A comparison between vapor tunnel and virtual basket for the treatment of proximal ureteral stones using holmium:YAG laser (Cyber Ho): which is the best tool to reduce retropulsion?

PURPOSE: To compare vapor tunnel (VT) and virtual basket (VB) tools to reduce retropulsion in the treatment of proximal ureteral stones. METHODS: Patients with a single proximal ureteral stone were randomly assigned to holmium laser lithotripsy with the use of VT (Group A) or VB (Group B) tool. The 150W holmium:YAG cyber Ho generator was used. We compared operative time, dusting time, need for flexible ureteroscopy due to stone push-up and occurrence of ureteral lesions. The stone-free rate (SFR) and the occurrence of postoperative ureteral strictures were assessed. RESULTS: 186 patients were treated, of which 92 with the VT (49.5%, Group A) and 94 with the VB (50.5%, Group B). Mean stone size was 0.92 vs. 0.91 cm in Groups A vs. B (p = 0.32). Mean total operative time and dusting time were comparable between groups. 7 (7.6%) vs. 6 (6.4%) patients in Groups A vs. B required a flexible ureteroscope because of stone push-up (p = 0.12). Ureteral mucosa lesions were observed in 15 (16.3%) vs. 18 (19.1%) cases in the VT vs. VB group (p = 0.09). 1-Month SFR was comparable (97.8% vs. 95.7%, p = 0.41). We observed one case (1.1%) of postoperative ureteral stricture in the VT group vs. two cases (2.1%) in the VB group (p = 0.19). CONCLUSIONS: VT and VB are equally safe and effective tools in reducing retropulsion of ureteral stones. Operative time, dusting time and SFR were comparable. They also equally avoided stone push-up and prevented ureteral lesions, which may later occur in ureteral strictures.

Evaluation of the learning curve for Thulium laser enucleation of the prostate in a contemporary cohort.

PURPOSE: To assess the learning curve of Thulium laser enucleation of the prostate (ThuLEP) of a single surgeon. METHODS: Hundred patients suffering from benign prostatic hyperplasia were treated by the same surgeon. In all cases, a well-trained urologist was present in the operating room. Patients urinary function was assessed preoperatively using the International Prostate Symptoms Score (IPSS), maximum flow rate and Post-Void Residual volume. Preoperative prostate volume was recorded. Enucleation and morcellation efficiency and complication rate were evaluated. Patients were divided into 5 cohorts of 20 consecutive cases to assess changes in outcomes through time. RESULTS: Mean age of patients was 73.1 years (SD 17.5) and mean prostate volume was 89.7 ml (SD 55.1). Overall, mean enucleation and morcellation efficiency were 1.7 (SD 2.9) and 5.1 (SD 2.7) g/min. A statistically significant increase in enucleation efficiency was observed when comparing cohort 1 vs 2 (0.9 vs 1.3 g/min, p = 0.03) and cohort 2 vs 3 (1.3 vs 1.7 g/min, p = 0.02). A statistically significant increase in morcellation efficiency was observed when comparing cohort 1 vs 2 (2.8 vs 3.7 g/min, p = 0.02) and cohort 2 vs 3 (3.7 vs 4.9 g/min, p = 0.03). In both cases, no significant differences were observed when comparing the following cohorts. Complication rate showed no significant differences throughout the caseload. CONCLUSIONS: In our single-surgeon experience, we observed a learning curve of nearly 60 cases for the ThuLEP procedure in presence of a well-trained surgeon. Complication rate was low from the beginning of surgical experience.

Influence of CYP2C19 on Helicobacter pylori eradication in Brazilian patients with functional dyspepsia.

The aim of this study was to examine the effect of polymorphisms in the cytochrome P450 (CYP) 2C19 gene (CYP2C19) on the Helicobacter pylori eradication rate in Brazilian patients with functional dyspepsia. Adults diagnosed with functional dyspepsia based on the ROME III criteria and infected with H. pylori were recruited to this study. The patients were subjected to gastrointestinal endoscopy and the H. pylori status was defined when both urease test and histopathology results were negative or positive. The patients were treated with proton pump inhibitor-based triple therapy (omeprazole, amoxicillin, and clarithromycin). CYP2C19*2 and CYP2C19*3 were genotyped by polymerase chain reaction-restriction fragment length polymorphism. One hundred and forty-eight patients (81.8% women) with a mean (± SD) age of 46.1 (12.2) years were included in this study. Based on the CYP2C19 genotypes, the patients were classified as homozygous extensive metabolizer (HomEM; 67.6%), heterozygous extensive metabolizer (HetEM; 26.3%), or poor metabolizer (PM; 6.1%). The H. pylori eradication rates in patients with HomEM, HetEM, and PM were 85.0, 89.7, and 100.0% (P = 0.376), respectively. The included study population comprised a high frequency of patients carrying the HomEM genotype. Although the genotypes of CYP2C19 variants were not statistically significant, the results of this study suggest a possible effect of the PM genotype on the efficacy of H. pylori eradication.

A proposed mathematical model to help preoperative planning between RIRS and MiniPerc for renal stones between 10 and 20 mm using holmium:Yag laser (Cyber Ho): the stone management according to size-hardness (SMASH) score.

To evaluate the performance of a mathematical model to drive preoperative planning between RIRS and MiniPerc (MP) for the treatment of renal stones between 10 and 20 mm. Patients with a renal stone between 10 and 20 mm were enrolled. A mathematical model named Stone Management According to Size-Hardness (SMASH) score was calculated: hounsfield units (HU) χ stone maximum size (cm)/100. Patients were divided into 4 groups: RIRS with score < 15 (Group A), RIRS with score ≥ 15 (Group B), MP with score < 15 (Group C), MP with score ≥ 15 (Group D). Cyber Ho device was always used. Stone free rate (SFR) was assessed after 3 months. Complication rate and need for auxiliary procedures were evaluated. Between January 2019 and December 2021, 350 patients were enrolled (87, 88, 82 and 93 in Groups A, B, C and D). Mean stone size was 13.1 vs 13.3 mm in Group A vs B (p = 0.18) and 16.2 vs 18.1 mm in Group C vs D (p = 0.12). SFR was 82%, 61%, 75% and 85% for Groups A, B, C and D. SFR was comparable between Groups C and D (p = 0.32) and Groups A and C (p = 0.22). SFR was significantly higher in Group A over B (p = 0.03) and in Group D over B (p = 0.02). Complication rate was 2.2%, 3.4%, 12.1%, 12.9% for Groups A, B, C, D. RIRS and MP are both safe and effective. The mathematical model with the proposed cut-off allowed a proper allocation of patients between endoscopic and percutaneous approaches.Registration number of the study ISRCTN55546280.

The role of the dentist and the orthodontist in early diagnosis of Gorlin-Goltz syndrome: a cephalometric and photometric study.

AIM: The aim of this study was to analyse the facial characteristics and the craniofacial morphology in GGS patients in order to enable an early diagnosis. BACKGROUND: Gorlin-Goltz syndrome (GGS) is a autosomic dominant disease, characterised by basal cell carcinoma, palmar/plantar pits, maxillary and mandibular keratocysts and dental abnormalities. METHODS: Nine out of a sample of 24 GGS patients had complete cephalometric and photographic records at an average age of 8.7 years. Cephalometric and photometric analysis were carried out with standard analyses and compared with healthy patients matched for sex and age. CONCLUSION: Early diagnosis of GGS based on clinical features could be useful to identify the presence of keratocysts through x-ray examination proceeding with surgical removal at an early stage, limiting space occupying damages.

Pulsed-wave vs Continuous-wave Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP): A Comparison of Perioperative Outcomes.

OBJECTIVE: To compare intra and early postoperative outcomes between pulsed-wave and continuous-wave Thulium Fiber Laser Enucleation of the Prostate (PW-ThuFLEP vs CW-ThuFLEP) for the treatment of benign prostatic hyperplasia. METHODS: 238 patients with lower urinary tract symptoms due to benign prostatic hyperplasia underwent PW-ThuFLEP (118 patients) vs CW-ThuFLEP (120 patients). Preoperative prostate volume, adenoma volume, prostate-specific antigen (PSA), and hemoglobin values were recorded. International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual volume, and International Index of Erectile Function-5 score (IIEF-5) were assessed. Operative time, enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin drop, and postoperative complications were recorded. Micturition improvements and sexual outcomes were evaluated 3months after surgery. RESULTS: CW-ThuFLEP showed shorter operative time (61.5 vs 67.4 minutes, P = .04). Enucleation time (50.2 vs 53.3 minutes, P = .12), enucleation efficiency (0.8 vs 0.7 g/min, P = .38), catheterization time (2.2 vs 2.1days, P = .29), irrigation volume (32.9 vs 32.8L, P = .71), hospital stay (2.8 vs 2.6days, P = .29) and hemoglobin drop (0.38 vs 0.39 g/dL, P = .53) were comparable. No significant difference in complication rate was observed. At 3-month follow-up, the procedures did not show any significant difference in IPSS, Qmax, post-void residual volume, IIEF-5, and PSA value. CONCLUSION: PW-ThuFLEP and CW-ThuFLEP both relieve lower urinary tract symptoms equally, with high efficacy and safety. Operative time was significantly shorter with CW-ThuFLEP, but with a small difference with low clinical impact. Enucleation time, enucleation efficiency, catheterization time, irrigation volume, hospital stay, hemoglobin and PSA drop, complication rate, and sexual outcomes showed no differences.

The gracilis muscle and its use in clinical reconstruction: an anatomical, embryological, and radiological study.

The gracilis muscle is used widely in reconstructive surgery, as a pedicled or as a free microsurgical flap, for soft tissue coverage or as a functioning muscle transfer. Many studies, based on cadaver dissections, have focused on the vascular anatomy of the gracilis muscle and provided different data about the number, origin, and caliber of its vascular pedicles. Computed tomographic (CT) angiography of both thighs of 40 patients (35 males and 5 females, mean age: 63 years) have been analyzed to provide a detailed anatomical description of the arterial supply of the gracilis muscle. The gracilis muscle had a mean length of 41 +/- 2.1 cm. The principal pedicle enters the gracilis muscle at a mean distance (+/-SD) of 10 +/- 1 cm from the ischiopubic attachment of the muscle. Its caliber shows a mean value of 2.5 +/- 0.5 mm, and it is statistically larger when originating directly from the deep femoral artery (45%) than from its muscular branch supplying the adductors, i.e., the "artery to the adductors" (46%) (P < 0.01). A significant correlation between the caliber of the artery of the main pedicle and the volume of the gracilis muscle was found (P < 0.01). The mean number of distal accessory pedicles is 1.8 (range, 1-4,) and the artery of the first of these pedicles shows a mean caliber of 2.0 mm. There is no correlation between either the number or the caliber of the artery of the accessory pedicles and the volume of the gracilis muscle. CT angiography, providing detailed images of the muscular and vascular structures of the thigh of each patient, could be a useful preoperative study for the reconstructive surgeon. It would allow a personalized planning of a gracilis flap, reducing the risk of iatrogenic damage.

Multiple symmetric lipomatosis: a defect in adrenergic-stimulated lipolysis.

The cellularity of normal and lipomatous adipose tissue and its response to different lipolytic agents have been studied in a group of 10 patients with multiple symmetric lipomatosis (MSL). In MSL patients, fat cells from lipomatous tissue are smaller than normal, uninvolved adipocytes. Fat cells from lipomata show minimal variations in size following conspicuous increase of lipomatous masses. These findings suggest that the growth of lipomata can be attributed to the neoformation of adipocytes rather than to an enlargement in the single fat cells. The incidence of reduced glucose tolerance and of hyperlipoproteinemia is similar in MSL patients and in controls. A significant reduction in plasma free fatty acids was observed in MSL patients after a 24-h fast as well as after noradrenaline infusion. A specific insensitivity of lipomatous tissue to the lipolytic effect of noradrenaline and isoprenaline was observed in vitro, as indicated by glycerol release in the medium, whereas response to theophylline and to dibutyryl cyclic AMP was retained. The lipolytic response to catecholamines was retained. The lipolytic response to catecholamines was normal in the nonlipomatous adipose tissue of MSL patients. In basal conditions ATP concentrations were similar in normal and in lipomatous adipose tissue. However, incubation with noradrenaline induced a significant fall in intracellular ATP levels in normal tissue, whereas no variations were observed in lipomatous tissue. Theophylline, instead, induced a prompt and significant decrease in intracellular ATP levels in lipomatous tissue. These observations indicate that the block in catecholamine-stimulated lipolysis in lipomatous tissue of MSL patients can be localized at a level preceding the formation of cyclic AMP.

How to early recognize mood disorders in primary care: A nationwide, population-based, cohort study.

BACKGROUND: Mood disorders are managed predominantly in primary care. However, general practitioners' (GPs) ability to detect and diagnose patients with mood disorders is still considered unsatisfactory. The aim of the present study was to identify predictors for the early recognition of depressive disorder (DD) and bipolar disorder (BD) in general practice. METHODS: A cohort of 1,144,622 patients (605,285 women, 539,337 men) was investigated, using the Health Search IMS Health Longitudinal Patient Database. Predictors of DD or BD were identified at baseline encompassing somatization-related features, lifestyle variables, medical and psychiatric comorbidities. Patients were followed up as long as the following events occurred: diagnoses of DD or BD, death, end of the registration with the GP, end of the study period. RESULTS: We found an incidence rate of DD or BD of 53.61 and 1.5 per 10,000 person-years, respectively. For both the conditions, the incidence rate grew with age. Most of the lifestyle variables and medical comorbidities increased the risk of mood disorders. The strongest effect was found for migraine/headache (HR [95% CI]=1.32 [1.26-1.38]), fatigue (1.32 [1.25-1.39]) irritable bowel syndrome (1.15 [1.08-1.23]), and pelvic inflammation disease (1.28 [1.18-1.38]). CONCLUSIONS: Several predictors, in particular somatic symptoms, could be interpreted as an early sign of a mood disorder, and represent a valid indication for the GPs diagnostic process of mental disorders.

The effect of histamine and H1 and H2 receptors on prolactin and luteinizing hormone release in humans: sex differences and the role of stress.

The present experiments were performed to investigate the possible role of histamine and its receptors, H1 and H2, in the control of PRL and LH release in normal adult humans of both sexes. Histamine infusion (200 microgram, iv, in 15 min) induced PRL and LH release in men; in women, histamine inhibited LH release without affecting PRL release. Two H1 antagonists, dexchlorpheniramine (10 mg, iv) and promethazine (50 mg, im), reduced PRL release in both sexes, stimulated LH release in men, and inhibited LH release in women. Cimetidine, an H2 antagonist (400 mg, iv), elicited PRL release in both sexes, more consistently in females than in males, and was without effect on LH release in either sex. These data suggest that in humans, the effect of histamine on PRL release is linked to H1 and H2 receptors, which respectively stimulate and inhibit PRL release independently of sex. The effect of histamine on LH release appears to depend on sex and to be mediated only by H1 receptors. To rule out the possibility that the effects of histamine are merely due to a nonspecific stress reaction, we have evaluated PRL and LH release in otherwise normal men and women undergoing surgery for gallstones. Surgery was accompanied by PRL release in both sexes, more evident in women, and by LH release only in men. These results indicate that the effect of histamine on PRL and LH release in humans is linked to sex and H1 and H2 receptors and is not due to stress; further studies are required to clarify the possible mechanism and site of action of histamine in modifying PRL and LH release in humans.

Very early nutrition supplementation in burned patients.

We studied some metabolic and hormonal effects of a very early nutrition supplementation in burned patients. The patients were divided into two groups of 10 patients each. Supplementation in the first group, the very early nutritionally supplemented (VENS) group, was started immediately after admission, ie, after 4.4 +/- 0.5 h (mean +/- SEM) from the injury; it was started after 57.7 +/- 2.6 h from the injury in the second group (control group). Hormonal and metabolic indices were recorded every 4 d up to 28 d. In the VENS group, the nitrogen balance became positive in 8.8 +/- 4.1 d whereas it took 24.1 +/- 6.9 d in the control group (p less than 0.05). Urinary catecholamine excretion and plasma glucagon concentrations were lower during the first 2 wk of observation in the VENS group compared with the control group. Insulin concentrations were significantly higher on the fourth and eighth days in VENS patients and plasma cortisol concentrations were similar in both groups.

Aminotransferase changes in burned patients.

The time course of serum transaminases (alanine aminotransferase and aspartate aminotransferase) has been followed in 30 selected consecutive patients presenting burn sizes ranging from 10% to 95% of the total body surface (mean 43.13) and a survival index from 0.99 to 0.00 (mean 0.59). The results show that in all the patients both transaminases change in parallel, increasing in 18 patients (60%). In nearly all patients both enzymes increase during the second week after injury and aspartate aminotransferase increases later than alanine aminotransferase. The higher transaminase levels are noted in moderately ill patients. No clear correlation between the overall increase of transaminases and the extent of burned surface area has been found. We conclude that functional liver alterations mostly contribute to the increase of serum transaminases in burns.

Early detection of melanoma: an educational campaign in Padova, Italy.

To evaluate a public campaign for the early referral and treatment of cutaneous melanoma, an educational programme based on self-selection by subjects was organized in Padova, Italy in 1991. In the period from 1991 to 1996, 90,000 leaflets containing information on naevi, melanoma and skin self-examination were mailed to each household, reaching a population of 243,000 subjects. A total of 2050 individuals requested a skin check as a result of the leaflet. Most were at low risk, the majority being female (68%) and aged under 40 years (51.6%), with no risk factors (58.3%). One hundred and ninety subjects were referred for surgery for pigmented and non-pigmented suspect lesions. Histological diagnoses, obtained for all lesions, comprised 13 melanomas, 17 dysplastic naevi, 17 basocellular carcinomas, 140 pigmented benign lesions and three lesions of other types. The percentage of thin melanomas (< 1.50 mm) was 92.3%. Three hundred and fifty patients considered at risk at the first skin examination attended regular follow-up examinations. The sensitivity and predictive positive value of the visual examination were 92.8% and 6.8%, respectively. The impact of this campaign was evaluated in the Local Health District of Padova, comparing data from the pre-campaign period (1987-1990) with those from the campaign period (1991-1996); a trend towards a lower stage was observed (mean thickness 2.0 mm versus 1.50 mm; P < 0.02).

Heart rate and metabolic response to burn injury in humans.

BACKGROUND: Although frequently done, estimating the energy requirements of individual burn patients without measuring their resting metabolic rate is a less than satisfactory method of evaluation. METHODS: We tested whether heart rate, which relates to the energy expenditure during physical activity, is also associated with postburn hypermetabolism (calculated as percentage increase of resting metabolic rate above the predicted normal fasting resting metabolic rate). Twenty-three patients [12 men and 11 women, aged 38 +/- 13 years (mean +/- SD); weight, 71.6 +/- 14.8 kg; body mass index, 25.4 +/- 3.6; total burn surface area, 35.3 +/- 17.8% (percentage of body surface)] were studied weekly for 3 weeks after an overnight fast. RESULTS: Measured resting metabolic rates and heart rates were 2016 +/- 497 kcal/d, 101 +/- 13 bpm (n = 19); 2231 +/- 485 kcal/d, 107 +/- 13 bpm (n = 18); and 1903 +/- 598 kcal/d, 99 +/- 14 bpm (n = 11) for weeks 1, 2, and 3, respectively. Postburn hypermetabolism was +36% +/- 19%, +55% +/- 27%, and +36% +/- 35% in the first, second, and third week, respectively. In each week postburn hypermetabolism correlated with heart rate (r = 0.65, p = .003; r = 0.69, p = .001; and r = 0.80, p = .002, respectively). Only in the second week did postburn hypermetabolism correlate with total burn surface area (r = 0.52, p = .02); there was no correlation with body temperature. In a multiple regression analysis, predicted resting metabolic rate, heart rate, and total burn surface area together explained 77% of all of the variance observed in the 48 fasting resting metabolic rates that were measured in the study (r2 = 0.77, p < .0001), and each of these variables also had a significant partial correlation with fasting resting metabolic rates (r2 = 0.45, p < .0001; r2 = 0.29, p < .0001; and r2 = 0.03, p < .03, respectively). CONCLUSIONS: In burn patients, variability in heart rate is associated with a significant part of postburn hypermetabolism variability. Therefore, heart rate may be considered a useful variable to be used for the evaluation of the energy requirements of severely burned patients.

Oral 5-fluorouracil in squamous cell carcinoma of the skin in the aged.

Multiple or recurrent squamous cell skin carcinoma is a rare tumor in the aged. These patients are currently treated with 5-fluorouracil (5-FU) cream as a local chemotherapy; in cases in which the disease progresses, few treatments are available. Two reports deal with the treatment of progressive squamous cell skin carcinoma with systemic 5-FU, but in only eight patients age less than 70 years. We prospectively investigated oral 5-FU therapy in 14 consecutive patients (average age 76 1/2 years) with histologically proven squamous cell skin carcinoma. The disease was aggressive, multiple, or recurrent and had not been eradicated by surgery, radiation therapy, topical 5-FU cream, and non-5-FU chemotherapy. Oral 5-FU was administered as mannitol-coated 5-FU tablets at the daily dose of 175 mg/m2 for 3 weeks every 5 weeks. Toxicity, effectiveness, quality of life, and compliance to therapy were evaluated. Total cycles amounted to 55 (range: 2-6, mean: 4 for each patient) at an average dose intensity of 740 mg/m2/week for from 12 to 36 weeks. Only gastrointestinal toxicity World Health grade I occurred. Quality of life and compliance to therapy were 90%. Therapy induced measurable improvement in nine patients (64.3%): two partial remissions (14.3%), three minimal remissions (21.4%), and four arrests of disease (28.6%) with a median duration of 30+ months. The study ended because of a lack of patients. We can conclude that, if elderly patients require chemotherapy because of progressive multiple or advanced squamous cell skin carcinoma, appreciable results may be obtained with oral 5-FU as a single agent.

Surgical repair of an anterior tibialis muscle hernia with Mersilene mesh.

The most frequent muscle hernia of the lower extremities is the anterior tibialis muscle hernia. A number of surgical procedures are available for the treatment of symptomatic anterior tibialis muscle hernias. However, in case of a large fascial defect, their use may be unfeasible or inconvenient. Moreover, current surgical procedures are prone to the risk of an anterior tibial compartment syndrome. The use of a synthetic patch could provide an alternative, particularly for large defects. In this paper we report the repair of a large, symptomatic, long-standing anterior tibialis muscle hernia with polyester mesh (Mersilene) fixed to the edges of the defect (muscular fascia and tibial periosteum). This simple procedure provided excellent functional results and a good cosmetic appearance without complications and sequelae.

Spontaneous regression of subcutaneous metastasis of cutaneous melanoma.

A case is presented of a 44-year-old Caucasian man who was operated on in October of 1988 for a cutaneous melanoma in his trunk and who in the space of 1 year manifested a single subcutaneous nodule compatible with a metastasis of melanoma by fine-needle aspiration biopsy. No other abnormal findings were revealed by physical and instrumental examinations. During the subsequent hospitalization, we witnessed (in conjunction with the occurrence of painful symptoms in the hands of an inflammatory nature) the total, progressive, spontaneous regression of the metastasis, which was confirmed by the clinic and the tests. After 15 months of follow-up, the patient has not shown any further signs of illness.

[Use of a latissimus dorsi myocutaneous flap in locally advanced breast cancer]. / L'uso del lembo miocutaneo di gran dorsale nel carcinoma mammario localmente avanzato.

Locally advanced breast cancer has a poor prognosis. Skin infiltration, ulceration and invasion of the chest wall, in the absence of distant metastases, worsen dramatically the quality of life. The Authors report 4 cases of one time wide resection and reconstruction using a pedicled myocutaneous flap of latissimus dorsi. This technique allowed good and rapid palliation of local symptoms.

The burn disease: a disease of great value in the cultural heritage of plastic surgery.

In 1961 I began my career as a plastic surgeon at the Department of Plastic Surgery of the Civic Hospital of Padua. In those years, the department was headed by its founder, Prof. G. Dogo, who had just gained his independence to work within the discipline of surgery. Its key feature consisted, at its core, in an entirely new section for those times: the Burn Centre, later known as the "Intensive Care Unit for Acute Burn Victims." At that time, Prof. Masellis, the founder of the Mediterranean Burn Club, was also working among us. The department was still dealing with the disastrous traumatic pathologies that the Italian population had from the Second World War. The beds were still largely occupied by patients suffering from war injuries caused by bomb explosions and fires. These were the reason for the creation of the Burn Centre and subsequently for the promotion of the establishment of a department of plastic surgery. I therefore had the opportunity to see a multitude of different clinical cases and to experiment with the various operation techniques known to plastic surgeons at the time. But it was not only the surgical aspect that fascinated me; I was fascinated by the burn as a disease - the extraordinary problems of their pathophysiology and the logic of treating them, generally and locally - no longer as had been suggested by vague suppositions, but by suggestive hypotheses based on clinical and experimental observations. Over the years, the skills involved in plastic surgery have expanded: its numerous therapeutic procedures have been applied to the treatment of many other diseases. But the burn-as-disease was always at the top of my cultural interests. It always had something to teach me, whether clinically, scientifically or ethically. Yes, even ethically, because the burn patient, like few others who are ill, truly challenges his physician's ethical core and moral strength. The contents of this piece of writing stem from "opinions" that the author has had in the practice of his profession while "listening and reading" everything that has happened to him during his work as a plastic surgeon over half a century. These opinions formed bit by bit; only now am I attempting to verify and justify them, intentionally seeking the bibliographic testimony and opinions of others.