Perioperative pain management after scapular tip free flap harvesting for head and neck reconstruction using mini-catheters to inject the local anesthetic

PURPOSE

Although functional and esthetic results after the use of a scapular tip free flap (STFF) in head and neck reconstruction, and the related donor-site morbidity, have been extensively described, data regarding acute postoperative donor-site pain management are lacking. Purpose of this study is to explore the use of mini-catheters to administer local anesthetics for donor-site pain management after reconstruction using STFF.

METHODS

Patients who underwent head and neck reconstruction using a STFF were prospectively enrolled and, through a perineural catheter placed in the donor site during the surgical procedure, a bolus of chirochaine was injected before the patient regained consciousness and at 8, 16, and 24 h postoperatively. Before and 40 min after each dose administration, donor-site pain on a numerical rating scale (NRS; 0-10) was evaluated.

RESULTS

Study population consisted of 20 patients (40-88 years). At 8 h, the pain scores before and after the injection were 0-10 (mean 3.35) and 0-5 (mean 1.25), respectively. At 16 h, the pain scores before and after the injection were 0-8 (mean 2.55) and 0-4 (mean 0.55), respectively. At 24 h, the pain scores before and after the injection were 0-8 (mean 1.30) and 0-4 (mean 0.30), respectively.

CONCLUSION

Statistical analysis confirmed a significant difference between the pain scores before and after administration at 8, 16, and 24 h (p < 0.001, p < 0.001, and p = 0.003, respectively). Mini-catheters for local anesthetic administration represent an effective strategy for pain control after STFF harvesting for head and neck reconstruction.

A Decision Support System for Diabetes Chronic Care Models Based on General Practitioner Engagement and EHR Data Sharing

Objective Decision support systems (DSS) have been developed and promoted for their potential to improve quality of health care. However, there is a lack of common clinical strategy and a poor management of clinical resources and erroneous implementation of preventive medicine. Methods To overcome this problem, this work proposed an integrated system that relies on the creation and sharing of a database extracted from GPs’ Electronic Health Records (EHRs) within the Netmedica Italian (NMI) cloud infrastructure. Although the proposed system is a pilot application specifically tailored for improving the chronic Type 2 Diabetes (T2D) care it could be easily targeted to effectively manage different chronic-diseases. The proposed DSS is based on EHR structure used by GPs in their daily activities following the most updated guidelines in data protection and sharing. The DSS is equipped with a Machine Learning (ML) method for analyzing the shared EHRs and thus tackling the high variability of EHRs. A novel set of T2D care-quality indicators are used specifically to determine the economic incentives and the T2D features are presented as predictors of the proposed ML approach. Results The EHRs from 41237 T2D patients were analyzed. No additional data collection, with respect to the standard clinical practice, was required. The DSS exhibited competitive performance (up to an overall accuracy of 98%±2% and macro-recall of 96%±1%) for classifying chronic care quality across the different follow-up phases. The chronic care quality model brought to a significant increase (up to 12%) of the T2D patients without complications. For GPs who agreed to use the proposed system, there was an economic incentive. A further bonus was assigned when performance targets are achieved. Conclusions The quality care evaluation in a clinical use-case scenario demonstrated how the empowerment of the GPs through the use of the platform (integrating the proposed DSS), along with the economic incentives, may speed up the improvement of care.

3D planning of ear prosthesis and navigated flapless surgery for craniofacial implants: A pilot study

New 3D digital technologies can be applied to implant-supported ear prostheses to restore anatomical structures damaged by cancer, dysplasia, or trauma. However, several factors influence the accuracy of implant positioning using a cranial template. This pilot study describes an innovative navigated flapless surgery for craniofacial implants, prosthetically guided by 3D planning of the ear prosthesis. Laser surface scanning of the face allowed for mapping of the healthy ear onto the defect site, and projection of the volume and position of the final prosthesis. The projected ear volume was superimposed on the skull bone image obtained by cone-beam computed tomography (CBCT), performed with the navigation system marker plate positioned in the patient's mouth. The craniofacial implants were fitted optimally to the ear prosthesis. After system calibration, real-time navigated implant placement based on the virtual planning was performed with minimally invasive flapless surgery under local anesthesia. After 3 months of healing, digital impressions of the implants were made, and the digital manufacturing workflow was completed to manufacture the ear prosthesis anchored to the craniofacial implants. The proposed digital method facilitated implant positioning during flapless surgery, improving the ear prosthesis manufacturing process and reducing operation time, patient morbidity, and related costs. This protocol avoids the need for a reference tool fixed in the cranial bone, as is usually required for maxillofacial surgery, and confirmed that surgical navigation is useful for guiding the insertion of craniofacial implants during flapless surgery.

P752 Mitral regurgitation in patients with severe aortic stenosis: role of valvular calcification in the persistence of mitral regurgitation after aortic valve replacement

Introduction

mitral regurgitation is often associated with severe aortic stenosis but the indications for its correction at the time of aortic valve surgery are still unclear. Despite the indication for mitral valve repair or replacement in the case of severe secondary mitral regurgitation, many patients are left untreated. This is due to the common belief that secondary mitral regurgitation mostly improves after the aortic valve is treated.

Purpose

the aim of the study is to investigate the prevalence and distribution of mitral calcifications, their role in the development of mitral regurgitation and in its reduction after aortic valve replacement.

Methods

we reviewed all patient’s records who underwent aortic valve replacement for aortic stenosis at our institution from 12/2014 to 12/2016. Pre and post-operative echocardiograms were reviewed by experienced echocardiographer. Patients were then divided into 4 categories (functional, mild, moderate and severe calcification) on the basis of the presence, distribuition and severity of calcification on the mitral apparatus.

Results

at the end 651 patients were collected and analyzed. Mean age was 74yo. 334 (51,4%) of them were males. Most patients (63,1%) had only mild mitral regurgitation but 147 (22,6%) of them had moderate or severe mitral regurgitation. The presences of moderate or severe calcification of the mitral apparatus resulted to be a risk factor for the presence of mitral regurgitation associated with aortic stenosis as shown in Table 1. After surgical aortic valve replacement less than 21% of the patients showed a reduction of the degree of mitral regurgitation. We found no statistical difference between groups about mitral regurgitation changes after aortic valve replacement.

Conclusions

Mitral regurgitation is a common finding in patients with severe aortic stenosis and it’s prevalence is higher in patients with mitral calcifications. Few patients, however showed a reduction in the degree of mitral regurgitation after surgical aortic valve replacement with no difference related to the severity of annular or leaflets calcifications.

TABLE 1 Logistic regression for the presence of mitral regurgitation Mitral Regurgitation Change after Aortic Valve Replacement CALCIFICATION DEGREE OR C.I. 95% p Reduced p Unchanged p Increased p Functional 53(21%) 176(71%) 18(7%) Mild 1.244571 0.81 - 1.93 0.32 28(20%) 0.86 105(76%) 0.43 6(4%) 0.34 Moderate 1.637297 1.05 - 2.56 0.03* 25(17%) 0.41 109(76%) 0.34 9(6%) 0.86 Severe 2.369245 1.46 - 3.85 &lt;0.01* 29(25%) 0.48 78(68%) 0.67 7(6%) 0.86 OR= Odds Ratio; C.I.=Confidence Interval; Functional= no calcification; Mild, Moderate and Severe= degree of mitral annular and leaflets calcifications.

Free flap head and neck reconstruction in the elderly: what is the impact on quality of life?

Morphofunctional reconstruction is a pivotal aspect in the surgery of head and neck neoplasms: nowadays, microvascular free flap surgery represents the gold standard. In choosing the surgical technique, the effects on residual quality of life, especially in elderly people, usually considered more fragile and so often excluded from microsurgical procedures, must be taken into account. This multicentre study evaluated the quality of life index in patients more than 75 years of age and who underwent to head and neck microsurgical reconstruction. Data from patients aged > 75 years at the time of major head and neck reconstruction conducted with free flaps between 1 January 2005 and 30 June 2015 were analysed retrospectively. We administered the Italian version of Quality of Life questionnaire SF-36, at least 24 months after surgery. Results were compared to those for the general Italian population of the same age. We enrolled 39 patients with an average age of 80.6 years. The results did not differ significantly from the reference population. The international literature has already shown that chronologic age is not a valid parameter to determine the surgical treatment modality. Even considering the quality of residual life, our study supports the indication for free-flap reconstruction of head and neck defects in the elderly, confirming its effectiveness in this population.

Performance of a high-resolution depth-encoding PET detector module using linearly-graded SiPM arrays

The goal of this study was to exploit the excellent spatial resolution characteristics of a position-sensitive silicon photomultiplier (SiPM) and develop a high-resolution depth-of-interaction (DOI) encoding positron emission tomography (PET) detector module. The detector consists of a 30  ×  30 array of 0.445  ×  0.445  ×  20 mm3 polished LYSO crystals coupled to two 15.5  ×  15.5 mm2 linearly-graded SiPM (LG-SiPM) arrays at both ends. The flood histograms show that all the crystals in the LYSO array can be resolved. The energy resolution, the coincidence timing resolution and the DOI resolution were 21.8  ±  5.8%, 1.23  ±  0.10 ns and 3.8  ±  1.2 mm, respectively, at a temperature of -10 °C and a bias voltage of 35.0 V. The performance did not degrade significantly for event rates of up to 130 000 counts s-1. This detector represents an attractive option for small-bore PET scanner designs that simultaneously emphasize high spatial resolution and high detection efficiency, important, for example, in preclinical imaging of the rodent brain with neuroreceptor ligands.

Masseteric cooptation and crossfacial nerve grafting: Is it still applicable 22 months after the onset of facial palsy?

BACKGROUND

Eighteen months is usually considered the cutoff time within which recovery of the mimic muscle remains possible using facial nerve cooptation. Few reports on the use of cooptation after this interval have appeared. Purpose of this study is to investigate the feasibility of this procedure also after 22 months.

METHODS

Six patients treated via crossfacial nerve grafting between healthy and paralyzed middle and middle-upper facial nerve branches and masseteric cooptation of the main trunk of the paralyzed facial nerve between 20 and 24 months after the onset of palsy were analyzed. Population consisted of two males and four females ages 8-42 years (mean 24 years). Facial palsy developed after acoustic neuroma resection in three patients, after the removal of a cerebellopontine angle astrocytoma in one, and as a consequence of Bell's palsy or cerebral hemorrhage in the other two (one each). House-Brackman and Sunnybrook clinical evaluation systems and FDI questionnaire were used to assess results.

RESULTS

House-Brackman scores changed from VI before the operation for all patients to II for two patients and III for four patients. Sunnybrook scores were 0-10 before the operation, but 62-84 at the last visit. Mean FDI scores moved from 24 to 38.5 meaning a statistical high significant improvement (P < .01).

CONCLUSIONS

Masseteric/crossfacial nerve grafting is feasible for patients with palsies 20-24 months in duration, affording satisfactory functional and esthetic results and a dramatic improvement in quality of life.

Inefficient skeletal muscle oxidative function flanks impaired motor neuron recruitment in Amyotrophic Lateral Sclerosis during exercise

This study aimed to evaluate muscle oxidative function during exercise in amyotrophic lateral sclerosis patients (pALS) with non-invasive methods in order to assess if determinants of reduced exercise tolerance might match ALS clinical heterogeneity. 17 pALS, who were followed for 4 months, were compared with 13 healthy controls (CTRL). Exercise tolerance was assessed by an incremental exercise test on cycle ergometer measuring peak O₂ uptake (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{{\rm{V}}}$$\end{document}V˙O_2peak), vastus lateralis oxidative function by near infrared spectroscopy (NIRS) and breathing pattern (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{{\rm{V}}}$$\end{document}V˙E _peak). pALS displayed: (1) 44% lower \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{{\rm{V}}}$$\end{document}V˙O_2peakvs. CTRL (p < 0.0001), paralleled by a 43% decreased peak skeletal muscle oxidative function (p < 0.01), with a linear regression between these two variables (r² = 0.64, p < 0.0001); (2) 46% reduced \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\dot{{\rm{V}}}$$\end{document}V˙E_peakvs. CTRL (p < 0.0001), achieved by using an inefficient breathing pattern (increasing respiratory frequency) from the onset until the end of exercise. Inefficient skeletal muscle O₂ function, when flanking the impaired motor units recruitment, is a major determinant of pALS clinical heterogeneity and working capacity exercise tolerance. CPET and NIRS are useful tools for detecting early stages of oxidative deficiency in skeletal muscles, disclosing individual impairments in the O₂ transport and utilization chain.

The Sulfate Supply Maximizing Arabidopsis Shoot Growth Is Higher under Long- than Short-Term Exposure to Cadmium

The processes involved in cadmium detoxification in plants deeply affect sulfate uptake and thiol homeostasis and generate increases in the plant nutritional request for sulfur. Here, we present an analysis of the dependence of Arabidopsis growth on the concentration of sulfate in the growing medium with the aim of providing evidence on how plants optimize growth at a given sulfate availability. Results revealed that short-term (72 h) exposure to a broad range of Cd concentrations (0.1, 1, and 10 μM) inhibited plant growth but did not produce any significant effects on the growth pattern of both shoots and roots in relation to the external sulfate. Conversely, long-term (22 days) exposure to 0.1 μM Cd significantly changed the pattern of fresh weight accumulation of the shoots in relation to the external sulfate, without affecting that of the roots, although their growth was severely inhibited by Cd. Moreover, under long-term exposure to Cd, increasing the sulfate external concentration up to the critical value progressively reduced the inhibitory effects exerted by Cd on shoot growth, indicating the existence of sulfate-dependent adaptive responses protecting the shoot tissues against Cd injury. Transcriptional induction of the high-affinity sulfate transporter genes (SULTR1; 1 and SULTR1; 2) involved in sulfate uptake by roots was a common adaptive response to both short- and long-term exposure to Cd. Such a response was closely related to the total amount of non-protein thiols accumulated by a single plant under short-term exposure to Cd, but did not showed any clear relation with thiols under long-term exposure to Cd. In this last condition, Cd exposure did not change the level of non-protein thiols per plant and thus did not alter the nutritional need for sulfur. In conclusion, our results indicate that long term-exposure to Cd, although it induces sulfate uptake, decreases the capacity of the Arabidopsis roots to efficiently absorb the sulfate ions available in the growing medium making the adaptive response of SULTR1; 1 and SULTR1; 2 "per se" not enough to optimize the growth at sulfate external concentrations lower than the critical value.

Polymeric Supports for Controlled Release of Ethylene for Food Industry

In modern fruit supply chain a common method to trigger ripening is to keep fruits inside special chambers and initiate the ripening process through administration of ethylene. Ethylene is usually administered through cylinders with inadequate control of its final concentration in the chamber. The aim of this study is the development of intelligent polymeric supports able to accurately regulate ethylene concentration in the atmosphere where fruits are preserved. Two different technologies were proposed: a polymeric (PEGDA) film and a polymeric (PLA) bag filled with inclusion complex of ethylene/α-cyclodextrin. The complex was prepared by molecular encapsulation which allows the entrapment of ethylene into the cavity of α-cyclodextrin. After encapsulation, ethylene can be gradually released from the inclusion complex and its release rate can be regulated by temperature and humidity. Intelligent polymeric film was prepared by dispersing inclusion complex into a thin polymeric film produced by UV-curing. Intelligent polymeric bag was made by inserting inclusion complex into heat sealed bag. The kinetics of ethylene release was studied for both systems, showing that it can effectively possible to control the release of ethylene within confined volume. Furthermore, modelling and simulations of ethylene release in a food container were made, demonstrating that it is possible to modulate release rate and, thus, control ripening.

Kinetic Analysis of Zinc/Cadmium Reciprocal Competitions Suggests a Possible Zn-Insensitive Pathway for Root-to-Shoot Cadmium Translocation in Rice

BACKGROUND

Among cereals, rice has a genetic propensity to accumulate high levels of cadmium (Cd) in grains. Xylem-mediated root-to-shoot translocation rather than root uptake has been suggested as the main physiological factor accounting for the genotypic variation observed in Cd accumulation in shoots and grains. Several evidence indicate OsHMA2 - a putative zinc (Zn) transporter - as the main candidate protein that could be involved in mediating Cd- and Zn-xylem loading in rice. However, the specific interactions between Zn and Cd in rice often appear anomalous if compared to those observed in other staple crops, suggesting that root-to-shoot Cd translocation process could be more complex than previously thought. In this study we performed a complete set of competition experiments with Zn and Cd in order to analyze their possible interactions and reciprocal effects at the root-to-shoot translocation level.

RESULTS

The competition analysis revealed the lack of a full reciprocity when considering the effect of Cd on Zn accumulation, and vice versa, since the accumulation of Zn in the shoots was progressively inhibited by Cd increases, whereas that of Cd was only partially impaired by Zn. Such behaviors were probably dependent on Cd-xylem loading mechanisms, as suggested by: i) the analysis of Zn and Cd content in the xylem sap performed in relation to the concentration of the two metals in the mobile fractions of the roots; ii) the analysis of the systemic movement of (107)Cd in short term experiments performed using a positron-emitting tracer imaging system (PETIS).

CONCLUSIONS

Our results suggest that at least two pathways may mediate root-to-shoot Cd translocation in rice. The former could involve OsHMA2 as Zn(2+)/Cd(2+) xylem loader, whereas the latter appears to involve a Zn-insensitive system that still needs to be identified.

Reaching 200-ps timing resolution in a time-of-flight and depth-of-interaction positron emission tomography detector using phosphor-coated crystals and high-density silicon photomultipliers

Current research in the field of positron emission tomography (PET) focuses on improving the sensitivity of the scanner with thicker detectors, extended axial field-of-view, and time-of-flight (TOF) capability. These create the need for depth-of-interaction (DOI) encoding to correct parallax errors. We have proposed a method to encode DOI using phosphor-coated crystals. Our initial work using photomultiplier tubes (PMTs) demonstrated the possibilities of the proposed method, however, a major limitation of PMTs for this application is poor quantum efficiency in yellow light, corresponding to the wavelengths of the converted light by the phosphor coating. In contrast, the red-green-blue-high-density (RGB-HD) silicon photomultipliers (SiPMs) have a high photon detection efficiency across the visible spectrum. Excellent coincidence resolving time (CRT; [Formula: see text]) was obtained by coupling RGB-HD SiPMs and [Formula: see text] lutetium fine silicate crystals coated on a third of one of their lateral sides. Events were classified in three DOI bins ([Formula: see text] width) with an average sensitivity of 83.1%. A CRT of [Formula: see text] combined with robust DOI encoding is a marked improvement in the phosphor-coated approach that we pioneered. For the first time, we read out these crystals with SiPMs and clearly demonstrated the potential of the RGB-HD SiPMs for this TOF-DOI PET detector.

Bismuth germanate coupled to near ultraviolet silicon photomultipliers for time-of-flight PET

Bismuth germanate (BGO) was a very attractive scintillator in early-generation positron emission tomography (PET) scanners. However, the major disadvantages of BGO are lower light yield and longer rise and decay time compared to currently popular scintillators such as LSO and LYSO. This results in poorer coincidence timing resolution and it has generally been assumed that BGO is not a suitable scintillator for time-of-flight (TOF) PET applications. However, when a 511 keV photon interacts in a scintillator, a number of Cerenkov photons are produced promptly by energetic electrons released by photoelectric or Compton interactions. If these prompt photons can be captured, they could provide a better timing trigger for PET. Since BGO has a high refractive index (increasing the Cerenkov light yield) and excellent optical transparency down to 320 nm (Cerenkov light yield is higher at shorter wavelengths), we hypothesized that the coincidence timing resolution of BGO can be significantly improved by efficient detection of the Cerenkov photons. However, since the number of Cerenkov photons is far less than the number of scintillation photons, and they are more abundant in the UV and blue part of the spectrum, photosensors need to have high UV/blue sensitivity, fast temporal response, and very low noise in order to trigger on the faint Cerenkov signal. In this respect, NUV-HD silicon photomultipliers (SiPMs) (FBK, Trento, Italy) are an excellent fit for our approach. In this study, coincidence events were measured using BGO crystals coupled with NUV-HD SiPMs. The existence and influence of Cerenkov photons on the timing measurements were studied using different configurations to exploit the directionality of the Cerenkov emissions. Coincidence resolving time values (FWHM) of ~270 ps from 2  ×  3  ×  2 mm3 BGO crystals and ~560 ps from 3  ×  3  ×  20 mm3 BGO crystals were obtained. To our knowledge, these are the best coincidence resolving time values reported for BGO to date. With these values, BGO can be considered as a relevant scintillator for TOF PET scanners, especially if photodetectors with even better near UV/blue response can be developed to further improve the efficiency of Cerenkov light detection.

SPAD aptasensor for the detection of circulating protein biomarkers

The need for decentralized clinical tests together with the concept of time and cost saving are pushing the development of portable, miniaturized, compact biosensors with diagnostic and prognostic purpose. Here, we propose an innovative detection system based on a Single Photon Avalanche Diode (SPAD) with high sensitivity and low noise, crucial features for an efficient chemiluminescence biosensor. The SPAD detector, having 60 µm diameter, has a Photon Detection Efficiency higher than 55% at 425 nm and a Dark Count Rate lower than 100 Hz at room temperature. Our design allows a good optical coupling efficiency between sample and detector. A specific biofunctional surface was implemented taking advantage of aptamers, short DNA sequences having high selectivity and affinity toward their targets. We successfully detected physiological levels of Vascular Endothelial Growth Factor (VEGF), a circulating protein biomarker highly correlated with cancer. The SPAD aptasensor showed a Limit of Detection (LoD) in the pM range, stability (up to 42 days) and re-usability (up to seven cycles). This compact biosensor is therefore a promising step toward the actual use of portable microdevices in diagnostics.

Acute focal brain damage alters mitochondrial dynamics and autophagy in axotomized neurons

Mitochondria are key organelles for the maintenance of life and death of the cell, and their morphology is controlled by continual and balanced fission and fusion dynamics. A balance between these events is mandatory for normal mitochondrial and neuronal function, and emerging evidence indicates that mitochondria undergo extensive fission at an early stage during programmed cell death in several neurodegenerative diseases. A pathway for selective degradation of damaged mitochondria by autophagy, known as mitophagy, has been described, and is of particular importance to sustain neuronal viability. In the present work, we analyzed the effect of autophagy stimulation on mitochondrial function and dynamics in a model of remote degeneration after focal cerebellar lesion. We provided evidence that lesion of a cerebellar hemisphere causes mitochondria depolarization in axotomized precerebellar neurons associated with PTEN-induced putative kinase 1 accumulation and Parkin translocation to mitochondria, block of mitochondrial fusion by Mfn1 degradation, increase of calcineurin activity and dynamin-related protein 1 translocation to mitochondria, and consequent mitochondrial fission. Here we suggest that the observed neuroprotective effect of rapamycin is the result of a dual role: (1) stimulation of autophagy leading to damaged mitochondria removal and (2) enhancement of mitochondria fission to allow their elimination by mitophagy. The involvement of mitochondrial dynamics and mitophagy in brain injury, especially in the context of remote degeneration after acute focal brain damage, has not yet been investigated, and these findings may offer new target for therapeutic intervention to improve functional outcomes following acute brain damage.

Timing and Energy Resolution of new near-UV SiPMs coupled to LaBr3:Ce for TOF-PET

The high light output and fast decay time of LaBr₃:Ce scintillation detectors leads to excellent timing performance. To realize the potential of timing resolution with LaBr₃:Ce we have investigated the performance with SiPMs, which enable 1-to-1 coupling to individual crystals, and which have been optimized for the near-ultraviolet (NUV) scintillation light emission of LaBr₃:Ce. Coincidence timing resolution (CTR) of 100 ps was measured for a 4×4×5 mm³ LaBr₃:30%Ce crystal directly coupled to a large-area 4×4 mm² NUV-SiPM. Results show very little dependence on temperature, in the range of -20° to 20°C, and bias voltage, from 2 V to 5 V over breakdown. Optimal performance was achieved at an over-voltage (OV) range of 3 V - 5 V, at which high gain and high photon detection efficiency are achieved. Though saturation was evident at 511 keV, an energy resolution of 6.8% was measured after correcting for non-linearity. We also measured a CTR of 110 ps for a 4×4×5mm³ LaBr₃:5%Ce crystal and 245 ps for a 4×4×30 mm³ LaBr₃:5%Ce crystal using the NUV-SIPM. The poorer timing measurement for the 30-mm long crystal is due mainly to a systematic shift in the time pick-off as a function of the depth-of-interaction. The excellent temperature stability, fast rise time, high gain, and low noise of the NUV-SiPM make it a practical and highly appealing photodetector for the readout of a LaBr₃:Ce TOF-PET detector.

The masseteric nerve: a versatile power source in facial animation techniques

The masseteric nerve has many advantages including low morbidity, its proximity to the facial nerve, the strong motor impulse, its reliability, and the fast reinnervation that is achievable in most patients. Reinnervation of a neuromuscular transplant is the main indication for its use, but it has been used for the treatment of recent facial palsies with satisfactory results. We have retrospectively evaluated 60 patients who had facial animation procedures using the masseteric nerve during the last 10 years. The patients included those with recent, and established or congenital, unilateral and bilateral palsies. The masseteric nerve was used for coaptation of the facial nerve either alone or in association with crossfacial nerve grafting, or for the reinnervation of gracilis neuromuscular transplants. Reinnervation was successful in all cases, the mean (range) time being 4 (2-5) months for facial nerve coaptation and 4 (3-7) months for neuromuscular transplants. Cosmesis was evaluated (moderate, n=10, good, n=30, and excellent, n=20) as was functional outcome (no case of impairment of masticatory function, all patients able to smile, and achievement of a smile independent from biting). The masseteric nerve has many uses, including in both recent, and established or congenital, cases. In some conditions it is the first line of treatment. The combination of combined techniques gives excellent results in unilateral palsies and should therefore be considered a valid option.

Selective deep lobe parotidectomy for pleomorphic adenomas

The authors' experience of the selective deep lobe parotidectomy for the treatment of pleomorphic adenomas of the deep parotid lobe is presented. A retrospective analysis of 11 patients treated between 1997 and 2010 was performed; seven were males and four were females, ranging in age from 35 to 51 years. Parameters evaluated included facial nerve weakness, the occurrence of Frey's syndrome, cosmetic outcome, and recurrence. Follow-up ranged from 18 months to 11 years. No major complications, permanent facial nerve weakness, or Frey's syndrome occurred. Four patients developed temporary facial nerve impairments that lasted between 2 and 6 weeks, and two developed a sialocele that healed in 9 days in one case and 12 days in the other. The overall cosmetic assessment was excellent in eight patients, good in two, and satisfactory in the remaining one. No recurrences occurred. The selective deep lobe parotidectomy can be considered an effective technique for the management of deep parotid lobe pleomorphic adenomas. The major advantages of this procedure include a reduction in complications such as facial nerve impairments and Frey's syndrome, and an improved cosmetic outcome.

Orthognathic surgery for the complete rehabilitation of Moebius patients: principles, timing and our experience

Moebius syndrome is a rare disorder found in approximately 1/100,000 neonates and the treatment of facial palsy is now well established worldwide and consists of free-muscle transplants reinnervated with motor nerves. Dentofacial deformities are often detected in Moebius patients, and different degrees of micrognathia are often present, particularly in patients with complete expressions of Moebius syndrome. However only two published reports have described the surgical treatment of such anomalies in these patients; in both cases, the suggested approach consisted of orthognathic surgery followed by soft-tissue management. In this paper we discuss the indications and correct timing of orthognathic surgery and suggest to perform facial animation at an early age and then to wait for the completion of maxillofacial skeletal growth before performing orthognathic surgery. Finally, facial animation should precede orthognathic surgery in adult patients to prevent lower lip deformities and to ensure more predictable and satisfactory results.

Free flaps in elderly patients: outcomes and complications in head and neck reconstruction after oncological resection

INTRODUCTION

Free flaps represent the first reconstructive option for many head and neck defects. The increasing life expectancy of the population results in increasing numbers of ageing patients facing complex reconstructive surgery. In this study we evaluated our experience with free-flap transfers in older patients, analysing the post-operative reconstructive and systemic complications.

MATERIALS AND METHODS

Between 2000 and 2009, 360 patients underwent free flap reconstruction of defects resulting from the treatment of head and neck tumours at the Operative Unit of Maxillofacial Surgery, University - Hospital of Parma, Italy. Fifty-five patients (15.3%) were more than 75 years old at the time of treatment.

RESULTS

At the end of the follow-up successful free-flap transfer was achieved in 360 of the 373 flaps harvested (96.5%). The overall reconstructive complication rate was 31.4%, (31.8% in the younger group and 29.1% in the remaining patients). Medical complications were observed in 29.2% of cases (less than 75 years: 28.8%; more than 75 years: 30.9%). The ASA status was associated with a statistically significantly higher incidence of complications within patients less than 75 years old (p < 0.0001).

DISCUSSION AND CONCLUSIONS

The results of this study, in agreement with previous studies, provide evidence that free-tissue transfer may be performed in ageing patients with a high degree of technical success. The chronologic age cannot be considered an appropriate criterion in the reconstructive decision. On the contrary, a careful selection of the patients based on comorbidities and general conditions (ASA status) is of primary importance in reducing post-operative complications and to improving the results of surgery.

HLA Genes in Mayos Population from Northeast Mexico

HLA class I and class II alleles have been studied in 60 unrelated people belonging to Mayos ethnic group, which lives in the Mexican Pacific Sinaloa State. Mayos HLA profile was compared to other Amerindians and worldwide populations’ profile. A total of 14,896 chromosomes were used for comparisons. Genetic distances between populations, Neigbour-Joining dendrograms and correspondence analyses were performed to determine the genetic relationship among population. The new specific Mayo HLA haplotypes found are: HLA-A*02-B*35-DRB1*1406-DQB1*0301; HLA-A*02-B*48-DRB1*0404-DQB1*0302; HLA-A*24-B*51-DRB1*0407-DQB1*0302 and HLA-A*02-B*08-DRB1*0407-DQB1*0302. However, the typical Meso American HLADRB1*0407 represents a 40% of all DRB1 alleles. While common HLA characteristics are found in Amerindian distant ethnic groups, still new group specific HLA haplotypes are being found, suggesting that a common founder effect (i.e. high DRB1*0407) is noticed. Moreover, new HLA haplotypes are almost certainly appearing along time probably due to specific pathogen (?) selection for diversity. Mayo language is close to the Tarahumara one (another geographically close group); notwithstanding both groups are not genetically close according to our results, showing again the different evolution of genes and languages, which do not correlate. Finally, Sinaloa is one of the Mexican States in which more European genes are found. However, the results presented in this paper, where no European HLA genes are seen in Mayos, should have a bearing in establishing transplant programs and in HLA and disease studies.

Successful salvage surgery after treatment failures with cross graft and free muscle transplant in facial reanimation

BACKGROUND

The microneurovascular transfer of a free-muscle transplant is the procedure of choice for facial animation, It is characterized by low morbidity in both adult and paediatric patients. In spite of the improvements in microsurgical techniques, failures due to absent revascularization or reinnervation of the transplanted muscle or infections causing flap necrosis are observed. We propose a second surgical procedure based on the gracilis muscle transplant reinnervated by the masseteric nerve as a solution for these cases.

METHODS

We analyzed and report on two patients treated in our department after the failure of a previous cross-facial nerve graft and free muscle transplant. They were treated with a new facial reanimation using the contralateral gracilis muscle and the masseteric nerve as the donor nerve.

RESULTS AND DISCUSSION

We did not observe any postoperative complications, and all of the flaps survived. Reinnervation and contraction of the muscle appeared 3-4 months postoperatively, with good functional and aesthetic results.

CONCLUSIONS

This technique is a one-step procedure characterized by reliable flap harvesting, low donor site morbidity and good activity of the masseteric nerve. We consider it as a good option for treatment of facial animation failures.

The cardiovascular burden of end-stage renal disease patients

Patients with end-stage renal disease are 10 to 20 times more at risk of cardiovascular death than the general population. Traditional cardiovascular risk factors are not able to explain the increase in the onset of cardiovascular diseases in dialysis patients. Some of the most important non traditional risk factors in uremic patients are: the inflammatory state of the patients, cytokines and growth factors, hyperhomocysteinemia, the presence of alterations of the calcium phosphorous product which can already be in progress when the glomerular filtration rate decreases to less than 60 mL/min. Clinically, these alterations cause vascular calcifications, calcifications of the heart valves and calcific uremic arteriolopathy or calciphylaxis. The pathogenesis of vascular calcification is complex and cannot be assigned to a simple, passive process: in fact, it includes factors which promote or inhibit calcification. In turn, these pathologic conditions have been found to be highly predictive of general and cardiovascular death. Given the serious clinical consequences that vascular calcifications can cause, it is necessary to carry out an early mapping of the traditional and non traditional risk factors of uremic patients as it seems that therapeutic interventions aimed at reducing or inverting the calcification process can improve the outcome of patients, above all when they are started quickly.

Voice quality monitoring: a portable device prototype

This paper addresses the important issue of voice monitoring throughout the day under a clinical perspective. This problem is of great concern, for rehabilitation and from the assistive technology point of view. A prototype for a new portable device is proposed, implementing basic voice quality indexes (fundamental frequency F0, jitter, relative average perturbation RAP, noise) by means of robust high-resolution techniques. The device is contact-less, as the transducer is a small microphone included in the device. A feedback for patients outside the clinic is provided, given by a led/audio unit that advices the patient for any abnormal vocal emission, to help patients with carryover of therapy goals outside the clinical environment. The device will collect audio recordings to be submitted to a PC for further analysis, to be performed off-line. Such device for self-diagnosis and vocal rehabilitation could give a valid support, both to clinicians and patients.