A randomized trial comparing ReCell system of epidermal cells delivery versus classic skin grafts for the treatment of deep partial thickness burns

BACKGROUND

Our purpose was to directly compare results obtained with the ReCell system and the classic skin grafting for epidermal replacement in deep partial thickness burns.

MATERIALS AND METHODS

We recruited all patients with deep partial thickness burns admitted at the Burn Centre of S. Eugenio Hospital in Rome over 2 years. Enrollment was conducted with a controlled strategy--sampling chart--that allowed homogeneous groups (ReCell and skin grafting) for age, gender, type of burns and total burn surface area (TBSA). We evaluated as primary endpoints of the study the (i) time for complete epithelization (both treated area and biopsy site) and (ii) aesthetic and functional quality of the epithelization (color, joint contractures). Secondary endpoints were the assessment of infections, inflammations or any adverse effects of the ReCell procedure, particular medications assumed, postoperative pain.

RESULTS

Eighty-two patients were analyzed in two homogeneous groups. All of them received adequate epidermal replacement, but skin grafting was faster than ReCell (p<0.05). On the contrary, ReCell biopsy areas and postoperative pain were smaller than classic grafting (p<0.05). The aesthetic and functional outcomes were similar between procedures.

CONCLUSIONS

ReCell is a feasible, simple and safe technique. It gives similar results to skin grafting but, harvesting minor areas, can open possible future applications in the management of large-burns patients.

The Maltese cross technique: umbilical reconstruction after dermolipectomy

A simple and easy technique for reconstruction of the umbilicus was devised, with emphasis on forming walls of the umbilicus and a depression in a caudal direction. A quite satisfactory result was obtained. A permanent and sufficient depression for the umbilicus can be expected as a result of three-dimensional formation of walls. We also obtained a natural-looking neo-umbilicus.

Devastating Methicillin Resistant Staphylococcus Aureus Wound Infection following Abdominoplasty in a Prior Bariatric Surgery Patient

A 46-year-old female smoker presented 12 months after laparoscopic adjustable gastric banding, with massive weight loss and skin excess of the abdomen and flanks. She underwent abdominoplasty with muscle plication and flanks liposuction, but on the 14th postoperative day this was complicated by a methicillin-resistant Staph. aureus wound infection. Multiple surgical debridements and high doses of intravenous antibiotics were necessary for cure and to avoid further septic complications. Complete wound closure was achieved after 3 months of therapy. Concomitant risk factors for wound infection (obesity, smoking, flap construction) contributed to a rare but potentially fatal wound complication following abdominoplasty. We alert the surgeon to such postoperative infections and the necessity for a non-conservative approach.

Anatomical identification of active contacts in subthalamic deep brain stimulation

BACKGROUND

Subthalamic Deep Brain Stimulation is a valid surgical procedure for the treatment of idiopathic PD, although its precise mechanism of action is still unclear; moreover, there are no conclusive data about the functional anatomy of the human subthalamic region. Identifying the location of active contacts for StnDBS can yield interesting insights on the mechanisms of action of DBS and the different role played by the anatomical structures of the subthalamic region.

METHODS

Twenty-five patients operated on for bilateral StnDBS were considered. During the surgical procedure, a complete intraoperative neurophysiological study was obtained by means of semimicrorecordings and stimulations. After surgery, an MRI study confirmed the position of the electrodes; MR images were subsequently superimposed onto a stereotactic atlas by using a dedicated workstation. The coordinates relative to the tip of the electrodes and active contacts were then calculated.

RESULTS

Most of the electrode tips are located inside the subthalamus or immediately ventrally to it. Of the active contacts used for chronic stimulation, 96.5% are located in a well-defined anatomical region, which includes subthalamus, zona incerta, and FF.

CONCLUSIONS

Our findings seem to suggest that other structures beyond the subthalamus itself play a clinical role in symptoms control after DBS for PD.

Acquired unilateral naevoid telangiectasia in a healthy boy

This article does not have an abstract.

Smokers: risks and complications in abdominal dermolipectomy

Cigarette smoke has many detrimental effects on health, with consequences such as cardiovascular diseases, respiratory diseases, and tumors. In plastic surgery, these effects appear during the wound healing process. This retrospective study showed wound healing in 57 patients who had undergone abdominal dermolipectomy surgery. The patients were divided into two groups: smokers and nonsmokers. According to the results, smokers face a great complication risk for surgical wounds, which cause aesthetically more undesirable scars than observed in nonsmokers. The authors hypothesize that abstinence from smoking for 4 to 12 weeks before surgery would improve the quality of the scars.

Extracorporeal photochemotherapy: a safety and tolerability pilot study with preliminary efficacy results in refractory relapsing-remitting multiple sclerosis

Extracorporeal photochemotherapy (ECP) is an immunomodulating procedure consisting of autologous reinfusion of peripheral blood mononuclear cells (PBMC) after direct exposure to 8-methoxy-psoralen and UV-A. It has been described as a successful treatment for different T-cell-mediated diseases and preliminary results suggest that ECP might be effective in the treatment of relapsing-remitting multiple sclerosis, but does not significantly alter the course of the progressive form of MS. In this study, we report the safety data and some preliminary efficacy evidence obtained using ECP in the treatment of five patients with refractory relapsing-remitting (RR) MS: in most cases ECP induced a reduction in the relapse rate and an EDSS stabilisation, with an apparent general MRI stabilisation. In conclusion, our results confirm ECP safety and tolerability and suggest that this treatment might be useful as a therapeutic alternative in the subgroup of RRMS patients not responsive to or not eligible for traditional immunomodulating or immunosuppressive treatments.

Fungal contamination in hospital environments

OBJECTIVES

To assess the degree of fungal contamination in hospital environments and to evaluate the ability of air conditioning systems to reduce such contamination.

METHODS

We monitored airborne microbial concentrations in various environments in 10 hospitals equipped with air conditioning. Sampling was performed with a portable Surface Air System impactor with replicate organism detection and counting plates containing a fungus-selective medium. The total fungal concentration was determined 72-120 hours after sampling. The genera most involved in infection were identified by macroscopic and microscopic observation.

RESULTS

The mean concentration of airborne fungi in the set of environments examined was 19 +/- 19 colony-forming units (cfu) per cubic meter. Analysis of the fungal concentration in the different types of environments revealed different levels of contamination: the lowest mean values (12 +/- 14 cfu/m(3)) were recorded in operating theaters, and the highest (45 +/- 37 cfu/m(3)) were recorded in kitchens. Analyses revealed statistically significant differences between median values for the various environments. The fungal genus most commonly encountered was Penicillium, which, in kitchens, displayed the highest mean airborne concentration (8 +/- 2.4 cfu/m(3)). The percentage (35%) of Aspergillus documented in the wards was higher than that in any of the other environments monitored.

CONCLUSIONS

The fungal concentrations recorded in the present study are comparable to those recorded in other studies conducted in hospital environments and are considerably lower than those seen in other indoor environments that are not air conditioned. These findings demonstrate the effectiveness of air-handling systems in reducing fungal contamination.

Role of Immunosuppressive Regimen on the Incidence and Characteristics of Cytomegalovirus Infection in Heart Transplantation: A Single-Center Experience With Preemptive Therapy

OBJECTIVE

This retrospective single-center report sought to evaluate the relation of immunosuppressive regimen with the incidence and characteristics of cytomegalovirus (CMV) infection from 1999 to 2003.

PATIENTS AND METHODS

Immunosuppression consisted of cyclosporine microemulsion (Neoral), azathioprine (AZA), and prednisolone associated with either thymoglobulin or ATG high-dosage induction from 1999 to 2000 (AZA, 64 patients [AZA-Thymo = 38 patients and AZA-ATG 26 patients]), or cyclosporine microemulsion (Neoral), mycophenolate mofetil (MMF), and prednisolone with low-dose thymoglobulin induction from 2001 onward (n = 52 patients). Ganciclovir preemptive therapy was guided by pp65 antigenemia monitoring without CMV prophylaxis.

RESULTS

The study groups were homogeneous with respect to major perioperative risk factors. Comparing the two AZA subgroups no difference emerged as to percentage of pp65 antigenemia-positive, preemptively treated patients reflecting CMV disease incidence and relapses. AZA-Thymo patient showed significantly shorter time to first positive pp65-antigenemia and higher viral load (AZA-Thymo vs AZA-ATG, P = .004 and P = .009). The two subgroups did not differ with regard to incidence of rejection, superinfection, and graft coronary disease. By shifting from AZA to MMF no difference emerged as to incidence and characteristics of CMV infections, but there was a significant reduction in acute rejection and superinfection (AZA vs MMF P = .001 and P = .008).

CONCLUSIONS

The distinct immunological properties of thymoglobulin versus ATG significantly altered the pattern of CMV expression. MMF with reduced-dose induction did not engender a higher CMV morbidity.

Sublingual ranula: report of a submandibular clinical case

Ranula is a raised mucocele on the oral floor. When the mucocele extends and passes the sublingual space and invades the submandibular space it may be called ''plunging ranula''. Its etiology is not completely known. Our clinical case is a clear example: a 10-year old formation, not painful, developed during several years and originally of small dimension located in the sublingual region. The purpose of this study is to underline that the surgical treatment of choice, in these clinical situations, is the drainage of the cavity and marsupialization rather than a radical removal.

Influence de la déforestation sur le fonctionnement hydrologique de petits bassins versants tropicaux

Les régions tropicales subissent une déforestation importante. En Amérique du Sud,la forêt est généralement remplacée par une prairie, C'est pourquoi nous avons étudié le comportement hydrologique de 2 petits (1,5 ha) bassins versants. Un bassin (bassin B) est recouvert par une forêt primaire, tandis que le second (bassin A) a été défriché et transformé en prairie (Digitaria swazilandensis, programme ÉCÉREX, ORSTOM/CTFT). Ces bassins, situés en Guyane Française, sont proches (500 m), escarpés et principalement constitués par des sols à drainage vertical ralenti. Le climat est de type tmpical humide avec une température moyenne (26 °C) et des précipitations moyennes annuelles (3500 à 3900 mm/an) élevées. L'évapotranspiration réelle et potentielle de la forêt primaire sont respectivement égales à 1470 mm/an et 1565 mm/an, En période d'étiage, nous avons observé un écoulement permanent à l'exutoire du bassin A, alors que le bassin B en est dépourvu. Deux crues (24 mai 1992 et 15 mai 1993) ont été étudiées, simultanément sur les 2 bassins. Pendant les crues, nous avons prélevé des échantillons d'eau des précipitations (pluie et pluviolessivat), des ruisseaux et du sol. Sur ces sites, l'eau circulant dans les couches peu profondes du sol présente une concentration élevée en K+ et faible en Cl-. Une signature opposée caractérise l'eau des couches pmfondes du sol. L'analyse des relations existant entre les traceurs chimiques (K+, Cl-) et isotopique l80) ainsi l'étude des propriétés hydrodynamiques du sol permet de décomposer qualitativement l'hydrogramme de crue en 3 réservoirs: sol superficiel (écoulement hypodermique), sol intermédiaire (de 0 à - 0,4 m), sol profond (bassin B) ou nappe (bassin A). Une décomposition quantitative a été effectuée en utilisant des traceurs chimique (Cl-) et isotopique l80). Nous avons ainsi montré que les crues sur les 2 bassins sont dominées par l'écoulement issu des couches intermédiaires du sol qui représente environ la moitié de l'écoulement total de crue. Cependant,les mécanismes de génération des crues diffèrent sur les 2 bassins. Sur le bassin A, les couches profondes du sol sont saturées avant la crue et participent donc à la totalité de la crue. Au contraire, sur le bassin B, les couches profondes de sol atteignent la saturation peu de temps avant le pic de crue et participent donc essentiellement aux écoulement pendant la décrue. Ces résultats confirment les études hydrologiques réalisées précédemment (FRITSCH, 199Ù) et permettent d'identifier les mécanismes de genèse des crues et ainsi de mettre en évidence l'effet de la déforestation.

[New view in the mammary asymmetry treatments]

AIM

Breast asymmetry is a huge chapter of breast abnormalities. Surgical therapy is the exclusive one. The breast of women can vary in shape, volume and position, thus creating esthetic, social and psychological problems.

METHODS

We classified breast asymmetry into 6 categories and then we treated them with different surgical techniques: reduction mammaplasty according to Planas; augmentation mammaplasty with prosthesis; grafts or both; ultimately mamma-prosthesis (association of mastopexy and prosthesis). We obtained satisfactory esthetic results often with one surgery procedure. Rarely we performed 2 or more procedures of symmetry. We treated 77 patients suffering from breast asymmetry. We excluded in this study the giant-mammary asymmetry (anomaly determined by severe and asymmetric mammary hypertrophy).

RESULTS

We found a low number of complications at short and long term. These results are likely due to the ability of the surgeon in the appropriated preoperative evaluation of the patients and of their expectancy and correct surgical techniques.

CONCLUSIONS

We tried to obtain 3 results: shape and position of the sick breast as same as possible to the contralateral breast and less evident scars located in hidden regions.

Three-phase sequential combined treatment with lamivudine and interferon in young patients with chronic hepatitis B

Alpha-interferon (IFN) or lamivudine monotherapy are ineffective in treating chronic HBeAg positive patients with high viral load and low alanine aminotransferase (ALT) levels. We investigated whether priming lamivudine treatment might enhance the antiviral and immunostimulant action of lamivudine/IFN combination in young tolerant patients. Eleven chronic HBeAg positive patients received: 100 mg/day lamivudine for 3 months followed by IFN 5 MU/m2/tiw with lamivudine 100 mg/day for 6 months and then lamivudine alone 100 mg/day for 9 months. Quantitative hepatitis B virus (HBV)-DNA was evaluated during treatment and core-promoter, precore and polymerase HBV mutants were detected by direct sequencing at the end of therapy. Serum HBV-DNA levels dropped during lamivudine monotherapy and in combination with IFN. After IFN withdrawal, viraemia transiently increased to high levels in five of 11 (45%) patients who showed rt M204V/I lamivudine mutant resistant. Two patients cleared HBeAg without anti-HBe seroconversion. One patient presented core-promoter (A1762T/G1764A) and precore stop codon mutations. Hence, three-phase sequential combined lamivudine/IFN treatment reduced HBV-DNA serum level, but did not lead to HBeAg and HBV-DNA clearance in these highly viraemic, normal ALT patients. Lamivudine/IFN combination did not prevent the emergence of YMDD lamivudine resistance. New schedules of antiviral treatments must be evaluated in this population at risk of disease progression.

Prevalence of Hepatitis C Virus Infection in Different Population Groups in Southern Italy

BACKGROUND

A cross-sectional investigation was carried out between 2000 and 2002 to assess the prevalence of hepatitis C virus infection (HCV) in Naples, southern Italy.

PATIENTS AND METHODS

Five groups of individuals were investigated, two at low risk and three at high risk for HCV infection. Blood sample sera were collected among 5,391 individuals (4,059 men and 1,332 women): 1,972 general practitioner (GP) patients and 781 employees of the National Cancer Institute (NCI) of Naples (low-risk groups); 524 male prisoners, 1,436 intravenous drug users (IDUs) and 678 hemodialysis patients (high-risk groups).

RESULTS

Overall HCV seropositivity rates ranged from 6.4% among employees of the NCI to 37.4% among male prisoners. HCV infection tended to generally increase with age, but in IDUs and in male prisoners the upward trend leveled off at 50 years of age. As compared to GP patients, IDUs (both sexes) and male prisoners had a nearly 6-fold increased risk of HCV infection, while HCV was nearly 3-fold more common among hemodialysis patients. Employees of NCI were at reduced risk of HCV infection, particularly women (odds ratio = 0.3).

CONCLUSION

The study findings confirmed the high risk for HCV infection in IDUs and identified other population groups in southern Italy that should be offered HCV screening and counselling given the severe implications of HCV infection on health.

Abnormalities of canines eruption

The aim of this article is to present the personal experience on the treatment of 2 groups of patients presenting the same problem: the recovery of teeth 13 and 23 in the dental arch. The 1(st) group consists of adult patients aged approximately 20-28 years with a retained position of the permanent canines and permanence of the respective deciduous teeth in the dental arch. In the 2(nd) group, the loss of the deciduous teeth had not been followed by the physiological eruption of the permanent teeth. The authors' aim is to demonstrate that similar orthodontic treatments can represent valid solutions for the treatment of pathologies with different etiopathogenesis.

Reconstruction of partially amputated external ear with costal cartilage graft: case report

Many causes are responsible for secondary anomalies of the outer ear, such as: car accidents, sport- or work-related accidents, assaults, bites from animals or humans, benign or malignant tumours, burns and the effects of surgical interventions of the ear (plastic surgery on the ear or attempts at correction of primary malformations of the ear). The anatomical complexity of the ear makes its reconstruction particularly complicated with post-operative results that are often disappointing. The Authors describe their experience in the reconstruction of a partially amputated outer ear following a dog bite. The therapeutic protocol required various surgical stages. Initially, a cutaneous expander was applied at the level of the mastoid in order to ensure a sufficient quantity of local skin. The second stage was to remove cartilage from the ribs, followed by construction of a cartilaginous model of the ear and its insertion into the subcutaneous mastoid region after removal of the cutaneous expander and any residual ear cartilage. The last stage was to separate the neo-formed outer ear from the mastoid skin with the insertion of a cartilage graft to the posterior region of the reconstructed ear. This graft was covered by the occipital fascia rotated at 180 degrees and by a skin graft removed from the pubis. The postoperative result was satisfactory with recuperation of a good aesthetic appearance of the ear. Aim of the present report is to describe the surgical technique employed in the reconstruction of secondary anomalies of the ear and to highlight errors committed during this procedure. These considerations have allowed us to stress some fundamental elements in the reconstruction of the ear. In particular, the watershed was the awareness that we had to create a cartilaginous model that respected, as far as possible, the anatomy of the outer ear with all its ridges, trenches and cavities. This as well as ensuring a sufficient quantity of local skin in order to cover the cartilaginous graft and, therefore, reduce the risk of exposing the cartilage and subsequent infection, to guarantee an optimal end result.

Efficacy and limitations of preemptive therapy against cytomegalovirus infections in heart transplant patients

OBJECTIVES

Cytomegalovirus (CMV) disease often represents a serious complication that promotes opportunistic infections in heart transplant recipients. In this study we evaluated the impact of preemptive gancylovir therapy, guided by pp65 antigenemia on the morbidity associated with viral reactivation.

PATIENTS AND METHODS

We have performed a CMV infection surveillance program since March 1999, with antigenemia pp65 determinations weekly for the first 2 months biweekly in the third months, and monthly to the sixth month. Patients with pp65 antigenemia value >/= 10 positive cells per 2 x 10(5) polymorphonuclear cells (PMN) were treated with intravenous gancyclovir followed by 1 month of oral gancyclovir.

RESULTS

Among the 107 patients who underwent the virological monitoring, 80 were pp65 antigenemia-positive with preemptive therapy administered in 48 cases. Five patients displayed symptomatic CMV disease (4.7% vs 18% rate in the period of 1988 to 1998 before the introduction of virologic monitoring; P <.01). We observed only one case of gancyclovir-resistant pneumonia which was successfully treated with foscarnet. CMV recurrence in 10 patients required a second cycle of gancyclovir treatment. Our experience included 13 opportunistic infections (12.7%) with 11 antigenemia-positive.

CONCLUSIONS

Preemptive therapy drastically reduces the incidence of CMV disease and the associated morbidity. Compared to universal prophylaxis, this approach may avoid unnecessary pharmacologic treatment in more than 50% of transplant recipients. Indeed, preemptive therapy does not fully prevent CMV disease, because it may manifest at the first antigenemia determination, and furthermore may select gancyclovir-resistant strains.

Midterm results of a prospective randomized comparison of two different rabbit-antithymocyte globulin induction therapies after heart transplantation

This prospective randomized study compared the effects in heart transplant recipients of thymoglobulin and ATG, two rabbit polyclonal antithymocyte antibodies available for induction therapy. Among 40 patients (29 men and 11 women, mean age: 40.7 +/- 14 years) undergoing orthotopic heart transplantation, 20 were randomly allocated to receive induction with thymoglobulin (group A) and 20 to ATG-fresenius (group B). Comparisons between the two groups included early posttransplant (6 months) incidence of acute rejection episodes (grade >/= 1B), bouts of steroid-resistant rejection, time to first rejection, survival, graft atherosclerosis, infections, and malignancies. The study groups displayed similar preoperative and demographic variables. No significant difference was found with regard to actuarial survival (P =.98), freedom from rejection (P =.68), number of early rejections > 1B (P =.67), mean time to first early cardiac rejection (P =.13), number of steroid-resistant rejections (P =.69). Cytomegalovirus reactivations were more frequent among group A (65%) than group B (30%; P =.028). New infections due to cytomegalovirus occurred only in group A (four patients; 20%; P =.05). No cases of malignancies were observed at a mean follow-up of 32.8 +/- 8.9 months. Although thymoglobulin and ATG showed equivalent efficacy for rejection prevention, they have different immunological properties. In particular, thymoglobulin seems to be associated with a significantly higher incidence of cytomegalovirus disease/reactivation.

Prospective randomized trial of submucosal hemorrhoidectomy with radiofrequency bistoury vs. conventional Parks? operation

BACKGROUND

Postoperative pain has always been the main adverse effect of the surgical treatment for hemorrhoids. Surgical techniques evolved mainly to solve this problem as well as postoperative bleeding, stenosis and recurrence. This randomized study compared the results obtained using submucosal hemorrhoidectomy with radiofrequency bistoury with those of the conventional Parks' operation.

METHODS

A total of 102 patients were randomized to undergo submucosal hemorrhoidectomy with radiofrequency bistoury (51 patients) or conventional Parks' haemorrhoidectomy (51 patients); loss of some patients at follow-up resulted in 49 and 45 patients available for analysis, respectively. The operating time, amount of pain (VAS scale, 1-10), postoperative analgesic requirement, intra- and postoperative complications, length of hospital stay and patient satisfaction were documented.

RESULTS

In comparison to Parks' technique, use of radiofrequency bistoury reduced mean operating time (61.2 min vs. 37.4 min; p<0.05), first postoperative day pain score (5.9 vs. 4.0; p<0.05), pain score at first evacuation (5.7 vs. 4.2; p>0.05), postoperative stay (2.2 days vs. 1.3 days; p<0.05), and pain score on postoperative day 7 (3.6 vs. 2.8; p>0.05). Fecal incontinence was never observed. Incontinence to flatus with spontaneous resolution within 2-3 weeks was reported by 4 subjects in each surgical group. Urinary retention requiring catheterization occurred in 21 subjects in the radiofrequency bistoury group and in 18 patients in the control group. No complications nor recurrences were reported at the 6-month follow-up in either group.

CONCLUSIONS

Performing submucosal hemorrhoidectomy with radiofrequency bistoury improves the results obtained with Parks' technique, allowing us to simplify the surgical procedure, reduce operating time, postoperative pain and bleeding, and shorten the hospital stay.

UNCONVENTIONAL AFFECTIVE SYMPTOMS AND EXECUTIVE FUNCTIONS AFTER STROKE IN THE ELDERLY

In the present study we assessed the presence and severity of unconventional affective symptoms (apathy, anhedonia and emotional lability) and depression in 33 elderly patients with first ever stroke and evidence of a single supratentorial lesion at neuroimaging. Patients were submitted to neurological, functional, and affective assessment at a mean interval of 2 weeks after stroke onset. Given the putative role of the frontal lobes in the pathogenesis of these symptoms, we also performed a cognitive assessment focused on executive functions. The prevalence of the various affective symptoms was as follows:apathy 15.2 %, anhedonia 6.1 %, emotional lability 48.5 %, depression 57.6 % of cases. Patients had a normal global cognitive level (mean short portable mental status questionnaire: 8.4 +/- 1.0, range 7-10). Apathy and anhedonia showed significant reciprocal correlations and they were also correlated with the executive score and the Barthel index;apathy was also correlated with depression; emotional lability, instead, was correlated only with depression. The study of possible anatomo-functional correlates between unconventional affective symptoms and lesion site did not show significant differences (stroke in the right versus left hemisphere, anterior versus posterior and cortical versus subcortical locations).