photodynamic therapy with topical aminolevulinic acid

Photodynamic therapy (PDT) is a relatively new therapy in dermatology that uses the topical application of a porphyrin derivative to selectively destroy a cutaneous target. The action is implemented by the application of a specific light frequency. The ability of porphyrin to selectively target tumor tissue has been known since the 1960s. In the late 1970s, the underlying mechanism was defined, and Dougherty’s discovery of the first chromophore led to the production and commercialization of Photofrin^®. Many other chromophores that can act as photosensitizers have been studied since then, with aminolevulinic acid currently the most commonly used chromophore in clinical practice. PDT is simple, minimally invasive and can be administered on an outpatient basis. The efficacy of PDT has been proven for actinic keratosis, Bowen’s disease and basal cell carcinoma; another of its well-known applications is the treatment of photoaging. Indications for its use are continuously increasing, and promising results are reported for various skin diseases. In this paper we report the mechanism of action of PDT with aminolevulinic acid, the literature concerning the most common diseases treated with PDT and the subsequent level of evidence.

Modified bilobed flap for one-stage earlobe reconstruction: a case report

Many techniques have been described in the literature for the reconstruction of congenital or acquired defects of the earlobe. Most techniques for earlobe reconstruction use adjacent tissue to compose a pedicled or bilobed flap, but usually require a two-stage procedure, or need a skin graft; more rarely reconstructive methods that led to a satisfactory result and a pleasant appearance in one-stage procedure have been described. We describe a personal and geometrical modification of the double-lobed flap according to Gavello's original technique, which allows to shape the anatomical curvature of the earlobe and to reduce the skin retraction without adding any scars or skin graft. In our opinion, the revisited reconstructive technique provides lots of advantages, improves aesthetical results and provides more natural appearance.

Assessment of the applicability of a "toolbox" designed for microbially assisted phytoremediation: the case study at Ingurtosu mining site (Italy)

The paper describes the fieldwork at the Italian test site of the abandoned mine of sphalerite and galena in Ingurtosu (Sardinia), with the aim to assess the applicability of a "toolbox" to establish the optimized techniques for remediation of soils contaminated by mining activities. A preliminary characterization-including (hydro)geochemistry, heavy metal concentration and their mobility in soil, bioprospecting for microbiology and botany-provided a data set for the development of a toolbox to deliver a microbially assisted phytoremediation process. Euphorbia pithyusa was selected as an endemic pioneer plant to be associated with a bacterial consortium, established with ten selected native strains, including metal-tolerant bacteria and producers of plant growth factors. The toolbox was firstly assessed in a greenhouse pot experiment. A positive effect of bacterial inoculum on E. pithyusa germination and total plant survival was observed. E. pithyusa showed to be a well-performing metallophyte species, and only inoculated soil retained a microbial activity with a high functional diversity, expanding metabolic affinity also towards root exudates. These results supported the decision to proceed with a field trial, investigating different treatments used singly or in combination: bioaugmentation with bacterial consortia, mycorrhizal fungi and a commercial mineral amendment. Microbial activity in soil, plant physiological parameters and heavy metal content in plants and in soil were monitored. Five months after the beginning, an early assessment of the toolbox under field conditions was carried out. Despite the cold season (October-March), results suggested the following: (1) the field setup as well as the experimental design proved to be effective; (2) plant survival was satisfactory; (3) soil quality was increased and bioaugmentation improved microbial activity, expanding the metabolic competences towards plant interaction (root exudates); and (4) multivariate analysis supported the data provided that the proposed toolbox can be established and the field trial can be carried forward.

Plant growth promotion by inoculation with selected bacterial strains versus mineral soil supplements

In the process of remediation of mine sites, the establishment of a vegetation cover is one of the most important tasks. This study tests two different approaches to manipulate soil properties in order to facilitate plant growth. Mine waste from Ingurtosu, Sardinia, Italy rich in silt, clay, and heavy metals like Cd, Cu, and Zn was used in a series of greenhouse experiments. Bacteria with putative beneficial properties for plant growth were isolated from this substrate, propagated and consortia of ten strains were used to inoculate the substrate. Alternatively, sand and volcanic clay were added. On these treated and untreated soils, seeds of Helianthus annuus, of the native Euphorbia pithyusa, and of the grasses Agrostis capillaris, Deschampsia flexuosa and Festuca rubra were germinated, and the growth of the seedlings was monitored. The added bacteria established well under all experimental conditions and reduced the extractability of most metals. In association with H. annuus, E. pithyusa and D. flexuosa bacteria improved microbial activity and functional diversity of the original soil. Their effect on plant growth, however, was ambiguous and usually negative. The addition of sand and volcanic clay, on the other hand, had a positive effect on all plant species except E. pithyusa. Especially the grasses experienced a significant benefit. The effects of a double treatment with both bacteria and sand and volcanic clay were rather negative. It is concluded that the addition of mechanical support has great potential to boost revegetation of mining sites though it is comparatively expensive. The possibilities offered by the inoculation of bacteria, on the other hand, appear rather limited.

Tensor fascia latae perforator flap: An alternative reconstructive choice for anterolateral thigh flap when no sizable skin perforator is available

Introduction:

The anterolateral thigh flap (ALT) is a versatile flap and very useful for the reconstruction of different anatomical districts. The main disadvantage of this flap is the anatomical variability in number and location of perforators. In general, absence of perforators is extremely rare. In literature, it is reported to be from 0.89% to 5.4%. If no sizable perforators are found, an alternative reconstructive strategy must be considered. Tensor fascia lata (TFL) perforator flap can be a good alternative in these cases: Perforator vessels are always present, the anatomy is more constant and it is possible to harvest it through the same surgical access. The skin island of the flap can be very large and can be thinned removing a large part of the muscle allowing its use for almost the same indications of the ALT flap.

Materials and Methods:

We report 11 cases of reconstruction firstly planned with the ALT flap, then converted into TFL perforator flap.

Results and Conclusion:

The result was always satisfactory in terms of the donor site morbidity and reconstructive outcome.

A scalable method for O-antigen purification applied to various Salmonella serovars

The surface lipopolysaccharide of gram-negative bacteria is both a virulence factor and a B cell antigen. Antibodies against O-antigen of lipopolysaccharide may confer protection against infection, and O-antigen conjugates have been designed against multiple pathogens. Here, we describe a simplified methodology for extraction and purification of the O-antigen core portion of Salmonella lipopolysaccharide, suitable for large-scale production. Lipopolysaccharide extraction and delipidation are performed by acetic acid hydrolysis of whole bacterial culture and can take place directly in a bioreactor, without previous isolation and inactivation of bacteria. Further O-antigen core purification consists of rapid filtration and precipitation steps, without using enzymes or hazardous chemicals. The process was successfully applied to various Salmonella enterica serovars (Paratyphi A, Typhimurium, and Enteritidis), obtaining good yields of high-quality material, suitable for conjugate vaccine preparations.

VAC therapy for wound management in patients with contraindications to surgical treatment

The treatment of complex wounds often requires multiple surgical debridement and eventually reconstruction with skin grafts or flaps, under local or general anesthesia. When the patient's general conditions contraindicate surgical procedures, topical negative pressure with vacuum assisted closure (VAC)) device can achieve wound healing with reduction of healing time and simpler management. We treated with VAC device four patients with complex wounds and important contraindications to surgery. In all the patients, we used VAC device with common protocol of topical negative pressure. The healing was obtained in a period variable between 18 and 40 days; the results were satisfactory in three cases, one patient developed an aesthetically unpleasant scar. We present our experience to propose VAC when surgical procedures are contraindicated.

VAC therapy for wound management in patients with contraindications to surgical treatment

The treatment of complex wounds often requires multiple surgical debridement and eventually reconstruction with skin grafts or flaps, under local or general anesthesia. When the patient's general conditions contraindicate surgical procedures, topical negative pressure with vacuum assisted closure (VAC)) device can achieve wound healing with reduction of healing time and simpler management. We treated with VAC device four patients with complex wounds and important contraindications to surgery. In all the patients, we used VAC device with common protocol of topical negative pressure. The healing was obtained in a period variable between 18 and 40 days; the results were satisfactory in three cases, one patient developed an aesthetically unpleasant scar. We present our experience to propose VAC when surgical procedures are contraindicated.