Infrahyoid myocutaneous flap in head and neck reconstruction: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to analyse the literature on the infrahyoid myocutaneous flap (IHMCF) and evaluate its clinical outcomes. The MEDLINE, Embase, Web of Science, Cochrane Library, and Scopus databases were searched (inception to December 31, 2021). Meta-analyses were then conducted to estimate the overall rates of partial flap loss, total flap loss, salivary fistula, and surgical revision. The 21 studies that met the inclusion criteria included 768 patients undergoing head and neck reconstruction with 773 IHMCF. The oral cavity (77.7%) and oropharynx (13.0%) were the most reconstructed sites. The meta-analyses estimated a pooled partial flap loss rate of 10.4% (99% confidence interval (CI) 5.4-16.7%), total loss rate of 1.8% (99% CI 0.8-3.2%), salivary fistula rate of 3.0% (99% CI 1.3-5.3%), and surgical revision rate of 1.9% (99% CI 0.7-3.7%). Fast flap harvesting and low donor site morbidity were other flap features. Previous thyroid surgery or neck dissection and advanced lymph nodal stage were considered contraindications to IHMCF reconstruction by most authors, while prior neck radiotherapy was reported as a relative contraindication. This pedicled cervical flap is a versatile and reliable reconstructive option for medium-sized head and neck defects. Careful preoperative assessment of the neck condition allows for its safe use.

Endocavitary contrast enhanced ultrasound (CEUS): a novel problem solving technique

Abstract

Contrast-enhanced ultrasound (CEUS) is a technique that has developed as an adjunct to conventional ultrasound. CEUS offers a number of benefits over conventional axial imaging with computerised tomography and magnetic resonance imaging, primarily as a “beside” test, without ionising radiation or the safety concerns associated with iodinated/gadolinium-based contrast agents. Intravascular use of ultrasound contrast agents (UCAs) is widespread with extensive evidence for effective use. Despite this, the potential utility of UCAs in physiological and non-physiological cavities has not been fully explored. The possibilities for endocavitary uses of CEUS are described in this review based on a single-centre experience including CEUS technique and utility in confirming drain placement, as well as within the biliary system, urinary system, gastrointestinal tract and intravascular catheters.

Teaching Points

• CEUS offers an excellent safety profile, spatial resolution and is radiation free.

• Endocavitary CEUS provides real-time imaging similar to fluoroscopy in a portable setting.

• Endocavitary CEUS can define internal architecture of physiological cavities.

• Endocavitary CEUS can confirm drain position in physiological and non-physiological cavities.

Head and neck reconstruction with pedicled flaps in the free flap era

Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis.

Pilot study on microvascular anastomosis: performance and future educational prospects

The introduction of microvascular free flaps has revolutionised modern reconstructive surgery. Unfortunately, access to training opportunities at standardised training courses is limited and expensive. We designed a pilot study on microvascular anastomoses with the aim of verifying if a short course, easily reproducible, could transmit microvascular skills to participants; if the chosen pre-test was predictive of final performance; and if age could influence the outcome. A total of 30 participants (10 students, 10 residents and 10 surgeons) without any previous microvascular experience were instructed and tested during a single 3 to 5 hour course. The two microanastomoses evaluated were the first ever performed by each participant. More than the half of the cohort was able to produce both patent microanastomoses in less than 2 hours; two-thirds of the attempted microanastomoses were patent. The pretest predicted decent scores from poor performances with a sensitivity of 61.5%, specificity of 100%, positive predictive value of 100% and negative predictive value of 40%. Students and residents obtained significantly higher scores than surgeons. Since our course model is short, cost-effective and highly reproducible, it could be introduced and implemented anywhere as an educational prospect for preselecting young residents showing talent and natural predisposition and having ambitions towards microvascular reconstructive surgery.

Pharyngocutaneous fistula following total laryngectomy: analysis of risk factors, prognosis and treatment modalities

The aim of this study was to establish the incidence, risk factors, and the management of pharyngocutaneous fistula (PCF) after primary and salvage total laryngectomy. A retrospective, match-paired analysis of 86 patients who developed fistula after total laryngectomy was carried out and compared with a control group of 86 patients without fistula, randomly selected from a pool of 352 total laryngectomies, performed between January 1999 to October 2014. The overall incidence of PCF in the series was 24.4%; we recorded rates of 19.0%, 28.6% and 30.3% following primary total laryngectomy (PTL), salvage laryngectomy post-radiotherapy (RT-STL) and salvage laryngectomy postchemoradiotherapy (CRT-STL), respectively. Multivariate analysis revealed that the relative risk of fistula was respectively 2.47, 3.09 and 7.69 for hypoalbuminaemia ≤3.5 g/dL, RT-STL and CRT-STL. An early onset of PCF within 10 postoperative days was recorded in case of salvage total laryngectomy. The management of PCF significantly differed between PTL, RT-STL and CTRT-STL, with exclusive conservative treatment for PTL (93.55%), while in the CRT-STL group surgical closure with regional flaps (58.82%) prevailed. Conservative management, adjuvant hyperbaric oxygen therapy and surgical closure were equally distributed in the RT-STL group. Thorough knowledge of patient-related risk factors and its prognostic value, allows the surgeon to better evaluate preventive strategies with the aim of minimising fistula formation, hospitalisation times and related costs.

Oral cavity reconstruction with the masseter flap

The purpose of this report is to highlight how an unusual, outdated, unpopular and overlooked reconstructive method such as the masseter flap can be a reliable, straightforward and effective solution for oral reconstruction in selected cases. We report the transposition of the masseter crossover flap in two previously pre-treated patients presenting a second primary oral squamous cell carcinoma; excellent functional results with satisfactory cosmetic appearance were obtained in both cases. In the literature, only 60 cases of oral cavity and oropharyngeal reconstructions using the masseter flap have been reported. The possible clinical utility of this flap, even in modern head and neck reconstructive surgery, is presented and discussed. We believe that the masseter flap should enter in the armamentarium of every head and neck surgeon and be kept in mind as a possible solution since it provides an elegant and extremely simple procedure in suboptimal cases for microvascular reconstruction.

Outcomes and indications for intervention in non-operative management of paediatric liver trauma: a 5 year retrospective study

AIM

To determine the applicability of accurate computed tomography (CT) evaluation and embolization as non-operative management for liver trauma in a paediatric population.

MATERIAL AND METHODS

A retrospective observational study of 37 children (mean age 10.5 years) with hepatic trauma (28 blunt, 9 penetrating) admitted to a trauma referral centre over a 5 year period. All patients were evaluated with CT and scored with an Association for the Surgery of Trauma score. Inpatient information was reviewed for demographics, associated injuries, modes of management, efficacy and complications of management, and outcome.Statistical analysis was performed.

RESULTS

There were seven contusions, two grade I, two grade II, nine grade III, and 17 grade IV liver lacerations. Only two patients (grade IV, penetrating) underwent surgery for the management of bowel perforation. All children had non-surgical treatment of their liver trauma: three cases (grade IV) had primary angiography due to CT evidence of active bleeding and embolization was performed in two of these. Seven patients (two grade III, five grade IV)had angiography during the follow-up for evidence of a complicating pseudoaneurysm and embolization was performed in six of them. Embolization was successful in all the children; one minor complication occurred (cholecystitis). Endoscopic retrograde cholangiopancreatography (ERCP) plus stenting was performed in two cases for a bile leak. All 37 children had a positive outcome.

CONCLUSION

The present study demonstrates that non-operative management of hepatic trauma is applicable to children and may have a higher success rate than in adults.

Dissection with harmonic scalpel versus cold instruments in parotid surgery

BACKGROUND

The harmonic scalpel (HS) has been used successfully in several head and neck surgical procedures. Some authors highlighted its advantages in reducing operative time, blood loss, and damages to surrounding tissue. In our study, we compared the results obtained during parotidectomy using the HS with the traditional approach to determine the benefits of the HS.

METHODS

130 patients with benign parotid tumors were enrolled and randomized into two groups for this prospective study. 63 patients underwent HS parotidectomy, and 67 patients received a parotidectomy using cold instruments and bipolar electrocautery hemostatic control (CI). 20 HS and 2 CI patients did not meet the inclusion criteria requirements, and were excluded.

RESULTS

The admission time was significantly shorter in the HS group than the CI group (3.9 ± 1.2 days and 4.7 ± 1.4 days, respectively, p < 0.01). In the early post-operative period, 84% of HS patients and 60% of CI cases showed no facial nerve impairment (p = 0.01). Significantly more CI patients than HS patients showed the onset of Frey's syndrome (29% and 9%, respectively, p = 0.01). Multivariate stepwise regression analysis confirmed the reduction in admission length (Odds Ratio (OR): 0.62; p = 0.02) and the lower risk of Frey's syndrome (OR: 0.29; p = 0.04) in HS compared to CI parotidectomies.

CONCLUSIONS

In parotid surgery, the HS is useful in preventing Frey's syndrome and reducing early transitory facial nerve dysfunction and admission times, and results in decreased medical costs and increased quality of life.

Contrast enhanced ultrasound (CEUS) characterization of grey-scale sonographic indeterminate focal liver lesions in pediatric practice

PURPOSE

To determine the usefulness of contrast-enhanced ultrasound (CEUS) in characterizing grey-scale sonographic indeterminate focal liver lesions (FLL) in pediatric practice.

MATERIALS AND METHODS

Local Ethics Board approval waiver was attained. Consent for CEUS examinations was acquired from parents. Forty-four children referred for CEUS assessment of grey-scale sonographic indeterminate FLL over a 5-year period underwent standard multiphase CEUS performed by experienced operators. A phospholipid microbubble agent was used and low mechanical index ultrasound imaging techniques employed. Interpretation by consensus of the CEUS examination was compared to consensus interpretation of other imaging and to histology. Follow-up imaging was used to confirm stability of benign abnormalities. Any contrast reactions were recorded.

RESULTS

The CEUS examination interpretation agreed with reference imaging in 29/34 (85.3 %) of cases. In discordant cases, reference imaging showed no abnormality (n = 5), with fatty change (n = 4) and regenerating nodules (n = 1) on CEUS and follow-up sonography. Where reference imaging was not performed (n = 10), histology (n = 7) or follow-up sonography (n = 3) confirmed the diagnosis. In one discordant case, all imaging modalities showed concordance identifying a malignant lesion; however histology demonstrated a benign hepatocellular adenoma. The specificity was 98.0 % (95 % CI; 86 - 100 %) and the negative predictive value was 100 %. No adverse effects to the contrast material were noted.

CONCLUSION

These findings demonstrate the usefulness of CEUS in characterizing indeterminate grey-scale sonography FLL in pediatric patients with the potential to reduce exposure to ionizing radiation.

[Epidemiological survey on urinary incontinence in school population in Verona (Italy)]

The authors tried to estimate the prevalence of urinary incontinence in children between 6 and 13/14 years by administering an anonymous questionnaire to students of primary and secondary 1 degree schools of the City of Verona. The disorder is found to be present only at night in 1.9% (male)--0.6% (females) in the elementary school; also in daytime in 2% (males)--1.3% (females) in the elementary school and 0.7% (male)--1.2% (females) in the middle school; only in daytime in 2,7% (males)--3,5% (females) in the elementary school and 2% (male)--3,3% (females) in the middle school. These data may be underestimated by the low adhesion to the survey by adolescents.

The value of ultrasound in assessing displacement of a medial clavicular physeal separation in an adolescent

We describe a case of medial clavicular physeal separation with posterior displacement of the metaphysis in a 13-year-old girl, focusing on the role played by ultrasound in the diagnosis, planning of treatment and post-reduction follow-up. On clinical examination and conventional radiography, the injury is essentially indistinguishable from a sternoclavicular dislocation or a fracture of the medial aspect of the clavicle; however, the pathogenesis is different, consisting in medial physeal separation and 'degloving' of the inner cancellous bone of the metaphysis from the surrounding periosteal collar with posterior metaphyseal dislocation. In our case, attempted closed reduction failed, and the injury required open reduction with relocation of the clavicle into the periosteal sleeve followed by suturing of the periosteal tear.

New surgical technique for endoscopic management of anterior glottic web

OBJECTIVES

In this study we report a new endoscopic technique for the management of anterior glottic web (AGW). Previously, various procedures with endoscopic or open surgical approaches have been described for the treatment of symptomatic AGW. We present an original, highly effective endoscopic technique that seems to have several advantages over traditional approaches.

METHODS

We used this novel technique in a preliminary series of four patients. Using a CO2 laser, a curvilinear mucosal flap based on the web is elevated from the superior surface of one vocal chord. The web is divided, and the flap is sutured at the inferior surface of the opposite vocal chord, ensuring that no raw surfaces will be left exposed on this side of the larynx. We accurately describe the technique, displaying diagrams of the surgical steps.

RESULTS

In three cases, a restoration of the laryngeal airway, with complete resolution of the AGW, was achieved. A limited residual web persisted close to the anterior commissure in the fourth patient.

CONCLUSIONS

The new endoscopic technique utilized in our preliminary series of patients is a simple, repeatable, and effective surgical procedure for managing AGW.

Necrotizing fasciitis of the neck associated with Lemierre syndrome

Necrotizing fasciitis of the head and neck is a rare, life-threatening, soft tissue infection rapidly involving superficial fat and fascia with necrosis of the overlying skin. If septic thrombophlebitis of the internal jugular vein complicates a parapharyngeal abscess, the clinical condition is referred to as Lemierre syndrome, also known as post-anginal sepsis. A lethal case of necrotizing fasciitis of the neck is herewith reported that developed following tooth extraction and was complicated by thrombosis of the internal jugular vein and superior vena cava in an elderly diabetic patient.

[Microsurgical reconstruction and full management of patients with head and neck cancer: importance of a quality approach and a patient care team]

MAIN OF STUDY: Management and surgical reconstruction of head and neck cancers remain a challenge. From the first consultation to surgery and radiotherapy it is necessary to gain time to ensure optimum treatment and better survival rates.

OBJECTIVE

To establish a kind of quality approach to the management of patients with head and neck cancers. 54 patients who received microsurgical reconstruction after head and neck cancer were included in this study between 1997 and 2006.

RESULTS

Multiple data were considered: body mass index (BMI), ASA stage, age, existence of a pre-or postoperative radiotherapy, the surgeon's experience and the number of drainage veins. The success rate is superior when more than one draining vein is sutured to the flap for patients with a BMI >20. Radiotherapy does not seem to affect the survival of the flap.

CONCLUSION

According to current literature, the survival rate of these patients is better when the overall time care is less than 100 days. That period is possible with a perfect organization of the medical and paramedical team. Therefore, we propose to include these patients in a circuit protocolisation care, which saves time, to better inform patients and improve survival rates.

Surgical management of surgery and radiation induced peristomal neck ulcerations

PROBLEMS/OBJECTIVE: Non-healing cervical skin ulcerations with concomitant necrosis of the subcutaneous tissue and muscle is a rare but feared complication of radiotherapy that can arise in cervical regions. Constant erosion of the surrounding tissue by the expansion of the necrotic front can threaten important structures. Very few reports in the literature deal with the surgical management of these injuries.

METHODOLOGY

This paper reports on two cases of non-healing, slow-growing cervical ulcerations that occurred as a result of radiotherapy and surgery.

RESULTS

After unsuccessful conservative treatment, definitive surgical repair was performed to achieve reparation of the defect and protect deep structures. The onset and characteristics of the ulcerations as well as the reconstructive options are discussed.

CONCLUSIONS

In the treatment of surgery and radiotherapy induced chronic cervical wounds, non surgical medical treatment should be always attempted for at least 6 months, and should always include hyperbaric oxygen therapy. If conservative methods fail, surgical repair by means of transposition of well vascularized tissue is mandatory to prevent serious complications such as major vessel rupture or fistulas.

Tracheotomy-related posterior tracheal wall rupture, trans-tracheal repair

Laceration of the membranous part of the tracheo-bronchial tree is a rare complication that can occur after single lumen intubation, double-lumen intubation, percutaneous and surgical tracheotomy. The case of a 76-year-old male is presented in whom a posterior tracheal wall laceration, related to tracheotomy, was diagnosed and immediately treated at the end of a head and neck operation. A 6 cm long laceration started 1.5 cm below the tracheotomy level and ended 2 cm above the carina. The tear was closed from distal to proximal area via the tracheotomy opening with PDS 4/0 interrupted sutures using a thoracoscopic needle-holder. This original surgical technique is described in detail. In tracheotomy related tears, the fact that an opening in the trachea already exists and that the lesion rarely extends beyond the carina, should guide the surgeon to make every effort to repair the laceration through this already existing access.

Evolution of elective neck dissection in N0 laryngeal cancer

Management of cervical lymph node metastasis is one of the most challenging problems facing clinicians dealing with head and neck cancer. A retrospective evaluation has been made of results in N0 laryngeal cancer patients treated from 1978 to date by comparing historical data reported in related papers previously published by our institution. The medical records of 2207 consecutive patients with cN0 SCC of the larynx were used as the source of data in the present study. Together with primary treatment, 759 (34.4%) received at least unilateral elective neck dissection, while the remaining 1448 (65.6%) were admitted to a wait-and-see protocol. Overall, in the electively dissected patients (ED): 128 (16.9%) cases were submitted to classical radical neck dissection, while 403 (53.1%) cases were submitted to functional neck dissection (FND) and 228 (30.0%) cases to jugular node dissection (JND, removing Level II, III and IV). In 125 of the ED group, a neck procedure on the contralateral N0 neck was associated, of which 15 were RNDs, 35 FNDs and 75 JNDs, respectively. Based on this large series population, the change in the philosophy was evaluated concerning elective neck treatment in N0 laryngeal cancer, from RND through FND towards JND. As far as concerns the reliability as a staging procedure, no statistically significant difference was found between RND, FND and JND (p = 0.794). The 5-year neck recurrence rate, as estimated by the Kaplan Meier, method, for all ED patients, was 7.7%. No significant difference in the rate of 5-year neck recurrence was detected between RND, FND and JND groups (p = 0.178). In the survival curves, no differences, in terms of actuarial survival by Kaplan Meier analysis, were observed, in our series, as far as concerns type of elective neck dissection performed (p = 0.222). In conclusion, following a critical revision of 25 years' experience, at our Institution, in the management of cN0 necks in laryngeal cancer patients, definitive changes were observed in the surgical approach to the treatment of occult disease in cN0 cases. JND, compared to more extensive neck dissections, did not show statistically significant differences in terms of neck control (p = 0.233), in terms of impact on survival (p = 0.122) and in terms of accuracy as staging procedure (p = 0.794).

Use of the infra hyoid musculo-cutaneous flap in soft palate reconstruction

AIMS

To review a series of 23 consecutive patients with squamous cell carcinomas arising from oropharynx who underwent infra hyoid musculo-cutaneous flap reconstruction including soft palate in alternative to free radial forearm flap or maxillofacial prosthesis. Post operative radiotherapy was performed for all patients.

RESULTS

Every reconstruction healed quickly without major wound complications. The functional results evaluated by speech and swallowing capacities, were good for 17 patients, fair for 4 patients and bad for 2.

CONCLUSIONS

The infra hyoid musculo-cutaneous flap is a versatile, reliable and convenient flap suitable for repairing small and medium sized defects; it can be used in combination with other flaps, and in selected cases obviates the need for a microvascular free radial forearm flap or maxillofacial prosthesis.

External monitor for buried free flaps in head and neck reconstructions

Head and neck defects following oncological surgery must often be repaired with soft tissue and/or bone from other areas of the body. Significant loss of soft tissue requires flaps of sufficient bulk to adequately reconstruct the defect. Microvascular free tissue transfer is a good method for reconstructing even large defects following oncological surgery for head and neck cancer. Continuous post-operative monitoring of the perfusion of a free flap is vitally important to achieve not only a favourable outcome but also to decrease morbidity. Microvascular thrombosis occurs in 4% of the flaps and the best chance for flap salvage is offered by the earliest possible revision of the microanastomosis. Use of buried flaps in head and neck reconstruction makes monitoring particularly difficult and exteriorization of a segment of the flap permits a direct visualization. An original technique is presented for harvesting forearm free flaps with a secondary monitor skin paddle to externally check the status of the paddle and, when modified, can also be used for fibula and rectus abdominis flap.

Infrahyoid myocutaneous flap reconstruction after wide local excision of a Merkel cell carcinoma

The case is presented of an 8 1-year-old female coming to our observation after two non radical local excisions of a Merkel cell carcinoma of the sub-mental skin region. After a wide local excision, with en bloc elective bilateral neck dissection, simultaneous reconstruction with an infra-hyoid myocutaneous flap was performed. A brief overview concerning this rare tumour is presented and the surgical technique of the reconstructive procedure is described in detail. The infra-hyoid myocutaneous flap represents a reliable flap, easy and quick to prepare, limiting the time of surgery. The donor site can be primary closed avoiding skin grafting or scars beyond the head and neck area with no significant cosmetic or functional sequelae in the donor area. In this elderly patient, reconstruction with an infra-hyoid myocutaneous flap appears to have been the best option for closing the surgical defect.

[Congenital obstruction of the gastric antrum: description of a case]

On an average of 100,000 of livebirths congenital obstructive gastric syndromes range from 1 to 3 cases. The syndrome of the congenital antral membrane represents 5% of the total reported cases. It is mostly located 1 to 3 centimeters above the pylorus-duodenal connection and it may occur both in infants and toddlers. In very young patients it might be difficult to differentiate an hypertrophic stenosis of pylorus from a pyloric spasm. In older babies the obstacle to food passage may be moderate and the pathology may not be evident or it can be treated with simple medial therapy. This report presents the case of a 15 months old female with congenital antral membrane.

Reflux esophagitis in children: a scanning and transmission electron microscopy study

In children, excess of gastroesophageal reflux causes lesions of the esophageal mucosa that we have studied by scanning and transmission electron microscopy (SEM and TEM respectively) in 27 grasp biopsies prelevated during endoscopic procedures. Ultrastructural lesions can be graded on the basis of their severity. In grade I, epithelial cells are well preserved in the deepest layers whereas the superficial cells display ultrastructural alterations such as irregular microridges or reduced intercellular junctions. In grade II, the surface is composed of extruding cells and in the intermediate layer, large intercellular spaces containing lympho-monocytic cells are visible. In grade III, the mucosal surface is characterized by crater-like erosions, degenerating cells are visible in all the layers; in two patients columnar epithelium-lined areas (Barrett's esophagus) have been identified. Our results suggest that in patients with reflux esophagitis, ultrastructural examination of grasp biopsies prelevated by pediatric endoscopes allows a grading of the anatomical lesions providing data that can not be obtained by conventional histology.

Surfactant-like material in the antral gastric mucosa of children

It has been proposed that the hydrophobicity of the gastric mucosa is due to surfactant-like material (SLM), mainly composed of phospholipid, adsorbed to the mucosal surface. Biochemical and physiological studies have been performed in different mammals but morphological data on children are lacking. In the present work, the presence of SLM on the antral gastric mucosa of children has been studied by electron microscopy. The results demonstrate that SLM is present and shows two different forms, lamellar bodies and lamellar layers. In the mucosae without endoscopic, histologic, and ultrastructural alterations we have found SLM when the tannic acid method has been used but not when the tissue has been fixed only in glutaraldehyde. Our results suggest that in children with ultrastructural alterations of the epithelium, the amount of gastric SLM is increased in respect to children with a normal mucosa and that the amount of SLM on the surface of the gastric antral mucosa is modified in pathologic conditions.

Oral zinc as initial therapy in Wilson's disease: two years of continuous treatment in a 10-year-old child

Two years of continuous therapy promoted a significant overall amelioration in a 10-year-old boy affected by an hepatic form of Wilson's disease in which zinc sulphate was the sole therapy. In particular, liver function returned to normal and hepatic histology also improved. The parameters characterizing copper metabolism were kept under good control, and a decrease in copper concentration was found in both erythrocytes and liver. The copper balance study performed during the 25th month of treatment showed that oral zinc was still efficiently inhibiting the intestinal absorption of copper. No side effects have been reported so far.

Oral zinc sulphate as primary therapeutic intervention in a child with Wilson disease

An 8-year-old boy with an hepatic form of Wilson disease was treated with oral zinc sulphate as the primary and sole therapy. After 4 months, liver function had dramatically improved, and the parameters characterizing copper metabolism had also normalized.

Potential complications in the use of wheat bran for constipation in infancy

A commercially available wheat bran preparation has been given to six infants between the ages of 6 and 16 months suffering from constipation not due to metabolic or anatomic causes. In all infants, normal bowel movements reappeared after a month of a diet containing bran. After a month on this diet, we observed the following: a decrease in blood levels of calcium, phosphate, and trace elements; an increase in fecal excretion of biliary salts and cholesterol; and an appearance of predominantly proteolytic fecal flora over the saccharolitic flora. These findings, especially the first one, indicate that bran preparations should be used in infancy with extreme caution because of possible side effect on the patient's nutritional status and growth. If bran is used, blood levels of minerals should be repeatedly checked in order to prevent the appearance of vitamin D-dependent rickets and the depletion of trace elements.

Gastric secretory function in coeliac disease

Volume, total titrable acidity, total proteolytic activity and pepsin activity have been determined in 14 coeliac patients and in 8 controls of comparable ages and body weights. Basal secretion (B.O.), total outputs (T. O.) and peak outputs (P.O.) after pentagastrin injection have been determined. Peak outputs (values 60 min/kg) of these parameters are as follows: volume 5.0+/-1.7 ml in coeliacs, 4.3+/-1.2 ml in controls; total titrable acidity 406.1+/-155.0 mEq in patients, 296.1+/-182.4 in conttrols; total proteolytic activity 962.1+/-501.1 micronEq in coeliacs, 569.6+/-272.2 in controls; pepsin activity 789.1+/-521.8 micronEq in patients, 447.6+/-150.4 in controls.

A simplified method for the evaluation of human faecal flora in clinical practice

Qualitative and quantitative evaluation of aerobic and anaerobic faecal flora was determined by a new and easy method. 10 microliter of 12 ten-fold dilutions in saline of samples of faeces were plated on the surface of culture media solidified in wells of sterile virology plexiglass plates (diameter 16 mm; 0.5 ml culture media) and incubated at 37 degrees C for 24 h. The same dilutions and the same plexiglass plates were used under anaerobic conditions for analysis of anaerobic flora (under atmosphere of N2 85%, CO2 10%, H2 5%, negative pressure, at 37 degrees C for 48 h). The analysis was performed on 35 healthy breast-fed newborn infants, 1--6 days old. After birth, the meconium in sterile; already at 25 h of life some bacterial species (Lactobacilli, Bifidobacteria, Bacteroides) show the maximal concentration in faeces and do not grow afterwards; other bacterial species (Coliforms, aerobic and anaerobic Streptococci) increase gradually during the first week of life. This method gives the same results as the conventional techniques (i.e. Petri dishes), but in an easier and quicker way; therefore it seems useful in clinical practice.

Persistent post-enteritis diarrhoea

Clinical, biochemical, and gastroenterological data have been examined im 48 patients in two age groups, one under 12 months of age, the other between 12 and 30 months with persistent post-enteritis diarrhoea. In these patients, the illness consisted of chronic diarrhoea which followed acute enteritis. It brought about a mild malabsorption syndrome with impairment of growth, particularly in infants under one year of age. Chronic inflammation with mucosal damage due to alteration of the intestinal microflora by inappropriate diets and therapy seemed to be the cause of persistent diarrhoea in these patients.