Bishop Flap and Sigma Flap to Repair Surgical Defects in High-Tension Anatomical Regions. / Colgajo obispo y colgajo sigma para defectos quirúrgicos en zonas anatómicas de elevada tensión.

BACKGROUND: The reconstruction of surgical defects in high-tension anatomical regions is challenging due to the ischemia and subsequent necrosis associated with tension closure. Research on new flaps capable of closing these defects exerting less tension would be a tremendous advancement in dermatological surgery. PATIENTS AND METHODS: We conducted a multicenter, retrospective study that used 2 new flaps-the bishop and the sigma ones-to repair surgical defects in high-tension regions such as the scalp, lower extremities, and the nasal pyramid. The bishop flap was used in 9 patients, 5 of whom exhibited their lesion in the nasal pyramid, 2 in the legs and another 2 in the scalp. The sigma flap was used in 6 patients, 5 of whom exhibited scalp lesions and 1 leg lesion. RESULTS: Uneventful and excellent results were obtained in all 15 patients due to infection, dehiscence, or necrosis. CONCLUSIONS: Both the bishop and the sigma flaps are a good alternative to repair surgical defects in high-tension regions such as the scalp, lower extremities, or the nasal pyramid.

Nautilus Flap and Bullfighter Crutch Flap for the Repair of Periorificial Surgical Defects of the Face. / Colgajo nautilus y colgajo en muleta taurina para defectos quirúrgicos faciales periorificiales.

BACKGROUND: Reconstruction of surgical defects located close to eyelid edges, nostrils, or the mouth is challenging, as tension generated by direct closure or skin flaps in these sensitive regions tends to cause distortion. New repair techniques that prevent retraction may significantly improve outcomes. PATIENTS AND METHODS: Retrospective study of the use of 2 novel flap designs-the nautilus flap and the bullfighter crutch flap-to repair surgical defects in the peripalpebral, perivestibular, nasal, and perioral areas. The nautilus flap was used to repair 4 peripalpebral defects and 2 perioral defects, and the bullfighter crutch flap to repair 14 nasal ala defects. RESULTS: Cosmetic and functional outcomes were very satisfactory in all 20 patients, with no cases of ectropion, nasal vestibule collapse, or labial asymmetry. Necrosis did not occur in any of the cases. CONCLUSIONS: The nautilus and bullfighter crutch flaps appear to be excellent choices for reconstructing surgical defects in periorificial areas.

[Translated article] Nautilus Flap and Bullfighter Crutch Flap for the Repair of Periorificial Surgical Defects of the Face.

BACKGROUND: Reconstruction of surgical defects located close to eyelid edges, nostrils, or the mouth is challenging, as tension generated by direct closure or skin flaps in these sensitive regions tends to cause distortion. New repair techniques that prevent retraction may significantly improve outcomes. PATIENTS AND METHODS: Retrospective study of the use of 2 novel flap designs-the nautilus flap and the bullfighter crutch flap-to repair surgical defects in the peripalpebral, perivestibular, nasal, and perioral areas. The nautilus flap was used to repair 4 peripalpebral defects and 2 perioral defects, and the bullfighter crutch flap to repair 14 nasal ala defects. RESULTS: Cosmetic and functional outcomes were very satisfactory in all 20 patients, with no cases of ectropion, nasal vestibule collapse, or labial asymmetry. Necrosis did not occur in any of the cases. CONCLUSIONS: The nautilus and bullfighter crutch flaps appear to be excellent choices for reconstructing surgical defects in periorificial areas.

Attendee Survey and Practical Appraisal of a Telegram®-Based Dermatology Congress During the COVID-19 Confinement. / Congreso virtual de dermatología realizado a través de Telegram® durante el confinamiento de la COVID-19: organización y evaluación.

INTRODUCTION: The COVID-19 pandemic outbreak introduced dramatic changes in all our lives, daily practice, and medical conferences. In search of a tool to spread dermatologic knowledge during confinement, an online medical meeting was held on April 25th to 26th, 2020. In this study, we aimed to assess the characteristics, opinion and satisfaction of the attendees to a free-of-charge online congress. Secondarily, we intended to explain how this meeting was prepared. MATERIAL AND METHODS: Online survey administered to the attendees to an online congress organised via the Telegram® Messenger App. Its organisation and planning, which needed no financial support and was done by volunteer organisers, moderators and speakers, is described step by step. RESULTS: The satisfaction of both speakers and attendees was very high. All participants considered that this format had a great present and future, and most of them rated it as superior to regular face-to-face meetings. Female gender and predominantly private practice favoured this opinion. DISCUSSION: The COVID-19 pandemic has forced the cancellation of most scientific gatherings. This has been seen by some authors as an excellent opportunity, encouraging medical societies and organisations to lead the change to virtual meetings. Although confinement did not allow real contact, our online meeting showed it was possible to ensure interaction and participation between attendees, moderators and speakers. Dermatologists enjoyed some dermatologic science, even despite the extraordinary circumstances disrupting their daily clinical practice. Most of them felt they were participating in something new and compelling that many felt superior to traditional meetings.

[Expanding the portfolio of laboratory services in primary care does not increase the cost]. / Ampliar la cartera de servicio de laboratorio en Atención Primaria no incrementa el gasto.

INTRODUCTION: Our health care system gives crucial importance to Primary Care, since it is the first step in medical care. The family doctor becomes the filter of the diseases that they attend to and direct the patients to the different services according to their needs. Therefore, a very important role is granted that conflicts with the limitation in access to diagnostic tests. However, in reality it appears that the Primary Care professionals have limitations in order to access complementary tests. MATERIAL AND METHOD: After the publication of a list of accessible laboratory tests for Primary Care, the use of these tests was evaluated without any type of limitation, except for the adequacy of the tests to the diagnosis, as happens in the hospital during 6months, measuring the number of determinations and the relative units of value used. A comparison was made with a previous period and with the activity developed. RESULTS: After 6months of follow-up and with equal care activity, the use of laboratory diagnostic tests decreased by 24%, and the relative value units decreased by 10%. CONCLUSIONS: Access to the portfolio of laboratory services for Primary Care does not translate into an increase in spending, while sending a positive message about the role that primary health care should play in our health system.

Perineal trauma with anal avulsion: case report.

Anorectal avulsion is an exceptional rectal trauma. In this kind of lesions, the anus and the sphincter no longer join the perineum and are pulled upward. We present a case of 34-years-old patient who was admitted because of a pelvic-perineal trauma, presenting a partial anorectal avulsion, exposed femoral fracture with thigh's lacerated-contused wound. Our treatment included primary plastic of the internal anal sphincter with replanting of the rectum on the anal canal and a diverting loop sigmoid colostomy (SCS), so as to prevent sepsis. Closure of the protective SCS was performed four months after the trauma.

Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer.

BACKGROUND: Colonic J pouch reconstruction has been found to be associated with a lower incidence of anastomotic leakage than straight anastomosis. However, studies on this topic are underpowered and retrospective. This randomized trial evaluated whether the incidence of anastomotic leakage was reduced after colonic J pouch reconstruction compared with straight colorectal anastomosis following anterior resection for rectal cancer. METHODS: This multicentre RCT included patients with rectal carcinoma who underwent low anterior resection followed by colorectal anastomosis. Patients were assigned randomly to receive a colonic J pouch or straight colorectal anastomosis. The main outcome measure was the occurrence of major anastomotic leakage. The incidence of global (major plus minor) anastomotic leakage and general complications were secondary outcomes. Risk factors for anastomotic leakage were identified by regression analysis. RESULTS: Of 457 patients enrolled, 379 were evaluable (colonic J pouch arm 190, straight colorectal arm 189). The incidence of major and global anastomotic leakage, and general complications was 14·2, 19·5 and 34·2 per cent respectively in the colonic J pouch group, and 12·2, 19·0 and 27·0 per cent in the straight colorectal anastomosis group. No statistically significant differences were observed between the two arms. In multivariable logistic regression analysis, male sex (odds ratio 1·79, 95 per cent c.i. 1·02 to 3·15; P = 0·042) and high ASA fitness grade (odds ratio 2·06, 1·15 to 3·71; P = 0·015) were independently associated with the occurrence of anastomotic leakage. CONCLUSION: Colonic J pouch reconstruction does not reduce the incidence of anastomotic leakage and postoperative complications compared with conventional straight colorectal anastomosis. Registration number NCT01110798 (http://www.clinicaltrials.gov).

Treatment of Peristomal granulomatosis with a Neem and Red Hypericum Oil application: Case studies.

BACKGROUND: Peristomal granulomatosis is a chronic inflammatory disease of uncertain aetiology, and a high recurrence rate. It frequently occurs in patients with enterostomy and urostomy. The most frequent type affects the mucocutaneous junction, causing bleeding and painful nodular lesions, which complicate management of the ostomy pouching system. Currently, only invasive treatments are available, consisting in cauterisation or surgical removal of the granuloma. Our objective was to evaluate efficacy of a topic mixture oil, composed by a 1:1 of extracts of Neem and Red Hypericum; amongst its many therapeutical properties, it is proven to inhibit the over-granulation process. METHOD: Two clinical cases presenting typical peristomal granulomatosis were selected. On first access after recruitment, the patients underwent an accurate nursing anamnesis, a global assessment was carried out according to the Toven Method and an assessment of peristomal sore skin according to SACS 2.0. Granulomatosis wounds were treated with the oil mixture, applied on a hydrofiber pad, secured over the wound site by means of a transparent film. This allowed the release of active ingredients while ensuring the pouching system secure adhesion. The chosen protocol consisted in 2 dressing changes per week, while monitoring the granulomatosis wound evolution by means of a TOR Form validated data form and documenting progress by taking photographs. RESULTS: Initially a regression of the inflammatory process was observed, with significant decrease of bleeding and pain. Gradually, the proliferating lesions reduced in size (both width and extent), and eventually healed completely. The product was very well tolerated, even when in contact with the stoma mucous membrane. No recurrence signs were observed either at the follow up visit 15 days from end of treatment, and in clinical case N.2 equally none were present two months after treatment. CONCLUSIONS: Compared to conventional methods which are invasive, not resolving, and not tolerated by patients, the product was demonstrated to be an innovative therapeutical solution, easy to apply, with no side effects and well-liked by patients. The excellent results obtained require further confirmation and validation through new studies on a statistically significant number of cases.

Work Related Violence As A Predictor Of Stress And Correlated Disorders In Emergency Department Healthcare Professionals.

AIMS: The aim of the study was to investigate the frequency, type, causes and consequences of violence and aggression experienced by Emergency Department workers during their interactions with patient, their relatives or companions and whether the phenomenon of violence at work is a specific risk factor predicting stress and possible stress related pathologies in emergency health workers. The study proposes a model of effective intervention for the prevention and management of violence and stress. METHODS: A cross-sectional retrospective study was performed with a sample of 323 healthcare workers at Department of Emergency and Acceptance of Level II and the Psychiatric Services of Diagnosis and Care of the University Hospital Policlinico Umberto I, in Rome, Italy, between June 2016 and February 2017. Data collection was conducted by a psychiatrist by means of a questionnaire method administered to each participant and by carrying out individual interviews. The two questionnaires used, both the Health Violence Questionnaire (QVS) and the Workers' Stress Perception Questionnaire (SPQR) were designed ad hoc, after some test sessions intended for the creation of their content. RESULTS: Eighty-seven percent of emergency healthcare workers experienced workplace violence by patients or their relatives. More than half of healthcare workers reported multiple consequences on their emotional sphere, in particular female healthcare professionals and all those who have suffered frequent incidents of violence. Regarding the effects on lifestyle, one third reported an increase in consumption of tobacco, food and sleep disorders and changes from social relationships to social isolation and avoidance of some places. More than one third of healthcare workers reported consequences on their well-being and health, especially the female workers. Distress was associated with frequent workplace violence. Healthcare workers who experienced frequent violence indicated lack of support from hospital administration and ED management as barriers to reporting workplace violence. CONCLUSIONS: The study confirms the diffusion of the workplace violence by patients and/or their relatives against the emergency healthcare professionals, related to the gender, the professional qualification, the role in the organization and the workplace. Almost all male and female healthcare workers reported they had suffered the effects on lifestyle, working habits and wellbeing and health following the workplace violence. Precipitating factors to violent incidents identified by healthcare professionals are consistent with the research literature. Commitment from hospital administrators, ED managers and hospital security is necessary to facilitate improvement and ensure a safer workplace for ED healthcare workers. Our study emphasizes the importance of analyzing, in addition to general job demands, the specific job demands such as the phenomenon of violence, considered a key risk factor, predictor of stress and possible mental disorders in healthcare workers operating in high-risk environments. This study confirms the importance of application of the modified model by Brough and Biggs of integrated multidimensional intervention on the prevention and management of workplace violence and work stress and shall be implemented on all three levels: individual, organizational and situational. The study also highlights the need to implement support strategies for the victims of violence.

Pelvic floor rehabilitation for defecation disorders.

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence.

BACKGROUND: The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT. METHODS: Patients aged over 18 years with FI were included in a multicentre, single-blinded RCT. The primary endpoint was reduction in the median or mean number of FI episodes per week. Secondary endpoints were changes in measures of FI severity, and disease-specific and generic quality of life. Outcomes were compared between PTNS and sham stimulation after 9 weeks of treatment. RESULTS: A higher proportion of patients in the PTNS (13 of 29) than in the sham (6 of 30) group showed a reduction of at least 50 per cent in the median number of FI episodes/week (incidence rate ratio (IRR) 2·40, 95 per cent c.i. 1·10 to 5·24; P = 0·028), but not in the mean number of episodes/week (10 of 29 versus 8 of 30; IRR 1·42, 0·69 to 2·92; P = 0·347). The absolute median number of FI episodes per week decreased in the PTNS but not in the sham group (IRR 0·66, 0·44 to 0·98; P = 0·041), as did the mean number (IRR 0·65 (0·45 to 0·97); P = 0·034). Scores on the Cleveland Clinic Florida faecal incontinence scale decreased significantly in both groups, but more steeply in the PTNS group (mean difference -1·3, 95 per cent c.i. -2·6 to 0·0; P = 0·049). The aggregated mental component score of Short Form 36 improved in the PTNS but not in the sham group (mean difference 5·1, 0·5 to 9·6; P = 0·028). CONCLUSION: PTNS may offer a small advantage in the clinical management of FI that is insufficiently responsive to conservative treatment. The key challenge will be to identify patients who may benefit most from this minimally invasive surgical procedure. Registration number: NCT00974909 (http://www.clinicaltrials.gov).

Canakinumab for the treatment of TNF-receptor associated periodic syndrome.

INTRODUCTION: TNF-receptor-associated periodic syndrome is an autoinflammatory disorder caused by mutations in TNF receptor superfamily 1A gene. The molecular pathogenesis of TRAPS remains unclear; it is known that a key role is played by mutations in TNFRSF1A that induce the hypersecretion of pro-inflammatory cytokines as well as IL-1ß, resulting in uncontrolled inflammatory reactions. Furthermore, TNFRSF1A gene mutations result in intracellular stress ultimately leading to increased production of interleukin-1ß, but the exact mechanism referred to in the connection between TNFRSF1A mutation and increased release of IL-1ß, is still under study. This explains why IL-1 inhibition treatment can be effective in treating TRAPS patients. The purpose of this review is to discuss the safety and efficacy of canakinumab, a high-affinity human monoclonal anti IL-1ß antibody. Areas covered: The data obtained from case reports, case series, Phase II study and a phase III randomized, double-blind, placebo controlled trial have been analyzed. Efficacy and safety profiles of canakinumab are discussed. Expert commentary: Was discussed an overview of treatment options in TRAPS patients. The understanding of pathogenesis of TNF-receptor-associated periodic syndrome led to realize why TRAPS patients respond to IL-1 inhibition. Canakinumab became approved for the treatment in TRAPS patients very recently.