Use of pragmatic randomized trials in multiple sclerosis: A systematic overview.

BACKGROUND: Pragmatic trials are increasingly recognized for providing real-world evidence on treatment choices. OBJECTIVE: The objective of this study is to investigate the use and characteristics of pragmatic trials in multiple sclerosis (MS). METHODS: Systematic literature search and analysis of pragmatic trials on any intervention published up to 2022. The assessment of pragmatism with PRECIS-2 (PRagmatic Explanatory Continuum Indicator Summary-2) is performed. RESULTS: We identified 48 pragmatic trials published 1967-2022 that included a median of 82 participants (interquartile range (IQR) = 42-160) to assess typically supportive care interventions (n = 41; 85%). Only seven trials assessed drugs (15%). Only three trials (6%) included >500 participants. Trials were mostly from the United Kingdom (n = 18; 38%), Italy (n = 6; 13%), the United States and Denmark (each n = 5; 10%). Primary outcomes were diverse, for example, quality-of-life, physical functioning, or disease activity. Only 1 trial (2%) used routinely collected data for outcome ascertainment. No trial was very pragmatic in all design aspects, but 14 trials (29%) were widely pragmatic (i.e. PRECIS-2 score ⩾ 4/5 in all domains). CONCLUSION: Only few and mostly small pragmatic trials exist in MS which rarely assess drugs. Despite the widely available routine data infrastructures, very few trials utilize them. There is an urgent need to leverage the potential of this pioneering study design to provide useful randomized real-world evidence.

Botulinum Toxin-A Infiltration to Control Post-Operative Pain after Mastectomy and Expander Reconstruction as Potentially Useful Tool: A Narrative Review.

Botulinum toxin-A (BTX-A), a neurotoxin produced by Clostridium botulinum, was assessed for relieving implant-related pectoralis major muscle's painful spasms. In detail, 100 units of BTX-A can reduce muscle activity and, as a consequence, muscle spasms. The latter is considered the leading cause of post-operative pain after the sub-pectoral tissue expansion, sometimes leading to early expanders' removal. In addition, women choosing post-mastectomy reconstruction surgery seem to suffer worse post-operative pain than those who stop at the mastectomy stage. However, there is no unanimous consensus concerning the potential benefits of BTX-A in reducing pain related to the sub-pectoral placement of tissue expanders in breast reconstruction due to the exiguity of evidence. Therefore, this review aims to describe BTX-A-related evidence in this reconstruction setting. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Is Quality of Life After Breast Reduction Influenced by Different Surgery's Technique? A Prospective Study.

BACKGROUND: Breast hyperplasia is a condition with a significant impact on the quality of life and psychological well-being of patients. Over time, various surgical techniques have been developed to reduce breast mass, which have proven effective in improving the quality of life of women undergoing the procedure. It is not yet well described how various techniques may influence the improvement in QoL (Quality of Life). The aim of this study is to assess the impact of different techniques on the improvement of quality of life. MATERIAL AND METHODS: We analyzed the responses to the Breast-Q questionnaire from 95 patients undergoing breast reduction surgery between 2021 and 2023. The questionnaires were completed both before the procedure and during the 6-month follow-up. We assessed the questionnaire responses and overall satisfaction with the results, categorizing the data based on the specific surgical technique used. RESULTS: A statistically significant improvement in the quality of life was observed in the postoperative period, as well as a remarkable satisfaction with the outcome (mean score of 81 out of 100). We did not detect statistically significant differences in the levels of quality of life and satisfaction with the outcome among the various techniques. CONCLUSION: The breast reduction surgery procedure continues to prove its ability to significantly improve the quality of life for patients with breast hypertrophy, regardless of the specific surgical technique employed. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Highly Concentrated Stabilized Hybrid Complexes of Hyaluronic Acid: Rheological and Biological Assessment of Compatibility with Adipose Tissue and Derived Stromal Cells towards Regenerative Medicine.

Cells and extracts derived from adipose tissue are gaining increasing attention not only in plastic surgery and for aesthetic purposes but also in regenerative medicine. The ability of hyaluronan (HA) to support human adipose stromal cell (hASC) viability and differentiation has been investigated. However, the compatibility of adipose tissue with HA-based formulation in terms of biophysical and rheological properties has not been fully addressed, although it is a key feature for tissue integration and in vivo performance. In this study, the biophysical and biochemical properties of highly concentrated (45 mg/mL) high/low-molecular-weight HA hybrid cooperative complex were assessed with a further focus on the potential application in adipose tissue augmentation/regeneration. Specifically, HA hybrid complex rheological behavior was observed in combination with different adipose tissue ratios, and hyaluronidase-catalyzed degradation was compared to that of a high-molecular-weight HA (HHA). Moreover, the HA hybrid complex's ability to induce in vitro hASCs differentiation towards adipose phenotype was evaluated in comparison to HHA, performing Oil Red O staining and analyzing gene/protein expression of PPAR-γ, adiponectin, and leptin. Both treatments supported hASCs differentiation, with the HA hybrid complex showing better results. These outcomes may open new frontiers in regenerative medicine, supporting the injection of highly concentrated hybrid formulations in fat compartments, eventually enhancing residing staminal cell differentiation and improving cell/growth factor persistence towards tissue regeneration districts.

Late relapse after CAR-T cell therapy for adult patients with hematologic malignancies: A definite evidence from systematic review and meta-analysis on individual data.

Chimeric Antigen Receptor (CAR)-modified T lymphocytes represent one of the most innovative and promising approaches to treating hematologic malignancies. CAR-T cell therapy is currently being used for the treatment of relapsed/refractory (r/r) B-cell malignancies including Acute Lymphoblastic Leukemia, Large B-Cell Lymphoma, Follicular Lymphoma, Multiple Myeloma and Mantle Cell Lymphoma. Despite the unprecedented clinical success, one of the major issues of the approved CAR-T cell therapy - tisagenlecleucel, axicabtagene, lisocabtagene, idecabtagene, ciltacabtagene and brexucabtagene - is the uncertainty about its persistence which in turn could lead to weak or no response to therapy with malignancy recurrence. Here we show that the prognosis of patients who do not respond to CAR-T cell therapy is still an unmet medical need. We performed a systematic review and meta-analysis collecting individual data on Duration of Response from at least 12-month follow-up studies. We found that the pooled prevalence of relapse within the first 12 months after CAR-T infusion was 61% (95% CI, 43%-78%); moreover, one year after the infusion, the analysis highlighted a pooled prevalence of relapse of 24% (95% CI, 11%-42%). Our results suggest that identifying potential predictive biomarkers of response to CAR-T therapy, especially for patients affected by the advanced stage of blood malignancies, could lead to stratification of the eligible population to that therapy, recognizing which patients will benefit and which will not, helping regulators to make decision in that way.

Upscaling cervical cancer screening and treatment for women living with HIV at a rural referral hospital in Tanzania: protocol of a before-and-after study exploring HPV testing and novel diagnostics.

BACKGROUND: Cervical cancer (CC) is nearly always caused by persistent human papillomavirus (HPV) infection. It is the most common cancer among women living with HIV (WLWH) and is the leading cause of cancer-related death in women in East Africa, with 10,241 new cases reported in Tanzania in 2020. In 2019, the World Health Organization (WHO) presented a global strategy for the elimination of CC as a public health problem, proposing targets to meet by 2030 for HPV vaccine coverage (90% of all 15-year-old girls), CC screening (70% of all women once at 35 and again at 45 years of age) and treatment delivery, to be scaled at national and subnational levels with a context-sensitive approach. This study aims to evaluate the upscaling of screening and treatment services at a rural referral hospital in Tanzania in order to address the second and third WHO targets. METHODS: This is an implementation study with a before-and-after design performed at St. Francis Referral Hospital (SFRH) in Ifakara (south-central Tanzania). CC screening and treatment services are integrated within the local HIV Care and Treatment Center (CTC). The standard of care, consisting of visualization of the cervix with acetic acid (VIA) and cryotherapy has been up-scaled with self-sampled HPV testing and also involved the introduction of mobile colposcopy, thermal ablation and loop electrosurgical excision procedure (LEEP). Participants are WLWH aged 18 to 65 years. Outcome measures included the percentage of women screened, HPV prevalence and genotype, and adherence to screening, treatment and follow-up plan. Additionally, we will explore the performance of novel diagnostic tests (QG-MPH®, Prevo-Check® and PT Monitor®), which share the features of being manageable and inexpensive, and thus a potential tool for effective triage in HPV high-prevalence cohorts. DISCUSSION: The study will provide relevant information about HPV prevalence and persistence, as well as reproductive and lifestyle indicators in a CC high-risk cohort of WLWH and about upscaling screening and treatment services at the level of a rural referral hospital in Tanzania. Furthermore, it will provide exploratory data on novel assays. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05256862, date of registration 25/02/2022. Retrospectively registered.

Use of BoneScalpel Ultrasonic Bone Dissector in Anterior Clinoidectomy and Posterior Fossa Surgery: Technical Note.

BackgroundFirst popularized by Dolenc, anterior clinoidectomies were performed with rongeurs, before the adoption of modern high-speed drills. We describe a novel application of the piezoelectric BoneScalpel™ in anterior skull base and posterior fossa surgeries. In the literature, to date, there are no mentions of anterior clinoidectomies performed with piezosurgical devices.MethodsWe reported a total of 12 patients, 8 affected by posterior fossa tumors and 4 treated for anterior skull base oncologic and vascular pathologies. This study aims to assess the safety and efficacy of the piezoelectric osteotomy in skull base and posterior fossa surgeries. In all patients, an ultrasonic bone dissector (BoneScalpel™ - Misonix) was used to perform the anterior clinoidectomy (AC) and craniotomy.ResultsA successful clinoidectomy was performed in 4 out of 12 patients (33.3%). We did not notice any heat damage to the surrounding soft tissue in critical areas such as paraclinoid structures. We documented only one durotomy in an oncologic patient, while no lesions of SSS or TS were detected.We recorded only a slightly increased surgery duration in the PIEZOSURGERY® and BoneScalpel™ group, compared to standard surgery with an osteotome to perform craniotomies, but no time difference in performing the clinoidectomy between BoneScalpel™ and a conventional high-speed drill.ConclusionWe report the first experience with piezosurgery for anterior clinoidectomy. There is no time difference in performing the clinoidectomy between BoneScalpel™ and a conventional high-speed drill, and this is an undoubted advantage in critical contexts such as clinoid-paraclinoid surgeries, where the risk of dural sinuses tears is common.

Fluoroscopy-Assisted Freehand Versus 3D-Navigated Imaging-Assisted Pedicle Screw Insertion: A Multicenter Study.

INTRODUCTION: Pedicle screw placement is a widely accepted surgical procedure for spinal fixation. Despite increases in knowledge about and expertise in pedicle screw insertion techniques, overall reported screw misplacement rates are still high. Spinal neuronavigation and intraoperative computed tomography (CT) imaging improves the accuracy and safety of pedicle screw placement through the continuous monitoring of screw trajectory. The purpose of this study is to compare pedicle screw placement under an O-arm intraoperative imaging system assisted by the StealthStation navigation system with screw placement under conventional fluoroscopy (C-arm). METHODS: For 222 patients, 1288 implanted pedicle screws in total were evaluated between 2018 and 2020. All patients underwent pedicle screw placement in the thoracic and lumbosacral regions through a posterior approach. Moreover, 107 patients (48.2%), 48 men and 59 women, underwent freehand screw placement under conventional fluoroscopy (C-arm group), whereas 115 patients (51.8%), 53 men and 62 women, underwent pedicle screw insertion under O-arm guidance with the help of the StealthStation neuronavigation system (Medtronic Navigation, Louisville, CO, USA) (O-arm group). Data were recorded and retrospectively analyzed. The accuracy of pedicle screw placement was postoperatively examined by using CT imaging and analyzed according to the Gertzbein-Robbins classification. RESULTS: Of the 1288 pedicle screws, 665 (51.6%) were placed with C-arm image-guided assistance with a mean of 6.21 ± 2.1 screws per patient and 643 (48.4%) with O-arm image-guided assistance with a mean of 5.59 ± 1.6 screws. The average time for the screw placement procedure was 3:57 ± 1:07 h in the C-arm group and 4:21 ± 1:41 h in the O-arm group. A correct screw placement was detected in 92.78% of patients in the C-arm group and in 98.13% of patients in the O-arm group. Medial cortical breach was shown in 13 Grade B screws (1.95%), 19 Grade C (2.86%), 14 Grade D (2.11%), and two Grade E (0.3%) in the C-arm group, whereas this was shown in 11 Grade B screws (1.71%) and one Grade C (0.16%) in the O-arm group. Lateral breach occurred in eight screws in both groups. Anterior vertebral body breach was shown in eight screws in the C-arm group, whereas it was shown in four screws in the O-arm group. Reoperation for screw misplacement was mandatory in five patients in the C-arm group and two patients in the O-arm group. CONCLUSION: Pedicle screw placement under an O-arm intraoperative imaging system assisted by spinal navigation showed greater accuracy compared with placement under conventional fluoroscopic control, thus avoiding the onset of major postoperative complications. Notably, a reduction in medial and anterior breaches has been demonstrated.

The one-step edge-to-edge technique in ventriculoperitoneal shunt.

BACKGROUND: Subcutaneous tunneling of the distal catheter is a potentially risky part of ventriculoperitoneal shunt (VPS) insertion. We describe our institutional experience with a simple trick to improve functional and aesthetic results in VPS by reducing the distal catheter tunneling to a single passage. MATERIALS AND METHODS: The one-step edge-to-edge technique has been performed in our institution over 14 years in 46 patients with a mean age of 63. 27 were female (58.7%). 7 patients suffered from post-traumatic hydrocephalus, 6 from normal pressure hydrocephalus, 15 from obstructive hydrocephalus and 18 from hydrocephalus secondary to subarachnoid hemorrhage. Operative blood loss varied from 20 to 40 cc. RESULTS: No complication related to the modified tunneling technique were described except a transitory peripheral VII nerve palsy (2.2%). The absence of middle skin incision is appreciated by the patient, especially in young females that not presented scars at the level of the neckline. CONCLUSION: Our technique is the first report of one step tunneling in adults. It reduces distal catheter tunneling time in VPS simplifying the procedure to a single step and using a simple reproducible trick.

Cervical radiculopathy as first presentation of CD3-positive diffuse large B-cell lymphoma of the cervico-thoracic junction.

BACKGROUND: Diffuse large B-cell lymphoma (DLBCL) in rare cases can presents an unusual expression of CD3 T-cell specific antigen. We report the first case of a CD3-positive DLBCL of the cervico-thoracic junction presenting with persistent cervical radiculopathy. CASE PRESENTATION: A 74-years-old male patient presented a severe and persistent right C8 radiculopathy associated with right-sided neck pain, progressive numbness and weakness of the right arm. The symptoms prominent during the night interfering with sleep and were resistant to anti-inflammatory drugs and cervical orthosis. Spine MRI showed a solid hypointense lesion on T2-weighted images and hyperintense on STIR sequences involving the epidural space at C7, T1 and T2. The patient underwent a C7-T1 decompressive laminectomy and left T2 hemilaminectomy with resection of the epidural tissue resulting in subtotal removal. Histology showed a DLBCL germinal center B-cell lymphoma with expression of CD3 T-cell specific antigen. Then the patient underwent adjuvant radiotherapy and chemotherapy consisting of R-CHOP protocol. At last follow-up (2 years) the patient is still in good clinical status (KPS = 80) with almost complete recovery of the cervical radiculopathy. CONCLUSIONS: To our knowledge this is the first case of DLBLC GCB-like CD3 positive to present with radiculopathy.

Diffuse cerebral angiomatosis associated to basilar apex aneurysm.

BACKGROUND: Diffuse cerebral angiomatosis (DCA) is a diffuse infiltration of normal brain by complex vascular structures. It differs from arteriovenous malformations (AVMs) that are composed of a nidus of vessels through which arteriovenous shunting occurs without interposed functional brain parenchyma. A rare subgroup of AVMs is diffuse with no recognizable nidus with functional neuronal tissue interspersed within the malformed vessels. We present a rare association of DCA and cerebral arterial aneurysm, which dramatically influenced the patient's prognosis. CASE DESCRIPTION: A 43-year-old male patient with right hemispheric diffuse cerebral angiomatosis presented with a ruptured basilar tip aneurysm that was successfully embolised. Unfortunately, the patient developed a locked-in syndrome. CONCLUSION: The present report shows a possible association between diffuse cerebral angiomatosis and cerebral aneurysms, but this association appears to be less strong than it is with other AVMs.

Chronic encapsulated intracerebral hematomas: a systematic review.

BACKGROUND: Chronic encapsulated intracerebral hematoma (CEICH) is a rare type of intracerebral hematoma (ICH) with peculiar radiological features and presenting as subtle slow-growing lesion exerting mass effect. We performed a systematic review of the literature focused on diagnosis and management of patients affected by CEICH. MATERIAL AND METHODS: A literature search according to the PRISMA statement was conducted using PubMed and Scopus databases and pertinent Mesh terms. All papers that reported intraventricular CEICH, or CEICH cases treated conservatively or by CT-guided needle aspiration were not included in this study. A total of 40 papers were included in this review, with 58 patients (38 males and 20 females) and a mean age of 41.44 ± 20.05 years (range 1-80). RESULTS: Neurological symptoms of onset include those related to an increase in intracranial pressure (ICP) in 28/58 cases (48.2%), seizures in 17/58 cases (29.3%), motor deficits in 14/58 cases (24.1%). The most frequent localization is atypical in 45/58 cases (77.6%). Surgical approach is not specified in 21/58 cases (36.2%), craniotomy was performed in 31/58 cases (53.4%), craniectomy in 5/58 cases (8.6%) and only in one case (1.7%) an endoscopic approach was performed. CEICH are usually located in an atypical site. CONCLUSIONS: There is not an association with anticoagulants and antiplatelets intake. Arteriovenous malformation is the most frequent cause. Surgery is suggested, and craniotomy is the most used approach even if further investigation should be directed to analyze the efficacy of endoscopic approach of these lesions, which may show favorable outcome.

"The Double S" Technique: Subfascial Dissection and Temporalis Muscle Splitting to Prevent Cerebrospinal Fluid Leak and Maximize Surgical Exposure.

BACKGROUND: Middle cranial fossa surgery commonly is approached either performing a subtemporal or a pterional craniotomy. To maximize a basitemporal region exposure, an adjunctive bone drilling could be required. In these cases, a watertight dura and temporalis muscle closure are mandatory. OBJECTIVE: To describe a modified temporalis muscle dissection in middle cranial fossa surgery to increase basitemporal region exposure while assuring a safe and effective closure thus avoiding cerebrospinal fluid (CSF) leakage. METHODS: A total of 8 patients have been enrolled. Five pterional and 3 subtemporal approaches were performed. In all cases, the novel subfascial muscle dissection and temporalis muscle splitting technique named "the double S technique," was performed to cut up the temporal muscle. RESULTS: In all cases, a subgaleal drainage was used and removed within 48 hours. No cases of postoperative CSF leak or hematoma collection were reported. CONCLUSIONS: The double S technique is a safe and effective alternative to enhance the basitemporal region exposure while avoiding the potential, common risk of CSF leak.

Current and future therapeutic perspective in chronic heart failure.

The incidence of heart failure is primarily flat or declining for a presumably reflecting better management of cardiovascular diseases, but that of heart failure with preserved ejection fraction (HFpEF) is probably increasing for the lack of an established effective treatment. Moreover, there is no specific pharmacological treatment for patients with heart failure with mildly reduced ejection fraction (HFmrEF) since no substantial prospective randomized clinical trial has been performed exclusively in such population. According to the recent 2021 European Society of Cardiology (ESC) guidelines, the triad composed of an Angiotensin Converting Enzyme inhibitor or Angiotensin Receptor-Neprilysin Inhibitor (ARNI), a beta-blocker, and a Mineralcorticoid Receptor Antagonist is the cornerstone therapy for all patients with heart failure with reduced ejection fraction (HFrEF) but a substantial gap exists for patients with HFpEF/HFmrEF. Despite the important role of the Renin-Angiotensin-Aldosterone System (RAAS) in heart failure pathophysiology, RAAS blockers were found ineffective for HFpEF patients. Indeed, even the new drug class of ARNI was found effective only in HFrEF patients. In this regard, a therapeutic alternative may be represented by drug stimulating the non-classic RAAS (ACE2 and A1-7) as well as other emerging drug classes (such as SGLT2 inhibitors). Reflecting on this global health burden and the gap in treatments among heart failure phenotypes, we summarize the leading players of heart failure pathophysiology, the available pharmacological treatments for each heart failure phenotype, and that in future development.

Largest neurosurgical social media group and its impact on communication and research.

BACKGROUND: The use of social media to communicate and disseminate knowledge has increased exponentially, especially in the field of neurosurgery. 'Neurosurgery cocktail' (NC) was developed by a group of young neurosurgeons as a means of sharing didactic materials and clinical experiences via social media. It connects 35.000 neurosurgeons worldwide on multiple platforms, primarily Facebook and Twitter. Given the rising utilization of social media in neurosurgery, the popularity of NC has also increased since its inception. In this study, the authors surveyed the social media analytics of NC for both Facebook and Twitter. Besides, we reviewed the literature on the use of social media in neurosurgery. METHODS: Facebook and Twitter metrics were extracted through each respective platform's analytics tools from December 2020 (earliest available date for data analysis) through January 2021. A literature search was conducted using PubMed (MEDLINE) and Scopus databases. RESULTS: On Facebook, as of January 2021, the group had a total of 25.590 members (87.6% male), most commonly (29%) between 35 and 44 years of age with over 100 countries were represented. As of January 2021, they had amassed 6457 followers on Twitter. During the last 28 d between December 2020 and January 2021, the account published 65 tweets that garnered a total of 196,900 impressions. Twelve articles were identified in our literature review on the use of social media within the neurosurgical community. CONCLUSIONS: NC is one of the most widely utilized neurosurgical social media resources available. Sharing knowledge has been broadened thanks to the recent social media evolution, and NC has become a leading player in disseminating neurosurgical knowledge.

Surgical Lip Remodeling Following Permanent Filler Injection: A Scoping Review.

ABSTRACT: Over the years, several techniques have been introduced to obtain permanent lip enhancement, such as the use of silicone lip implants or the off-label use of permanent fillers. Although some reports indicate that permanent lip filler is safe, many others describe early- and late-onset complications. The main issue with permanent lip fillers is the lack of a standard technique to correct undesirable results. The aim of this scoping review was to list and evaluate the surgical pathways described in literature to correct lip deformity resulted from the injection of permanent fillers. The methods and the inclusion criteria of this work were specified in advance and documented in a protocol, according to the PRISMA 2009 checklist. The research was carried out on electronic databases PubMed, Cochrane Library, and Scopus databases identifying articles from March 1991 to December 2020 and conducted up to December 23rd, 2020. Articles language was limited to English. The selection process identified 3 retrospective studies eligible for inclusion. 73 patients and a total of 111 lips (72 upper and 39 lower) were considered. Two early complications were identified, 1 suture dehiscence and 1 total lip mucosa necrosis. Surgical lip remodeling following permanent filler injection seems to be an effective approach although the surgical pathway needs to be customized per each patient. Complication rate seems to be coherent to lip surgery performed with reconstructive purposes. To confirm these data case-control studies with much wider cohorts are needed to reach statistical significance.

Transvascular Hydrolysis of Hyaluronic Acid Filler With Hyaluronidase: An Ex Vivo Study.

BACKGROUND: Despite the favorable safety profile of hyaluronic acid (HA) dermal fillers, side effects can occur. Skin necrosis is one of the most severe early-occurring complications resulting from accidental vascular impairment. Hyaluronidase (HYAL) is commonly used to degrade HA chains, allowing the degraded product to pass through vessels, and thus relieving the vascular obstruction. OBJECTIVE: The purpose of this study is to evaluate, in an ex vivo setting, the capability of HYAL to degrade crosslinked HA that was injected into human vessels. MATERIALS AND METHODS: During a neck dissection, a portion of the anterior jugular vein and facial artery was harvested. The vein and artery specimens were filled with 25 mg/mL of crosslinked HA filler. Each specimen was soaked in 0.5 mL of HYAL (300 IU/mL), in its own test tube, for 4 hours, after which the remaining HA was quantified. RESULTS: The remaining HA volume was found to be 0.02 mL in the vein segment and 0.002 mL in the artery segment. CONCLUSION: A single administration of HYAL may not be adequate to restore blood flow in the event of embolism, and relatively high doses of this enzyme must be injected hourly into the affected tissue until resolution is complete.

The Boundless World of Cranioplasty: A Multicenter Retrospective Study and Therapeutic Flow-Chart Patient-Specific Based.

BACKGROUND: Cranioplasty is both a functional and aesthetical therapeutic option. In the clinical scenario every cranioplasty's material is potentially qualified to achieve the goal of calvarian reconstruction but there is a lack of agreement about the optimum choice, especially between the heterologous ones. The choice of cranioplasty widely depends on surgeon's personal preferences. In this retrospective multicentric study a comparative analysis of hydroxyapatite or titanium cranioplasties was carried on analyzing the main factors considered by the surgeon to choose a material rather than another one. Our results and data were compared with those reported in the scientific literature and a flow-chart regarding the therapeutic approach in the choice of the most suitable cranioplasty was proposed and discussed. METHODS: The authors present a multicentric study considering 2 groups of patients who underwent 2 different kinds of cranioplasty: hydroxyapatite and titanium. The outcomes measures included the surgical timing and the maintenance of post-operative subgaleal drain. RESULTS: A total of 40 patients that had cranioplasty treatment were evaluated. The surgical technique was analyzed. In patients that underwent titanium cranioplasty we observed a reduction in the operative times and in subgaleal drain maintenance. In relation to the age, comorbidity, and neurological status a score, called most suitable material (MSM), was elaborated and a therapeutic algorithm is proposed. CONCLUSIONS: This study confirms the known advantages and drawback of titanium and hydroxyapatite prostheses. Thanks to the lessons learned from our experience on this field, we elaborated the MSM score that coupled with the therapeutic flow-chart proposed could address the choice of the MSM for a specific patient.

Acrometastases to the Hand: A Systematic Review.

Background and Objectives: The term acrometastases (AM) refers to secondary lesions sited distally to the elbow and knee, representing 0.1% of all bony metastases. By frequency, pulmonary cancer and gastrointestinal and genitourinary tract neoplasms are the most responsible for the reported AM. Improvements in oncologic patient care favor an increase in the incidence of such rare cases. We performed a systematic review of acrometastases to the hand to provide further insight into the management of these fragile patients. We also present a peculiar case of simultaneous acrometastasis to the ring finger and pathological vertebral fracture. Material and Methods: A literature search according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement was conducted using the PubMed, Google Scholar, and Scopus databases in December 2020 on metastasis to the hand and wrist, from 1986 to 2020. MeSH terms included acrometastasis, carpal metastasis, hand metastasis, finger metastasis, phalangeal metastasis, and wrist metastasis. Results: In total, 215 studies reporting the follow-up of 247 patients were analyzed, with a median age of 62 years (range 10-91 years). Overall, 162 out of 247 patients were males (65.6%) and 85 were females (34.4%). The median reported follow-up was 5 months (range 0.5-39). The median time from primary tumor diagnosis to acrometastasis was 24 months (range 0.7-156). Acrometastases were located at the finger/phalanx (68.4%), carpal (14.2%), metacarpal (14.2%), or other sites (3.2%). The primary tumors were pulmonary in 91 patients (36.8%). The average interval from primary tumor diagnosis to acrometastasis varied according to the primary tumor type from 2 months (in patients with mesenchymal tumors) to 64.0 months (in patients with breast cancer). Conclusions: Acrometastases usually develop in the late stage of oncologic disease and are associated with short life expectancy. Their occurrence can no longer be considered rare; physicians should thus be updated on their surgical management and their impact on prognosis and survival.

Hyaluronic Acid Injections to Correct Lips Deformity Following Surgical Removal of Permanent Implant.

One of the most attractive areas of the face are the lips, they are crucial for emotion and communication, both during animation and at rest. Throughout the years, several techniques to obtain permanent lip enhancement have been introduced, such as the use of nonresorbable fillers. The main problem related to permanent fillers is that undesirable results could not always be repaired; although lip sequelae can be addressed surgically, some surgeons will not perform this type of procedure due to its complexity and the lack of guidelines.In this paper, the authors present a case of a labial incompetence developed after lips implant removal performed elsewhere; after clinical examination the patient was planned for surgery, although during preoperative instrumental examination (chest X-ray) a solitary pulmonary nodule was noted; further investigation performed with needle biopsy revealed a lung cancer. For this reason, the surgical procedure planned for lip restoration was not performed; however, the patient asked for a minimally invasive procedure, thus to improve, although temporarily, her lips appearance.For the aforementioned reasons, the patient was treated just with hyaluronic acid injections achieving a pleasant result, solving also the labial incompetence at rest.To the best of the author's knowledge, this paper represents the first one describing the use of hyaluronic acid injections to restore lip competence following surgical removal of permanent implant.