Prevalence of Second-Hand Smoke Exposure After Introduction of the Italian Smoking Ban: The Florence and Belluno Survey

Aims and Background

A law banning smoking in enclosed public places was implemented in Italy on January 10, 2005. The aim of this paper is to present a cross-sectional survey on two representative samples of non-smokers of two Italian towns (Florence and Belluno), conducted one year after the introduction of the ban, in order to assess prevalence of second-hand smoke exposure, to record the attitudes towards the ban, and the perception about its compliance in a representative sample of non-smokers.

Methods

Computer-assisted telephone interviews were carried out in March 2006, from a random sample of households from telephone registries. Respondents were 402 non-smokers from Belluno and 1,073 from Florence.

Results

About 12% of Florentines and 7% of Belluno respondents were exposed at home; 39% and 19%, respectively, at work; 10% and 5% in hospitality venues; 20% and 10% in cars. The smoke-free law was almost universally supported (about 98%) even if a smaller proportion of people (about 90%) had the perception that the ban was observed.

Conclusions

Second-hand smoke exposure at home and in hospitality premises has dropped to ≤10%, whereas exposure at work remained higher. These results suggest the need for more controls in workplaces other than hospitality venues.

[Lung function of dust-exposed workers]

Workers exposed to dust have to undergo medical check-ups every 2 years including lung function testing. Here we report on the routine lung function data (FVC, FEV1, MEF50) of 994 workers from Austria. Lung function data were compared to the Austrian standard values that are based on routine testing of healthy volunteers. For all parameters the workers' values were significantly poorer than the Austrian standards (FVC: -0.4 l; FEV1: -0.5 l; MEF50: -0.9 l/s). The difference from the standard increased with increasing duration of the dust exposure. This increase was significant for the total group for MEF50 even after controlling for smoking. About half of the workers were exposed to quartz dust and had poorer lung function values (p = 0.02 for MEF50) than the other workers. Smoking significantly reduced all 3 lung function parameters with a significant interaction between strong smoking (compared to non-smokers) and quartz exposure (compared to all other exposures). Current Austrian limit values are not protective against chronic damage of the respiratory system. The combined impact of cigarette smoke and high concentration of mineral dust (quartz) is especially dangerous.

Characterizing the performance of two optical particle counters (Grimm OPC1.108 and OPC1.109) under urban aerosol conditions

The performance of Grimm optical particle counters (OPC, models 1.108 and 1.109) was characterized under urban aerosol conditions. Number concentrations were well correlated. The different lower cut-off diameters (0.25 and 0.3 μm) give an average difference of 23.5%. Both detect less than 10% of the total particle concentration (0.01-1 μm; Differential Mobility Analyzer), but in the respective size ranges, differences are <10%. OPC number size distributions were converted to mass concentrations using instrument-specific factors given by the manufacturer. Mass concentrations for OPC1.108 were 60% higher than for OPC1.109 and (in case of OPC1.109) much lower than those measured with an impactor in the relevant size range or a TSP filter. Using the C-factor correction suggested by the manufacturer, OPC1.109 underestimated mass concentrations by 21% (impactor) and by about 36% (TSP filter), which is in the range of comparability of co-located different mass concentration methods (Hitzenberger, Berner, Maenhaut, Cafmeyer, Schwarz, & Mueller et al., 2004).

Synthetic musks in blood of healthy young adults: relationship to cosmetics use

Production of polycyclic musk compounds is increasing accompanied by a decline in nitro musk production. Although it can be assumed that due to this reduction nitro musks are less prevalent in human body fluids, there are no data available from the last decade. This study examined the concentrations of five nitro musks and six polycyclic musks in blood samples from young healthy volunteers. Blood was taken from 100 healthy students of the Medical University of Vienna. The lipophilic fraction was extracted and after purification analyzed by GC-MS. Study participants also completed a questionnaire on the use of cosmetics, about nutrition and other life-style aspects. Highest percentages of synthetic musks in blood plasma samples were found for galaxolide (91%, median 420 ng L(-1)) and musk xylene (79%, median 11 ng L(-1)). Both musk ketone and tonalide were found in 17%. In two cases musk ambrette was detected. In a multivariate approach only younger age, use of lotion and perfumes did significantly predict blood concentrations of polycyclic musks. For nitro musks except body surface area no significant predictor could be found. High percentage of the population is still exposed to nitro musk compounds although blood concentrations of nitro musks are generally lower than those of polycyclic musks. Compared to earlier investigations performed in the 1990s nitro musks were detected in lower percentages and concentrations. There seems to be no dominant source of nitro musk uptake although relationship to body surface area indicates cosmetic products applied to the skin as the likely origin of plasma concentrations.

Exposure to indoor mould and children's respiratory health in the PATY study

BACKGROUND

Living in a damp or mouldy home reportedly damages children's respiratory health, yet mould appears not to be a prominent risk factor in the public's perception. Analyses of data on over 58,000 children from the Pollution and the Young (PATY) study are presented. In this collaboration, researchers from 12 cross-sectional studies pooled their data to assess the effects of air quality on a spectrum of children's respiratory disorders.

METHOD

Original studies were conducted in Russia, North America and 10 countries in Eastern and Western Europe. Pooled analyses were restricted to children aged 6-12 years. Associations between visible mould reported in the household and a spectrum of eight respiratory and allergic symptoms were estimated within each study. Logistic regressions were used, controlling for individual risk factors and for study area. Heterogeneity between study-specific results and mean effects (allowing for heterogeneity) were estimated using meta-analysis.

RESULTS

Visible mould was reported by 13.9% of respondents in Russia, increasing to 39.1% in North America. Positive associations between exposure to mould and children's respiratory health were seen with considerable consistency across studies and across outcomes. Confounder-adjusted combined ORs ranged from 1.30 (95% CI 1.22 to 1.39) for "nocturnal cough" to 1.50 (1.31 to 1.73) for "morning cough". Evidence of stronger effects in more crowded households was statistically significant for only asthma and sensitivity to inhaled allergens. No consistent interactions between mould and age, sex or parental smoking were found.

CONCLUSION

Indoor mould exposure was consistently associated with adverse respiratory health outcomes in children living in these diverse countries.

Exposure to indoor mould and children's respiratory health in the PATY study

BACKGROUND

Living in a damp or mouldy home reportedly damages children's respiratory health, yet mould appears not to be a prominent risk factor in the public's perception. Analyses of data on over 58,000 children from the Pollution and the Young (PATY) study are presented. In this collaboration, researchers from 12 cross-sectional studies pooled their data to assess the effects of air quality on a spectrum of children's respiratory disorders.

METHOD

Original studies were conducted in Russia, North America and 10 countries in Eastern and Western Europe. Pooled analyses were restricted to children aged 6-12 years. Associations between visible mould reported in the household and a spectrum of eight respiratory and allergic symptoms were estimated within each study. Logistic regressions were used, controlling for individual risk factors and for study area. Heterogeneity between study-specific results and mean effects (allowing for heterogeneity) were estimated using meta-analysis.

RESULTS

Visible mould was reported by 13.9% of respondents in Russia, increasing to 39.1% in North America. Positive associations between exposure to mould and children's respiratory health were seen with considerable consistency across studies and across outcomes. Confounder-adjusted combined ORs ranged from 1.30 (95% CI 1.22 to 1.39) for "nocturnal cough" to 1.50 (1.31 to 1.73) for "morning cough". Evidence of stronger effects in more crowded households was statistically significant for only asthma and sensitivity to inhaled allergens. No consistent interactions between mould and age, sex or parental smoking were found.

CONCLUSION

Indoor mould exposure was consistently associated with adverse respiratory health outcomes in children living in these diverse countries.

Italy and Austria before and after study: second-hand smoke exposure in hospitality premises before and after 2 years from the introduction of the Italian smoking ban

The aim of this paper was to compare nicotine concentration in 28 hospitality premises (HPs) in Florence and Belluno, Italy, where a smoking ban was introduced in 2005, and in 19 HPs in Vienna, Austria, where no anti-smoking law entered into force up to now. Airborne nicotine concentrations were measured in the same HPs in winter 2002 or 2004 (pre-ban measurements) and winter 2007 (post-ban measurements). In Florence and Belluno, medians decreased significantly (P < 0.001) from 8.86 [interquartile range (IQR): 2.41-45.07)] before the ban to 0.01 microg/m3 (IQR: 0.01-0.41) afterwards. In Austria (no smoking ban) the medians collected in winters 2004 and 2007 were, respectively, 11.00 (IQR: 2.53-30.38) and 15.76 microg/m3 (IQR: 2.22-31.93), with no significant differences. Measurements collected in winter 2007 in 28 HPs located in Naples, Turin, Milan (0.01 microg/m3; IQR: 0.01-0.16) confirmed post-ban results in Florence and Belluno. The medians of nicotine concentrations in Italy and Austria before the Italian ban translates, using the risk model of Repace and Lowery, into a lifetime excess lung cancer mortality risk for hospitality workers of 11.81 and 14.67 per 10,000, respectively. Lifetime excess lung cancer mortality risks for bar and disco-pub workers were 10-20 times higher than that calculated for restaurant workers, both in Italy and Austria. In winter 2007, it dropped to 0.01 per 10,000 in Italy, whereas in Austria it remained at the same levels. The drop of second-hand smoke exposure indicates a substantial improvement in air quality in Italian HPs even after 2 years from the ban.

PRACTICAL IMPLICATIONS

The nation-wide smoking ban introduced in Italy on January 10, 2005, resulted in a drop in second-hand smoke exposure in hospitality premises, whereas in Austria, where there is no similar nation-wide smoking ban, the exposure to second-hand smoke in hospitality premises remains high. Given that second-hand smoke is considered a group 1 carcinogen according to the International Agency for Research on Cancer classification, the World Health Organization Framework Convention on Tobacco Control strongly recommends the implementation of nation-wide smoke-free policies in order to improve the indoor air quality of hospitality premises and workplaces. Results from our study strongly supports this recommendation.

Long term success of short smoking cessation seminars supported by occupational health care

The objective of this longitudinal (3 year) study was to determine predictors of abstinence in 515 employees of a steel plant (28% female, age 18-67 years) after participation in Allen Carr seminars (intensive group counselling in a single session of 6 h). Answers given in computer aided phone interviews were analysed by stepwise and Cox regression. Of 510 responding persons 262 (51.4%) reported continuing abstinence. In a random sample of 61 respondents cotinine concentration in urine was measured, showing high agreement with smoking history. Social support increased abstinence, which was more persistent in males and office workers. Also in female participants the non-smoking spouse was a significant predictor for abstinence while a higher body weight predicted relapse. Relapsed female smokers did not show a sustainable reduction of cigarette consumption. Compared to cessation clinics higher population coverage would be achievable by workplace seminars. Every second smoker motivated to participate seems to be able to quit even without medication and to stay abstinent. Especially in females these seminars should be followed by physical exercise and continued support of gender specific occupational health care.

Subjective symptoms, sleeping problems, and cognitive performance in subjects living near mobile phone base stations

BACKGROUND

The erection of mobile telephone base stations in inhabited areas has raised concerns about possible health effects caused by emitted microwaves.

METHODS

In a cross-sectional study of randomly selected inhabitants living in urban and rural areas for more than one year near to 10 selected base stations, 365 subjects were investigated. Several cognitive tests were performed, and wellbeing and sleep quality were assessed. Field strength of high-frequency electromagnetic fields (HF-EMF) was measured in the bedrooms of 336 households.

RESULTS

Total HF-EMF and exposure related to mobile telecommunication were far below recommended levels (max. 4.1 mW/m2). Distance from antennae was 24-600 m in the rural area and 20-250 m in the urban area. Average power density was slightly higher in the rural area (0.05 mW/m2) than in the urban area (0.02 mW/m2). Despite the influence of confounding variables, including fear of adverse effects from exposure to HF-EMF from the base station, there was a significant relation of some symptoms to measured power density; this was highest for headaches. Perceptual speed increased, while accuracy decreased insignificantly with increasing exposure levels. There was no significant effect on sleep quality.

CONCLUSION

Despite very low exposure to HF-EMF, effects on wellbeing and performance cannot be ruled out, as shown by recently obtained experimental results; however, mechanisms of action at these low levels are unknown.

Parental education and children's respiratory and allergic symptoms in the Pollution and the Young (PATY) study

Inequalities in health between socio-economic groups are a major public health concern. The current authors studied associations between parental socio-economic status (SES) and children's respiratory and allergic symptoms in 13 diverse countries, including the Russian Federation, North America (Canada and the USA), and countries across Eastern and Western Europe. Data of 57,000 children aged 6-12 yrs, originating from eight cross-sectional studies, were analysed. SES was defined by parental education. Respiratory and allergic symptoms were defined by parental questionnaire reports. Multiple logistic regressions showed that low parental education was associated with a decreased risk of inhalant allergy and itchy rash in school children. Furthermore, low parental education was associated with an increased prevalence of wheeze and nocturnal dry cough. No clear association was found between parental education and prevalence of doctor-diagnosed asthma and bronchitis. Part of the difference between socio-economic groups with regard to their children's symptoms was explained by established risk factors, such as parental allergy, smoking during pregnancy, pet ownership, crowding, mould/moisture in the home, use of gas for cooking, and air pollution (particulate matter with a diameter of <10 microm). However, differences remained after adjusting for these variables. Children's health was associated with parental education. The association could not fully be explained by established risk factors.

Low levels of air pollution induce changes of lung function in a panel of schoolchildren

In search of sensitive screening parameters for assessing acute effects of ambient air pollutants in young schoolchildren, the impact of 8-h average air pollution before lung function testing was investigated by oscillatory measurements of resistance and spirometry with flow-volume loops. At a central elementary school in Linz, the capital of Upper Austria, 163 children aged 7-10 yrs underwent repeated examinations at the same time of day during 1 school year, yielding a total of 11-12 lung function tests per child. Associations to mass concentrations of particulate matter and nitrogen dioxide (NO(2)) measured continuously at a nearby monitoring station were tested, applying the Generalised Estimating Equations model. Reductions per 10 microg.m(-3) (both for particles and for NO(2)) were in the magnitude of 1% for most lung function parameters. The most sensitive indicator for acute effects of combustion-related pollutants was a change in maximal expiratory flow in small airways. NO(2) at concentrations below current standards reduced (in the multipollutant model) the forced expiratory volume in one second by 1.01%, maximal instantaneous forced flow when 50% of the forced vital capacity remains to be exhaled (MEF(50%)) by 1.99% and MEF(25%) by 1.96%. Peripheral resistance increased by 1.03% per 10 microg.m(-3) of particulate matter with a 50% cut-off aerodynamic diameter of 2.5 mum (PM(2.5)). Resistance is less influenced by the child's cooperation and should be utilised more often in environmental epidemiology when screening for early signs of small airway dysfunction from urban air pollution, but cannot replace the measurement of MEF(50%) and MEF(25%). In the basic model, the reduction of these parameters per 10 microg.m(-3) was highest for NO(2), followed by PM(1), PM(2.5) and PM(10), while exposure to coarse dust (PM(10)-PM(2.5)) did not change end-expiratory flow significantly. All acute effects of urban air pollution found on the lung function of healthy pupils were evident at levels below current European limit values for nitrogen dioxide. Thus, planned reduction of nitrogen dioxide emission (Euro 5; vehicles that comply with the emission limits as defined in Directive 99/96/EC) of 20% in 2010 would seem to be insufficient.

Smoking cessation at the workplace: 1 year success of short seminars

OBJECTIVES

In search of less time-consuming methods of smoking cessation Allen Carr' seminars performed at workplaces in Austria were evaluated.

METHODS

Of all the 357 smokers attending a seminar in summer 2002, 308 (86%), consented to participate in a repeated health survey, including the SF-36 questionnaire. After 3 months 268 (87%) gave computer-aided telephone interviews and 223 (72%) after 1 year. Analysis by logistic regression was done separately for males and females.

RESULTS

The 1-year quit rate was 40% (worst case assumption) to 55% (best estimate). In 96% of quitters an intensive counseling for 6 h without pharmaceutical aid thereafter was sufficient to maintain abstinence for 12 months. A long smoking history or many earlier unsuccessful attempts to quit did not predict failure. The risk of relapse was found higher in young men with a high number of pack-years and in women with good physical fitness but high Fagerstroem score and financial reasons for the intention to quit smoking. While an average weight gain of 3 kg in males was not associated with failure to quit smoking, we found the highest weight gain (4 kg) in females in the group abstinent at 3 months but smoking again at 12 months. In all participants subjective life quality scored by SF-36 improved. In quitters perception of general health improved more.

CONCLUSIONS

Group counseling at the workplace was found to be an efficient method of smoking cessation, capable of increasing subjective life quality and health and to smooth the way to smoke-free enterprises.

Environmental tobacco smoke exposure in public places of European cities

BACKGROUND

Exposure to environmental tobacco smoke (ETS) has important public health implications. The results of the first European multi-centre study that measured ETS exposure in a range of public places (transport, educational settings, and leisure facilities such as bars and restaurants) are presented.

METHOD

Nicotine vapour phase was measured using ETS passive samplers containing a filter treated with sodium bisulfate.

RESULTS

Bars and discos are the places with the highest concentrations of nicotine from ETS, median ranging from 19 to 122 microg/m(3). Restaurants had the next highest values. Concentrations of nicotine generally range from 0.1-5 microg/m(3) in airports, and from 0.5-10 microg/m(3) in train stations. Nicotine was also found in schools and universities, yet schools tended to have the lowest concentrations compared to all the other public places sampled. In hospitals levels were generally below 5 microg/m(3).

CONCLUSIONS

Although there is some variability between cities, this study shows that tobacco smoke is present in most of the studied public places. The study also showed that in areas where smoking is prohibited, concentrations of nicotine are lower than in areas where smoking is allowed but they are not zero. The results of this study indicate that policies should be implemented that would effectively reduce levels of tobacco smoke in public areas.

Blood concentrations of polycyclic musks in healthy young adults

Knowledge on the concentration of polycyclic musk fragrance compounds in human blood is sparse. This study examined the concentrations of six polycyclic musks in blood samples from healthy volunteers. Blood was taken from hundred healthy students of the Medical University of Vienna. The lipophilic fraction was extracted and after purification analyzed by GC-MS. Study participants also completed a questionnaire on the use of cosmetics, about nutrition and other life-style aspects. Two compounds -- galaxolide and tonalide -- were identified in higher percentages of the blood plasma samples. Maximum plasma levels over 100 ng/l were also only found for galaxolide (4100 ng/l) and tonalide (800 ng/l). Women showed significantly higher levels than men. In a statistical multivariate approach only use of body lotion and age were predictive of positive galaxolide concentrations. For tonalide no significant predictor could be found. The findings mirror the replacement of nitro musk fragrances by polycyclic musks, mainly galaxolide. The high concentrations of galaxolide in human blood raise concern since few toxicological data are available.

Lung cancer and dust exposure: results of a prospective cohort study following 3260 workers for 50 years

AIMS

To study the lasting health impact of occupational dust exposure on life expectancy and specific causes of death.

METHODS

Male Viennese workers, selected at age > or =40 (mean 54) years during preventive check-ups between 1950 and 1960, were followed prospectively until death. Half of them (1630) were exposed at work to (non-fibrous) particulates, while the non-exposed workers were matched for year, age, and smoking status at the start of observation.

RESULTS

Average life expectancy of those exposed was 1.6 years less than that of those non-exposed. Only a small part of this decrease in life expectancy (hazards ratios in brackets) was related to acknowledged occupational diseases such as silicosis and silicotuberculosis (67.12). Chronic obstructive lung disease (1.82) and cancer of the lung (1.42) and stomach (1.77) were found more frequently among those exposed.

CONCLUSIONS

Results support the hypothesis that high exposure to insoluble particulates such as silica in the metal, glass, ceramics, and stone industries promotes bronchial cancer and chronic obstructive pulmonary disease. The finding of an increased incidence of stomach cancer might be related to particles swallowed after clearance from the airways.

Moulds in housing: visual inspection and spore counts comparison--implications for future strategies in the public health setting

OBJECTIVES

Among the problems of health related to living conditions presented to a public consulting centre for environmental medicine in Vienna, the main point at issue was damp housing and mould growth. On answering this demand indoor exposure to fungal spores was identified by visual semi-quantitative assessment of fungal growth on the one hand and quantitative measurement of viable spores on the other hand. The validity and practicability of this approach was investigated.

METHOD

We applied these two simple methods in a standardised form and compared the results in a field study, which has been conducted between 1995 and 1999. In 197 rooms in Viennese flats (183 of which were claimed to be "mouldy") fungal spore concentrations were measured by RCS-impactor and Rose-Bengal-agar. Outdoor measurements were taken simultaneously outside the buildings and were used for reference.

RESULTS

Independent classification of visible growth of mould in flats correlated significantly (r = 0.635; p < 0.0001) with the ratio of indoor/ outdoor concentration of fungal spores.

CONCLUSIONS

It is usually possible to classify the severity of the problem just by local inspection. Visible plaques should always be an indication for sanitary measures. However, spore counting is indicated for quantifying health relevant exposures, for scientific comparisons and in documentation and follow up such as for litigation purposes. Quantitative data bear more credibility and so help to prove the need of sanitation.

[Toxicologically determined indoor air guidelines values]

At the Austrian Ministry for Environment (now: Federal Ministry for agriculture and forestry, environment and water management) a working group was established to propose indoor air guideline values. This consists of representatives of different disciplines, such as physicians, toxicologists, engineers and lawyers. Already in the constituent meeting it was decided to employ a set pattern for establishing toxicologically sound guideline values. It was then agreed to use the pattern proposed by the German ad-hoc-working team. The interdisciplinary discussions, however, demonstrated the need for additional clarification, since representatives of different disciplines obviously interpret the various terms and principles differently. In particular, there is a need for discussing in detail the relation between the guideline values for indoor air to other air quality standards (outdoor air and workplace) and to specify their scope and application, especially the need to describe in greater detail what should be done in case either guideline value I or II was exceeded.

[Determinants of patient satisfaction with services of the Vienna environmental medicine counseling center]

Client satisfaction is a relevant aspect for assessing the efficiency of a Medical Advisory Board. The study presented here aimed at determining the factors that guarantee satisfaction. These findings are essential for the further development of the service of the Advisory Board of the City of Vienna for Environmental Medicine ("UMB"). To this end a brief anonymous questionnaire was sent to 245 clients. This comprised elements evaluating the degree of satisfaction with the consultant service of the Advisory Board, fulfillment rate of expectations, solutions offered for various problems, and whether--if necessary--the "UMB" Advisory Board would be consulted again. A satisfactory response rate of 43% was obtained. The results show a high degree of satisfaction among the clients with the consultations (= 78%) despite unresolved or only partly resolved problems (71%) and questions that remained open for discussion (38%). Approximately 90% of the clients would again consult "UMB" for advice. The reasons for consultation did not show any significant influence on the client satisfaction. However, satisfaction of clients depended on whether or not a solution was found in respect of their problem and on the action taken by "UMB" to solve it. Summarising the findings, the analyses show that apart from on-the-spot assessment and detailed inspection, comprehensive case histories and interviews are an important basis for further clarification of problems caused by environmental factors.

Continuing progressive deterioration of the environment in the Aral Sea Region: disastrous effects on mother and child health

Scientists, non-governmental experts (NGOs) and governmental officials from the Central Asian Republics and an international group of invited scientists and NGO representatives participated in a workshop on the disastrous health problems in the Aral Sea Region. Various serious problems were reported in more than 20 presentations. Particular emphasis was put on the way in which adverse environmental factors such as contaminated water and food have contributed to the deterioration of human health, particularly that of mothers and children.

CONCLUSION

There is an urgent request that the international community assists local scientists to develop programmes to improve the health of the population in the Aral Sea Region.

Wrap-around arterialized venous flap for salvage of an avulsed finger

The case of an avulsed finger with extensive soft-tissue trauma is presented. The digit was salvaged using an arterialized wrap-around flow-through venous flap from the forearm.

[Iatrogenic necrosis of the large toe after tourniquet placement--clinical course and reconstruction]

We present a necrosis of the big toe in a 20-year-old woman with an ingrowing toenail after wedge-shaped excision in the big toe. The reason for the necrosis was a tourniquet that was left in place after the operation. The ischemia, which lasted for 2 days, resulted in subtotal necrosis of the big toe. Six weeks after the operation the patient underwent microsurgical reconstruction. This is a report on the treatment of this complication from the beginning. Early surgical intervention is advocated.

[The lower trapezius muscle island flap. Anatomic principles and clinical relevance]

Up to now, there is no uniform anatomic description neither of the branches of the subclavian artery nor of the pedicle of the lower myocutaneous trapezius flap. A dissection study was carried out on 140 necks in 70 cadavers. Variations of the subclavian artery and its branches, vessel diameter at different levels, the course of the pedicle under the levator scapulae muscle, the arc of rotation of the island flap, and the variations of the segmental intercostal branches to the lower part of the trapezius muscle were examined. Results of this study enable us to suggest a new nomenclature for the branches of the subclavian artery, a proper pedicle definition, and a technique for safe flap elevation. The lower trapezius island flap is a thin and pliable myocutaneous flap with a constant pedicle which ensures safe flap elevation. This flap has the potential for a wider acceptance due to minor donor site morbidity, large arc of rotation, and an ample range of clinical applications in the head and neck area as an island flap as well as a free flap.

[The posterior interosseous flap--review and personal experience]

The posterior interosseous flap was first introduced by Zancolli and Angrigiani (1985) and short time later by Penteado and Masquelet (1986). The flap is used for soft tissue reconstruction in the hand but has not gained wide acceptance due to tedious pedicle dissection and venous problems. In 1993, Angrigiani et al. published a simplified modification in the elevation of the flap. They included a constant fasciocutaneous perforating vessel in the flap to enhance the viability. We applied the modified elevation technique in twelve patients. Our experience, indications, and complications will be discussed. In contrast to Angrigiani's statement, our flaps still show a temporary mild to moderate venous congestion similar to the flaps raised in the original technique.

Venous thrombosis in a replanted finger with underlying factor V Leiden mutation

Resistance to activated protein C (APC resistance) was described recently as a cause for thrombophilia. APC inactivates coagulation co-factors Va and VIIIa. A single base-pair mutation changing Arg506 to Gln at the APC cleavage site of the factor V gene leads to a factor V Leiden variant, which is the most frequent cause of APC resistance. Recently, its role in peripheral venous thrombosis during pregnancy was described. We here report a case with thrombosis of the venous anastomoses after finger replantation with resistance to activated protein C associated with factor V Leiden mutation.