Impact of COVID-19 on hand surgery in Italy: A comparison between the Northern and the Southern regions

The aims of this study were to evaluate the impact of the COVID-19 pandemic on emergency and elective hand surgery in four Italian regions that had either a high (Lombardy and Piemonte) or a low (Sicilia and Puglia) COVID-19 case load to discuss problems and to elaborate strategies to improve treatment pathways. A panel of hand surgeons from these different regions compared and discussed data from the centers they work in. The COVID-19 pandemic had an enormous impact on both elective and emergency surgery in Italy, not only in highly affected regions but also – and paradoxically even at a higher extent – in regions with a low COVID-19 case load. A durable and flexible redesign of hand surgery activities should be promoted, while changing and hopefully increasing human resources and enhancing administrative support. Telematics must also be implemented, especially for delivering rehabilitation therapy.

In-situ gelling xyloglucan formulations as 3D artificial niche for adipose stem cell spheroids

Three-dimensional spheroidal cell aggregates of adipose stem cells (SASCs) are a distinct upstream population of stem cells present in adipose tissue, with enhanced regeneration properties in vivo. The preservation of the 3D structure of the cells, from extraction to administration, can be a promising strategy to ensure optimal conditions for cell viability and maintenance of stemness potential. With this aim, an artificial niche was created by incorporating the spheroids into an injectable, in-situ gelling solution of partially degalactosylated xyloglucan (dXG) and an ad hoc formulated culture medium for the preservation of stem cell spheroid features. The evolution of the mechanical properties and the morphological structure of this artificial niche was investigated by small amplitude rheological analysis and scanning electron microscopy, respectively. Comparatively, systems produced with the same polymer and the typical culture medium (DMEM) used for adipose stem cell (ASC) growth in adherent cell culture conditions were also characterised. Cell viability of both SASCs and ASCs incorporated inside the hydrogel or seeded on top of the hydrogel were investigated as well as the preservation of SASC stemness conditions when embedded in the hydrogel.

AN OVERVIEW AND OUR APPROACH IN THE TREATMENT OF MALIGNANT CUTANEOUS TUMOURS OF THE HAND

INTRODUCTION

Diagnosis of malignant cutaneous tumours of the hand is often difficult because of the different anatomic structures present in this region and yet clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. Due to the hand's complex structures located in a small area, surgeons must evaluate constantly the balance of inadequate surgery against functional and cosmetic aspects. Thus, a multidisciplinary approach is recommended for a correct diagnosis and treatment design.

MATERIALS AND METHODS

Between 2006 and 2017, 354 consecutive patients with basal and squamous cell carcinomas, and melanoma of the hand were retrospectively analysed at the Department of Plastic and Reconstructive Surgery at the University of Palermo, treatment was surgical for all of them; also radio- and chemotherapy were necessary based on the histological diagnosis.

RESULTS

The most common tumour was basal cell carcinoma (BCCs), followed by squamous cell carcinoma (SCCs). Melanoma was the most frequent lesion diagnosed in the digits. Radical excision was the main treatment of choice. In 29 cases (11 with SCC, 18 with melanoma) axillary lymphadenectomy was performed, because of lymph nodes metastases. In the follow up, the spread of cancer to distant organs caused the death in three cases. Recurrence rate was higher in case of infiltrative SCCs and BCCs.

CONCLUSIONS

The major references provide only limited information on malignant soft-tissue tumours of the hand. Our retrospective study aims to present the most commonly observed malignant soft-tissue tumours of the hand, analysing their causes, their objective and instrumental evaluation, and their treatments.

Oral propylene glycol modifies follicular fluid and gene expression profiles in cumulus-oocyte complexes and embryos in feed-restricted heifers

Dietary supplementation with propylene glycol (PG) increases in vitro production of high-quality embryos in feed-restricted heifers. The aim of the present study was to evaluate the effects of PG in feed-restricted heifers on follicular fluid insulin and insulin-like growth factor (IGF) 1 concentrations, expression of IGF system genes in oocytes and cumulus cells and the expression of selected genes in blastocysts. Feed-restricted (R) heifers were drenched with water or PG during induced oestrous cycles (400mL of PG or water/drench, daily drenching at 1600 hours for the first 9 days of the oestrous cycle). Ovum pick-up (OPU) was performed after superovulation to produce in vitro embryos and without superovulation to recover oocytes, cumulus cells and follicular fluid. OPU was also performed in a control group (not feed restricted and no drenching). Follicular fluid IGF1 concentrations were reduced by R, and PG restored IGF1 concentrations to those seen in the control group. In cumulus cells, expression of IGF1, IGF1 receptor (IGF1R) and IGF binding protein 4 (IGFBP4) was decreased in the R group, and fully (IGF1 and IGF1R) or partially (IGFBP4) restored to control levels by PG. Blastocyst perilipin 2 (PLIN2; also known as adipophilin), Bcl-2-associated X protein (BAX), SCL2A1 (facilitated glucose/fructose transporter GLUT1), aquaporin 3 (AQP3), DNA (cytosine-5)-methyltransferase 3A (DNMT3A) and heat shock 70-kDa protein 9 (HSPA9B) expression were decreased in R heifers; PG restored the expression of the last four genes to control levels. In conclusion, these results suggest that, during follicular growth, PG exerts epigenetic regulatory effects on gene expression in blastocyst stage embryos.

Choosing a culture medium for SCNT and iSCNT reconstructed embryos: from domestic to wildlife species

Over the past decades, in vitro culture media have been developed to successfully support IVF embryo growth in a variety of species. Advanced reproductive technologies, such as somatic cell nuclear transfer (SCNT), challenge us with a new type of embryo, with special nutritional requirements and altered physiology under in vitro conditions. Numerous studies have successfully reconstructed cloned embryos of domestic animals for biomedical research and livestock production. However, studies evaluating suitable culture conditions for SCNT embryos in wildlife species are scarce (for both intra- and interspecies SCNT). Most of the existing studies derive from previous IVF work done in conventional domestic species. Extrapolation to non-domestic species presents significant challenges since we lack information on reproductive processes and embryo development in most wildlife species. Given the challenges in adapting culture media and conditions from IVF to SCNT embryos, developmental competence of SCNT embryos remains low. This review summarizes research efforts to tailor culture media to SCNT embryos and explore the different outcomes in diverse species. It will also consider how these culture media protocols have been extrapolated to wildlife species, most particularly using SCNT as a cutting-edge technical resource to assist in the preservation of endangered species.

SURGICAL CORRECTION OF LABIA MINORA HYPERTROPHY, A PERSONAL TECHNIQUE

BACKGROUND

Labia minora hypertrophy is a congenital or acquired condition in which both labia minora (or more rarely only one) protrude beyond the edge of the labia majora. The authors present a surgical technique of volumetric reduction of hypertrophic labia minora, associated with lipofilling of the labia majora.

METHODS

Between 2005 and 2014, 27 patients underwent surgical reduction of labia minora, as described by Altier and Rouzier. The indications for surgical treatment varied and were as follows: interference with sexual intercourse; poor hygiene; difficulty wearing tight-fitting pants; difficulty while performing sporting activities such as cycling; aesthetic complaints. The surgical resection was associated with fat graft injection in labia majora in order to protect and cover the labia minora. The mean follow up was 1 year.

RESULTS

The labia majora, increased in volume and firmness, cover and protect the labia minora slightly hypertrophic or surgically reduced. All patients reported an improvement in comfort, aesthetic appearance, when wearing close-fitting clothes and an improvement in their sexuality. In one case we recorded a "recurrence", with an increase of dimensions in width of labia minora, still lower than the preoperative situation but greater than the immediate postop.

CONCLUSIONS

The reduction of labia minora hypertrophy with conservative techniques allows achieving excellent results in terms of aesthetics and functionality. The simple lipofilling of labia majora allows preserving and protecting the labia minora through a volumetric increase of the labia majora.

The activity of three glycosidases (β-Ν-acetyloglucosaminidase, α-mannosidase, and β-galactosidase) in the follicular fluid and in the maturation medium affects bovine oocyte maturation

We studied the role of follicular fluid's (FF) glycosidase (α-mannosidase [α-ΜΑΝ], β-Ν-acetyloglucosaminidase [NAGASE], β-galactosidase [β-GAL]) activity during IVM of bovine oocytes. Oocytes were allocated into two groups according to the follicular size (small follicle [SF]: 2-5 mm, large follicle [LF]: >5-8 mm). In experiment 1, cumulus-oocyte complexes (COCs) quality was evaluated according to morphologic criteria (grades A, B-C, D); oocyte (n = 801) nuclear maturation was assessed after 24 hours of incubation. Bovine embryos were produced in vitro in groups (experiment 2, n = 1503 oocytes) or individually (experiment 3, n = 50 oocytes). More grade-A and -BC COCs were collected from SF and LF groups, respectively (P < 0.05). Maturation rate (experiment 1) and cleavage rate (experiments 2 and 3) were similar in SF and LF groups. Activity of all glycosidases in FF was higher (P < 0.05) in SF group than in LF group, whereas in maturation medium of SF group it was, overall, significantly lower than in that of LF (experiments 2 and 3). In FF of SF group, NAGASE positively associated with grade-A oocytes and negatively with BC oocytes; increased β-GAL was associated with degenerated oocytes. Cleavage rate in LF group, related negatively to NAGASE and positively to α-MAN in maturation medium. These results indicate that during maturation, COCs release NAGASE and consume β-GAL, but differences probably exist between individual and group maturation.

124 CRYOPRESERVED BOVINE OVIDUCTAL EPITHELIAL CELLS SURVIVAL, GROWTH, AND ABILITY TO SUPPORT EARLY EMBRYO DEVELOPMENT

Previous experiments demonstrated that co-culture of bovine embryos with bovine oviducal epithelial cells (BOEC) improved blastocyst rate and quality (Cordova et al. 2014). However, the use of primary cell support for improving embryo development in vitro may introduce a higher variability of the results between different BOEC batches used, as well as sanitary risks. The use of well-controlled large batches of frozen BOEC may help to solve these problems. Therefore, the aim of the present study was to characterise the survival and functionality of frozen-thawed BOEC. Bovine oviducts attached to ovaries showing recent ovulation were collected at a local slaughterhouse during 4 replicates (3 oviducts per replicate). Epithelial cells were expelled by gentle squeezing and washed 3 times. Half of the cell pellet was diluted 100-fold in culture medium (TCM199 + 10% FCS) for culture of fresh cells. The other half was diluted 10-fold in cell freezing medium (TCM199 + 20% FCS + 10% dimethyl sulfoxide), allowed to equilibrate in this medium for 10 min, and frozen at –80°C in a container filled with isopropyl alcohol. After 4 h, the tubes were transferred into LN for at least 1 h. The tubes were then thawed (5 min in 37°C water bath), diluted 1 : 1 in cell culture medium, and centrifuged for 10 min at 100 × g. The pellet was then diluted 100× in cell culture medium. Fresh or frozen-thawed cells were seeded in 4-well NUNC plates for 7 days at 38.8°C in a humidified atmosphere with 5% CO2 in air. The medium was renewed every 48 h, and the viability of cells was assessed by calcein-AM and ethidium homodimer labelling. After 7 days of culture, the medium was replaced by SOF medium + 5% FCS, and bovine in vitro-produced zygotes were added the day after and co-cultured for 8 days at 38.8°C in a humidified atmosphere with 5% CO2 in air to evaluate embryo development. Half of the medium was renewed every 48 h. Frozen-thawed cells showed the same viability than fresh ones at Days 0 and 7 of culture and reached confluence at the same time (Day 7). Development results are shown in Table 1. Frozen and fresh cells support early embryo development at the same rate. In conclusion, the present study showed that BOEC frozen on the day of collection are equivalent to fresh BOEC in regards to their survival and proliferation and their ability to support early embryo development. At collection, the cells may face stresses that are just as considerable as freezing/thawing (temperature shock, scrapping, change of environment). This may explain why they are not affected by freezing than at collection. The differentiation status of these cells is now under analysis by immunocytochemistry. Table 1.Cleavage rate and blastocyst rate in 3 different types of culture systems

[Use of an in vitro model in bovine to evidence a functional and molecular dialogue between preimplantation embryo and oviduct epithelial cells]

Beyond being a pipe between ovary and uterus, the oviduct is an active player in different aspects of early reproductive processes, in particular in the transport of embryos to the site of implantation and the regulation of its early development. Different studies evidenced a communication between oviduct and early embryo at the molecular and functional levels. Since the study of these interactions is difficult in vivo, different in vitro systems have been developed to mimic the maternal milieu during early development. These systems allowed to confirm the action of the cells on the quality of early development (blastocyst rate and viability). In turn, the embryos are producing signals that are able to modify and adapt the activity of maternal cells.

Issues in biomedical research: what do Hispanics think?

OBJECTIVE

To examine barriers and facilitators of biomedical research participation among Hispanics in a rural community in Washington State.

METHODS

Questionnaires addressed socio-demographics, health care access, and barriers and facilitators of participation in biomedical studies. This is a descriptive analysis of the findings.

RESULTS

Barriers include the need to care for family members (82%), fear of having to pay for research treatments (74%), cultural beliefs (65%), lack of time (75%) and trust (71%), and the degree of hassle (73%). Facilitators include having a friend/relative with the disease being researched (80%) and monetary compensation (73%).

CONCLUSION

Researchers should be mindful of these facilitators and barriers when recruiting for biomedical research studies.

Giant condylomata (Buschke-Löwenstein tumours): our case load in surgical treatment and review of the current therapies

BACKGROUND

Buschke-Löwenstein tumour (BLT) or giant condyloma is a verrucous infiltrating lesion, due to a sexually transmitted virus infection, human papilloma virus subtypes 6 and 11. Poor hygiene, promiscuity, chronic irritation and cellular immunocompromised states are often implicated in its genesis. Typical treatment of giant condyloma includes imiquimod cream, podophillin resin, cryotherapy, laser surgery, tangential shave excision with electrocautery.

OBJECTIVE

The authors report their case load in the treatment of giant condyloma and the review of the modern therapies.

METHODS AND MATERIALS

27 consecutive patients (18 men, nine women) underwent surgery for giant condylomata of perianal region and externa genitalia at the Department of Plastic Surgery of the University of Palermo, from October 2006 to December 2009. All the patients had been treated before with conservative therapies without significant results. We performed the radical excision with split-thickness skin graft in all the patients.

RESULTS

No significant complications have occurred in all the cases. The functional and aesthetic outcome were satisfying. No recurrence of disease were noticed in the follow-up.

CONCLUSION

the radical excision with split-thickness skin graft appears to be a successful option of treatment for Buschke-Löwenstein tumours. Compared to other methods it does not necessitate several stages of treatment, moreover it has the advantage of a lower risk of recurrence, it allows a complete histologic examination, the healing process is rapid, the improvement of quality of patients's life is significant.

The effect of variable practice on wheelchair propulsive efficiency and propulsive timing

AIM

The net mechanical efficiency of wheelchair propulsion is very low, approximately 13%. It is necessary to look for effective practice methods to obtain greater output with less energy expenditure during wheelchair propulsions. Literature indicates that variable practice (VP) is more effective than constant practice (CP) in motor-skill learning. However, it is unknown if VP is more effective than CP in improving wheelchair propulsive efficiency. The purpose of the study was to determine how propulsive efficiency and propulsive timing were affected by variable practice and constant practice.

DESIGN

This was an observational and experimental study.

SETTING

The experiment was conducted in a well-controlled university research laboratory.

POPULATION

A total of 33 able-bodied subjects participated in this study.

METHODS

Participants were randomly placed into one of the three training groups, two constant practice groups and one variable practice group. One constant group practiced wheelchair propulsion on a roller system with a single speed, 30% of the maximum speed, while the other constant group practiced using 55% of the maximum speed. The variable group practiced with both speeds. Three dependent variables, propulsive efficiency, timing, and intercycle variability of the timing, were measured.

RESULTS

All groups improved the three dependent variables significantly after the training, and in general the VP group had greater improvement than the others in improving the propulsive efficiency.

CONCLUSION

This study is the first to demonstrate the advantage of the VP over the CP in improving the propulsive efficiency.

CLINICAL REHABILITATION IMPACT

This finding has great implication for paraplegics because they require greater workloads for upper-extremity activities.

Dupuytren's contracture as result of prolonged administration of phenobarbital

Dupuytren's disease is a fibroproliferative condition involving the superficial palmar fascia, leading to a progressive and irreversible flexion of the fingers. In literature, there are different opinions regarding the phenobarbital, a common antiepileptic drug, and its effective role in the genesis and development of Dupuytren's disease. In this retrospective investigation the association between phenobarbital and Dupuytren's contracture is discussed. Three patients in treatment with phenobarbital who had no others significant risk factors for Dupuytren's contracture were included in this study. The disease occurred after one to four years of drug therapy, at dosage of 100 mg/day. After surgery, Dupuytren's disease showed different evolutions in relation to dosage and type of antiepileptic drug used. Phenobarbital causes a dose and time-dipendent profibrotic effect. A clinical regression was observed when phenobarbital was substituted by carbamazepine, maintaining the same dosage (100 mg/day). This data confirms that not all the antiepileptic drugs are implicated in palmar fibrosis, and suggests that, according to the efficacy and adverse effects, the administration of benzodiazepine reduces the risk of Dupuytren's recurrence.

Uncommon case of symmetrical fibrous hyperplasia of the hard palate

The fibrous hyperplasia of the palate (fibroma) is a benign tumor which has its origin in the soft tissue and whose frequency is estimated to be 1.2% on adult subjects. Rarely the size exceeds the cm, but in these cases a complaint of increasing difficulty of mastication and swallowing appears. We describe the case of a young white woman affected with two peculiar symmetric lesions of the secondary hard palate, that could be the consequence of an abnormal answer to a chronic inflammatory stimulation.

Reconstruction of the face with skin-grafted muscle flaps: optimizing the aesthetic outcome

BACKGROUND

Cutaneous facial defects repaired with perforator or fasciocutaneous flaps do not always give optimal aesthetic results due to excess bulk and colour mismatch. The authors present their experience in reconstruction of cutaneous facial defects with skin-grafted free muscle flaps.

MATERIALS AND METHODS

From May 2004 to May 2006, 9 serratus anterior, 2 gracilis and 1 vastus lateralis skin-grafted free muscle flaps were used on 12 patients, after cancer excision in 11 cases and after hardware exposure in 1 case. Full thickness skin grafts were taken from the supraclavicular skin in 3 cases, from the groin in 1 case and from the muscle donor site in 8.

RESULTS

No major complications were observed. Results were excellent in terms of contour and colour match. In the elderly, FTSGs taken from the muscle harvesting incision seem to eventually make a good colour match with the facial skin. No relevant donor site morbidity was observed with the muscles used in this series.

CONCLUSIONS

In the search for good aesthetic results in facial skin reconstruction, skin-grafted muscle flaps permit optimal contour and colour match to be achieved with little donor site morbidity and a shorter operating time.

Free style facial artery perforator flap for one stage reconstruction of the nasal ala

The nasolabial skin is the ideal donor site for nasal ala reconstruction. The classic techniques involve a two-stage procedure to reconstruct an aesthetically pleasing nasal ala. A one-stage technique for reconstruction of the nasal ala with a free style nasolabial perforator flap is presented in this article.

PATIENTS AND METHODS

The technique has been used in eight patients between November 2004 and June 2007. In most of the cases (seven out of eight) the whole alar subunit was reconstructed.

RESULTS

Besides a small distal 2mm necrosis in one flap--which healed without further treatment--all the flaps healed uneventfully with aesthetically pleasing results using the one-stage technique.

CONCLUSIONS

The free style perforator nasolabial island flap has become the method of choice in the authors' institution for nasal ala reconstruction, especially when the defect involves the whole subunit. It allows one-stage reconstruction with very similar tissue and a concealed scar in the natural groove.

Unexpected ulnar nerve schwannoma. The reasonable risk of misdiagnosis

Peripheral nerve tumors are rare clinical entities that can present with mild symptoms and no neurological deficit. The authors describe one case of asymptomatic schwannoma of the ulnar nerve in a 64-year-old man. The mass was associated with mild and sporadic discomfort due to the mass size; the clinical neurological examination was not conclusive, with Tinel's sign negative; surgery confirmed the nervous origin of the tumor and the histopathologic exam confirmed the diagnosis of schwannoma. These tumors are difficult to diagnose clinically and have often been confused with other benign tumors such as lipomas, hemangiomas, synovial cysts, neurofibromas, etc. Clinical care is important to prevent, during the surgery, the unfortunate resection of the nerve; all too frequently this diagnosis is made intraoperatively or postoperatively with the potential to compromise the outcome of the treatment. An appropriate degree of awareness is necessary for the inclusion of peripheral nerve tumors as a differential diagnosis of an upper extremity mass.

Further application of the bilobed flap: the split bilobed flap for reconstruction of composite posterior auricular and mastoid defects

In this article a modified bilobed flap from mastoid and lateral neck skin for reconstruction of complex defects of the posteromedial surface of the auricle and mastoid skin, with the preservation of the retroauricular sulcus, is described. Reconstruction of the postero-medial auricular surface has almost never been a concern for reconstructive surgeons. It is in fact a shaded area with little aesthetic relevance and direct closure, skin grafting and even secondary healing are used for skin cancer defects repair. Also mastoid skin defects can be repaired with simple techniques such as skin grafts or transposition flaps from the remaining mastoid skin or from the neck. On the other hand, cancers involving the postero-medial auricular surface, the retroauricular sulcus and the mastoid skin require wide and deep resections that involve the posterior auricular muscles and reach the perichondral and periosteal surfaces. Direct closure with undermining, if feasible, will obliterate the retroauricular sulcus causing asymmetry with the contralateral ear and, if defects are cephalad will impair the possibility of wearing spectacles, thus leaving functional and aesthetic impairment. Transposition flaps from the remaining mastoid skin, due to the lack of skin laxity, are not feasible because the donor site cannot be closed. Two patients, both affected by basal cell carcinoma involving the posteromedial auricular surface and the mastoid skin have been treated with this flap. In both cases the use of the modified bilobed flap described in this article allowed preservation of the retroauricular sulcus and closure of the donor site. Scars were hidden along minimal tension lines and the possibility of wearing spectacles along with sensitivity all over the reconstructed area were maintained.

Dupuytren's contracture: an update of biomolecular aspects and therapeutic perspectives

The so-called fibrogenic cytokines, able to induce the growth of fibroblasts and their differentiation into myofibroblasts and to stimulate their production of extracellular matrix, are involved in the genesis of Dupuytren's contracture. Although many studies have been made of biomolecular aspects of palmar fibromatosis, practical applications from them are still far from imminent because of the real difficulty of blocking their action in vivo, even in a chronic, progressive lesion such as Dupuytren's disease. Consequently, surgical excision of the palmar fascia still remains the treatment of choice.

Surgical treatment of pharyngostomes in irradiated patients. Our experience with musculocutaneous pectoralis major flap and hyperbaric oxygen therapy

CONCLUSION

Our experience confirms that pectoralis major flap is the first-choice technique for repairing recurrent hypopharyngeal fistulae in previously irradiated patients in whom microsurgical techniques are not indicated, and that hyperbaric oxygen therapy helps to solve this complex pathology.

OBJECTIVES

A pharyngostome is a complication encountered when performing surgical operations on pharyngolaryngeal structures. The authors present their experience of treating recurrent complex pharyngostomes in previously irradiated patients in poor physical health. These patients need a simple, safe reconstruction with a low incidence of postoperative complications.

MATERIAL AND METHODS

A pedicled pectoralis major flap was used for reconstruction: the skin side of the flap was used to restore the continuity of the pharyngeal mucosa, while the muscle was used to reconstruct the intermediate layer. The skin layer was completed by means of a free skin graft. In all cases, surgical treatment was combined with hyperbaric oxygen therapy before and after the operation.

RESULTS

A total of 10 patients, all of whom had previously undergone surgery and radiotherapy, had recurring or pluri-recurring pharyngostomes. All patients (8 males, 2 females; age range 52-80 years) had previously been affected by carcinoma of the pharyngolaryngeal region. All underwent major local Ablation together with radical neck dissection and radiotherapy. In all cases there was mucosa on the posterior wall; a musculocutaneous pectoralis major flap was used in all cases for reconstruction.

Poor response to desmopressin acetate (DDAVP) in children with Hermansky-Pudlak syndrome

BACKGROUND

Hermansky-Pudlak syndrome (HPS) is a common genetic disorder in Puerto Rico. In children with HPS, bleeding is the most disturbing and incapacitating problem. Desmopressin (1-deamino-8-D-arginine vasopressin, (DDAVP)) has been recommended in the management of bleeding disorders characterized by platelet dysfunction, such as HPS.

METHODS

Nineteen pediatric Puerto Rican patients with HPS and prolonged bleeding time (BT) were tested for response to administration of DDAVP.

RESULTS

Baseline BT was abnormal in 18 (95%) of the patients. The BT following DDAVP administration improved in two cases (11%): one from 7.2 to 5.6 min and the other from 8 to 6 min (Tables II and III). BT measurements remained very prolonged (>15 min) in 17 (89%) of the patients. Patients with the HPS 1 gene mutation had a statistically significant correlation with the poor response following DDAVP (P = 0.03).

CONCLUSIONS

DDAVP seldom improves the BT of Puerto Rican children with HPS. Response to DDAVP should be determined individually and platelet transfusion should remain the treatment of choice for a major bleeding episode or surgical procedure.

An innervated retroauricular skin flap for total earlobule reconstruction

In this article, the authors describe a technique for total earlobule reconstruction in a patient who underwent earlobule excision for basal cell carcinoma. The reconstruction was by means of an innervated retroauricular skin flap, folded double. The flap presented preserved skin sensitivity over all the reconstructed area, which is compromised by those techniques using a cranially or medially based flap which lead to the reconstruction of an insensible earlobule. This is a very important aspect of this technique, especially for those who wear pendant earrings, since a non-sensitive lobule would be more vulnerable to traumas causing laceration. In addition, it allows a good aesthetic result without evident donor site scars. Further investigation is needed to decide if this method is suitable for other types of total earlobule loss (e.g. congenital, traumatic), or not.

The supra-auricular arterial network: anatomical bases for the use of superior pedicle retro-auricular skin flaps

The authors present an anatomical study on vascularization of the retro-auricular skin, focusing on the origin, distribution and anastomoses of the superior auricular artery. This artery is used as the pedicle of a retro-auricular flap to repair defects in the upper third of the auricle and in the temporal region. The study was carried out on 13 fresh cadavers, with a total of 25 auricles. The common carotid artery had previously been injected with dyed latex. The superior auricular artery was found in all specimens. It had constant course and caliber, mean axial length 2.4 cm, mean caliber 0.8 mm. This artery connected the superficial temporal artery, or its parietal branch, and the posterior auricular artery network. This branch proved a reliable vascular pedicle for the mobilization of retro-auricular flaps. The results of this study are presented together with preliminary clinical results obtained using an antero-superior retro-auricular flap, never previously described, to reconstruct the superior third of the auricle and the temporal region.

[External oblique muscle-cutaneous flap use of the in the reconstruction of large chest wall defects after mastectomy]

The use of an external oblique muscle-cutaneous flap in the reconstruction of large chest wall defects after mastectomy is described. The flap is drown as a V-Y advancement-rotation flap, laterally based, on the ipsilateral abdominal wall. The flap extends from the posterior axillary line to the linea alba, vascular supply is provided by the musculo-cutaneous perforating arteries of the intercostal vessels. Mobilization starts medially including the anterior rectus sheath, décollement continues between the external and the internal oblique muscles as far as the posterior axillary line. The abdominal wall, after flap mobilization, is reinforced by the plication of the internal oblique sheath. The flap was used in 13 patients with major anterior chest-wall defects after mastectomy. In one patient a marginal skin necrosis of about 2 cm was observed. The flap described differs from other external oblique flaps already described in several technical innovations that allow to obtain better functional and esthetic results.

Lepidium meyenii (Maca) improved semen parameters in adult men

AIM

The present study was designed to determine the effect of a 4-month oral treatment with tablets of Lepidium meyenii (Maca) on seminal analysis in nine adult normal men aged 24-44 years old.

METHODS

Nine men received tablets of Maca (1500 or 3000 mg/day) for 4 months. Seminal analysis was performed according to guidelines of the World Health Organization (WHO). Serum luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (PRL), testosterone (T) and estradiol (E2) were measured before and after treatment.

RESULTS

Treatment with Maca resulted in increased seminal volume, sperm count per ejaculum, motile sperm count, and sperm motility. Serum hormone levels were not modified with Maca treatment. Increase of sperm count was not related to dose of Maca.

CONCLUSION

Maca improved sperm production and sperm motility by mechanisms not related to LH, FSH, PRL, T and E2.

Effect of Lepidium meyenii (maca) roots on spermatogenesis of male rats

AIM

To determine the effect of oral administration of an aqueous extract from the roots of Lepidium meyenii (maca) on spermatogenesis in adult male rats.

METHODS

Male rats received an aqueous extract of the root (66.7 mg in one mL) twice a day for 14 consecutive days.

RESULTS

Treatment with Lepidium meyenii resulted in an increase in the weights of testis and epididymis but not the seminal vesicle weight. The length and frequency of stages IX-XIV seminiferous tubules, where mitosis occurred, were increased and stages I-VI were reduced in rats treated with Lepidium meyenii.

CONCLUSION

The Lepidium meyenii root invigorates spermatogenesis in male rats by acting on its initial stages (IX-XIV).

Thallium-201 scintigraphy is not predictive of late cardiac complications in patients with Hodgkin's disease treated with mediastinal radiation

PURPOSE

To assess whether abnormalities depicted by Thallium-201 scintigraphy can predict the occurrence of late cardiac complications in patients with Hodgkin's disease treated with mantle field radiation therapy.

METHODS AND MATERIALS

Thallium scintigraphy was performed in 49 patients at a median of 75 months after initial treatment (range 28-208 months). Initial treatment consisted in chemotherapy, given to two-thirds of the patients and mantle field radiation, delivered to all patients, using a 25-MV linear accelerator. Myocardial perfusion defects were observed in 78% of patients on thallium scintigraphy. These patients had their cardiac status reassessed at a median follow-up of 13.5 years after treatment.

RESULTS

Forty-two patients were assessable, as data on the cardiac status were missing in 7 patients. The majority of patients received at least 40 Gy, and 75% of them were treated with one field per day. The median follow-up of patients is 13.5 years (range 9-24.5). Eleven cardiac complications were observed in 9 patients (coronary artery disease [n = 2], conduction-system abnormalities [n = 3], valvular defects [n = 5], and congestive heart disease [n = 1]). The median 15-year actuarial incidence of cardiac complications was 21% (95% confidence interval of 9-40%). The positive and negative predictive value of thallium scintigraphy was 19% and 77%, respectively. The univariate analysis showed that the extent of left ventricle exposure to irradiation was an adverse prognostic factor, and chemotherapy administered before mantle field irradiation was of borderline significance.

CONCLUSION

Thallium scintigraphy is not predictive of late cardiac complications. The extent of left ventricle exposure to radiation and possibly chemotherapy given before radiation treatment are adverse prognostic factors.

Innervated island flaps in morphofunctional vulvar reconstruction

In this article, the authors present their own experience in vulvar reconstruction following vulvectomy using two different innervated island flaps according to the size and site of the defect. Island-flap mobilization is possible thanks to the rich blood supply of the perineal region. The methods described are a "V-Y amplified sliding flap from the pubis" and a "fasciocutaneous island flap" raised from one or both gluteal folds. The V-Y amplified sliding flap from the pubis is indicated when the defect is symmetric and located anteriorly. This flap is harvested from the pubis and vascularized by the deep arterial network of the pubis. Sensory innervation is provided by branches of the ileo-inguinal nerve. The fasciocutaneous island flap, raised from one or both gluteal folds, can be used following hemivulvectomy or radical vulvectomy, respectively, to cover posteriorly located defects. Vascularization is provided by the musculocutaneous perforating branches of the pudendal artery, whereas sensory innervation is maintained through the perineal branches of the pudendal nerve. Twenty-two patients have undergone reconstructive surgery of the vulvar region from 1989 to date. On 14 patients, a V-Y amplified sliding flap was used; on 7 patients, reconstruction was carried out by island flaps raised from the gluteal fold. Both techniques are compatible with inguino-femoral lymphadenectomy, and they allow for a correct morphofunctional reconstruction and provide good local sensibility. The final result is aesthetically satisfactory, as all final scars are hidden in natural folds.

[Conformal radiotherapy of brain tumors]

Conformal irradiation of brain tumours is based on the three-dimensional reconstruction of the targeted volumes and at-risk organ images, the three-dimensional calculation of the dose distribution and a treatment device (immobilisation, beam energy, collimation, etc.) adapted to the high precision required by the procedure. Each step requires an appropriate methodology and a quality insurance program. Specific difficulties in brain tumour management are related to GTV and CTV definition depending upon the histological type, the quality of the surgical resection and the medical team. Clinical studies have reported dose escalation trials, mostly in high-grade gliomas and tumours at the base of the skull. Clinical data are now providing a better knowledge of the tolerance of normal tissues. As for small tumours, the implementation of beam intensity modulation is likely to narrow the gap between conformal and stereotaxic radiotherapy.

A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects

A new extended external oblique musculocutaneous flap utilized in the reconstruction of chest-wall defects is described. The flap is drawn as a V-Y rotation flap on the ipsilateral abdominal wall. It is laterally based, and its pedicle coincides with the five lowest costal insertions of the external oblique. The flap extends above the transiliac line, from the posterior axillary line to the linea alba, and includes the dynamic territory of the external oblique muscle. Vascular supply is provided by the musculocutaneous perforating arteries of the intercostal vessels and their subcutaneous branches. The flap is raised medially and includes the anterior sheath of the rectus. Undermining continues between the external and the internal oblique muscles as far as the posterior axillary line. The donor site on the abdominal wall is reinforced by the plication of the internal oblique sheath. This flap was used in 13 patients with major anterior chest-wall excisional defects. The mean chest-wall defect was about 390 cm2. Marginal necrosis with distal skin loss was observed in one patient. All other flaps healed without complications. The extended external oblique musculocutaneous flap differs from other external oblique flaps already described in several aspects that allow it to obtain better functional and aesthetic results.

Platysma muscle cutaneous flap for large defects of the lower lip and mental region

Based on the experience acquired using the depressor anguli oris flap for lateral lower lip reconstruction, the authors in this paper present their own technique to reconstruct large deficits of the lower lateral lip, involving the commissure and the mental region, by means of a platysma muscle cutaneous flap with a triangular skin island. The flap is oriented in the mandibular cheek region. The skin and the platysma muscle fibers, which run vertically, are incised and turned 90 degrees, so the edges of the platysma fibers are sutured to the edge of the residual orbicularis. The mucosal layer and the vermilion are reconstructed with a rotational flap from the cheek mucosa. The motor nerve and the vascular pedicle are preserved during the mobilization. The authors have treated six cases without relevant complication. A thorough knowledge of the anatomy of the region is mandatory; the surgical work must be precise and takes a long time, but results are highly satisfactory.

Psychosocial factors associated with complementary treatment use in fibromyalgia

OBJECTIVE

To examine the frequency and predictors of reported complementary treatment use in a sample of 111 subjects with fibromyalgia (FM). The perspective was adopted that complementary treatment use represents a form of medical help-seeking that may be subject to a variety of biological, social, and psychological influences.

METHODS

Patients with FM were recruited from community and university based clinics and support groups throughout the greater San Diego, California, area. Patients participated in a comprehensive evaluation of their pain, psychological functioning, and disability prior to their potential involvement in a clinical trial designed to help them copy with their condition. They were also administered a rheumatological evaluation to verify their FM and a 20 item questionnaire to assess their use of complementary treatment strategies specifically for coping with FM.

RESULTS

Ninety-eight percent of the sample reported the use of at least one strategy over the preceding 6 months. Exercise, bed rest, vitamins, heat treatment, and spirituality/praying were the most frequently used strategies by subjects on a daily basis. Multiple regression analysis revealed that lower age, higher pain, and higher disability were uniquely associated with higher complementary treatment use. The Pain Rating Index, a measure of the subjective severity of pain from the McGill Pain Questionnaire, proved highly significant in explaining the relationship between pain and questionnaire scores. Pain coping strategies and quality of social support did not predict complementary treatment use.

CONCLUSION

The findings suggest that poor clinical status is a major predictor of complementary treatment use in FM. However, longitudinal research is recommended to clarify the relationship between clinical status and help-seeking patterns in patients with FM over time.