Oral cavity defect reconstruction using anterolateral thigh free flaps.

BACKGROUND: It is estimated that about 92,000 new cases of oral cavity and pharyngeal cancer occurred in Europe in 2008. During the past 30 years in the USA and Western Europe, the prognosis for oral cancer has clearly improved thanks to the possibility of reconstruction with microvascular free flaps, resulting in broader and safer resections. The anterolateral thigh flap is now being increasingly employed for this goal. The aim of the present work is to evaluate the anterolateral thigh free flap in the reconstruction of oral cavity defects. MATERIALS AND METHODS: Between July 2004 and February 2009, we harvested 73 free flaps for the reconstruction of soft tissue defects in the oral cavity of 70 patients at our institution. The oncological and functional results in these 70 patients were evaluated, particularly in those patients reconstructed with anterolateral thigh (ALT) free flap. We also evaluated the quality of life using the FACT-H&N questionnaire. RESULTS: We observed no significant differences in functional and oncological results between patients reconstructed by ALT and patients reconstructed with other flaps. Swallowing may be more difficult in patients who undergo adjuvant irradiation. CONCLUSIONS: In our opinion, the very low morbidity at the donor site, great versatility, and very long pedicle make the ALT free flap the first choice for reconstructing soft tissue defects in the oral cavity (particularly mobile tongue).

PROPAT: a study to improve the quality and reduce the cost of diabetes care.

OBJECTIVE: In PROPAT we implemented an integrated approach to diabetes care designed to improve the quality and reduce the cost of care. STUDY DESIGN AND METHODS: PROPAT was a case-control study matching patients by age and gender (diabetes:control ratio 1:2) within IOMA, a public employment-based health maintenance organization (HMO) of the Province of Buenos Aires, Argentina. Costs were evaluated using prevalence data from an HMO perspective. We currently report clinical and biochemical data and costs from the first 297 patients enrolled who completed 1 year in PROPAT, and compare them with those derived from control patients. RESULTS: All recommended practices recorded as care provided at baseline increased significantly 1 year after implementing PROPAT, with a parallel significant improvement in several clinical and biochemical parameters, and markedly lower total annual per capita costs. CONCLUSIONS: These results demonstrate that the implementation of a comprehensive diabetes care program can simultaneously improve quality while reducing costs.

Radiofrequency volumetric inferior turbinate reduction: long-term clinical results.

The aim of our study was to assess long-term results of radiofrequency volumetric tissue reduction of inferior turbinates (RVTR). We performed a prospective long-term longitudinal evaluation of 305 patients affected by rhinitis (114 allergic and 191 non-allergic) who were unresponsive to medical treatment and underwent RVTR (January 2004 - December 2010). Subjects were followed for a mean period of 39.70 ± 19.41 months (range 24-60). Patients completed the NOSE-scale questionnaire pre- and post-operatively after 1 month and yearly for 5-years. Recurrence was assumed if the post-operative total NOSE score increased by at least 75% during follow-up and the patient restarted medical treatments. Estimation of relapse over time was performed by Kaplan-Meyer analyses. We documented overall good satisfaction of patients regarding the procedure, with a good rate of pain control and a low rate of complications. Post-operatively there was a significant improvement in nasal stuffiness, nasal obstruction and mouth breathing (p < 0.05). We observed a worsening trend for symptoms after 36 months with progressive increasing rate of recurrences that were significantly higher in allergic than non-allergic patients (p < 0.05). We also observed a slight worsening trend of global satisfaction of patients. Our study confirms the minor discomfort and low risk of side effects of RVTR. Our data showed good efficacy of the procedure in the majority of patients for at least 36 months after surgery, and in fact in this time period the cumulative probability to remain relapse-free was up to 0.8. In the following 2 years, we observed a worse temporal trend in term of recurrence rate, and in particular in allergic patients with a significant difference vs non-allergic individuals (p < 0.05).

Sensory dysfunction and quality of life after great auricular nerve sacrifice during parotidectomy: our experience.

OBJECTIVE: This study aimed to investigate the impact on patients' quality of life of great auricular nerve sacrifice during parotidectomy. METHODS: A retrospective review was conducted of 191 consecutive patients who underwent parotidectomy with great auricular nerve sacrifice between 2006 and 2011. Residual sensory dysfunction and its impact on quality of life was analysed using an eight-item quality of life survey. RESULTS: In all, 139 out of 191 patients (72.8 per cent) experienced one or more abnormal sensations in the ear or neck region after surgery. There was a moderate inverse correlation between the number of abnormal sensations and time elapsed since surgery. Moreover, the degree of discomfort correlated significantly with the frequency of symptom occurrence (p < 0.001), duration of the abnormal sensation (p < 0.001) and size of the affected area (p < 0.001). CONCLUSION: Sacrifice of the great auricular nerve has only a small impact on patient quality of life; their daily activities are not significantly affected.

Hospitalization and re-hospitalization of people with and without diabetes in La Plata, Argentina: comparison of their clinical characteristics and costs.

OBJECTIVE: To examine the prevalence, characteristics, and costs of hospitalization and re-hospitalization of diabetic and non-diabetic patients in La Plata, Argentina, and to compare the data with those of developed countries. RESEARCH DESIGN AND METHODS: We studied all in-hospital registries of diabetic patients enrolled in a health maintenance organization of the Province of Buenos Aires (IOMA, November 1996). For each diabetic patient (127 persons), the characteristics of two other hospitalized non-diabetic patients matched by age and gender were simultaneously recorded. RESULTS: Of the 2200 recorded hospitalizations, 5.8% were for diabetic patients, accounting for 10.5% of the hospitalization cost. Cardiovascular diseases were the major cause of hospitalization in both groups. The per capita hospitalization cost of diabetic patients was significantly higher: 1628.5+/-1754.0 US dollars versus 833+/-842 US dollars; P=0.00002. Percent re-hospitalizations were five and a half times higher in diabetic patients (P=0.0001), and significantly associated with history of severe episodes of acute (odds ratio: 3.61; 95% CI: 1.11-11.70; P=0.03) and chronic (odds ratio: 4.26; 95% CI: 1.60-11.29; P=0.004) complications. CONCLUSIONS: The combination of higher and longer hospitalization rates and frequent re-hospitalizations resulted in increased costs for our diabetic population. Implementation of care programs based on education (for physicians and patients) could effectively decrease current and future costs of the disease.

The amino acid cerebral pool after toxic doses of lidocaine and mexiletine. An experimental study on guinea pigs.

Lidocaine and Mexiletine are two anti-arrhythmic drugs which when administered in toxic doses cause alterations in the central nervous system (convulsions, tremors, coma). An experimental study was carried out to clarify some neurological side-effects caused by these two drugs, by studying the variations of the brain amino acid pool. With Lidocaine one can observe an increase of phenyl-alanine and tyrosine, a decrease of glycine, GABA, alanine, aspartate and glutamate, while taurine and ammonia showed no significant changes. After Mexiletine one can observe an increase of ammonia, a decrease of GABA, glutamine, glycine and alanine, while glutamate, taurine, phenyl-alanine and tyrosine remain within normal values. In conclusion, on the basis of the data obtained by comparing the two drugs, one could say that Lidocaine has a greater interference on the catecholaminic precursors which are little influenced by Mexiletine. For the rest, the data obtained are practically super- imposable .

The combined use of hyperbaric oxygen, antibiotics and surgery in the treatment of gas gangrene.

The clinical course and treatment of 21 critically ill patients suffering from gas gangrene are reported. Analysis of the results has underlined the importance of intensive care and hyperbaric management to prevent the evolution of disease and to improve patients' clinical conditions for surgical procedures.

Outpatient hysteroscopy in the diagnosis of neoplastic and preneoplastic lesions of the endometrium.

The results of a study performed on a case series of 250 women treated in our out-patient department for abnormal uterine bleeding are reported. Half of these patients (125) were 45 years of age or over and therefore at risk of adenocarcinoma or endometrial hyperplasia while the other half were under 45 years of age. All the patients were submitted to hysteroscopic examination as out-patients (no important side-effects occurred), together with cytologic and/or histological examination of the endometrium. This procedure revealed no disease in 59 cases (23.6%) and the presence of one or more benign conditions in 188 patients (75.2%) (inflammation, polyposis, myomatosis, endocervical or uterine adenomiosis, endometrial hyperplasias, dysfunctional patterns, intrauterine foreign bodies). Endometrial adenocarcinoma was diagnosed in 3 patients (1.2%). The discovery of 3 cases (1.2%) of adenocarcinomas and 62 cases (24.8%) of endometrial hyperplasias (58 simple glandular hyperplasia, 3 cystic-glandular hyperplasias and 1 polypoid hyperplasia) emphasive the reliability of hysteroscopy in the diagnosis of endometrial neoplasias and their precursors.

Endometrial carcinoma. Clinical and pathological correlations with survival and surgical treatment.

From 1978 to 1985 a total of 151 patients were treated for endometrial carcinoma. Of these, 25 patients underwent extrafascial abdominal hysterectomy and pelvic lymphadenectomy, 25 were treated according to Wertheim procedure and pelvic lymphadenectomy and 32 underwent intrafascial abdominal hysterectomy; 62 women underwent vaginal surgery, 7 of whom according to Shauta. A correlation between the degree of myometrial invasion, histological grading, hystological type and stage of the tumor showed no statistically significant difference. The 5-year actuarial survival rate was found to be 76.5%. A comparison between survival and age of patients showed a significant difference in the survival (p less than .01) of the group less than 55 years as compared to the older age group. As far as the surgical treatment instituted is concerned, no statistical difference in survival was found between patients operated vaginally and those operated abdominally (p greater than .05). The site of recurrences were then analyzed in 22 patients, 50% were local recurrences, and the remaining distant metastases. Of these only one patient was cured and is still free of disease 5 years after recurrence. The criteria used to select patients for vaginal surgery are also indicated.

[Evaluation and cost of the health care process of diabetic patients]. / Evaluación y costos del proceso de atención de pacientes diabéticos.

The aim of this randomized trial o evaluate the quality and cost of health care provided to people with diabetes in a Public Employment-Based Health Insurance program in La Plata, Argentina. Consequently, 1590 diabetic patients were interviewed and the data obtained were analyzed using univariate and multiple logistic regression. Patients treated without insulin (48%) were significantly older and reported obesity, hypertension, and macroangiopathy more frequently than those treated with insulin. Hospitalization rates were significantly higher in insulin-treated patients. These rates were comparable in people without complications or microangiopathy alone, but increased significantly in patients with macroangiopathy. Many recommended practices were not performed during the preceding year: foot exams (20-30%), referral to ophthalmologist (21-29%), and HbA1c test (60-78%). In contrast, the rate of medical testing and visits was high, even in uncomplicated patients, resulting in an estimated cost of the care 22.7% higher than it would have been if the tests and procedures had been performed as recommended by international guidelines. We conclude that the current care for diabetes is inefficient and expensive; the implementation of data-based guidelines would result in a more effective allocation of resources, thus improving the quality of diabetes care and overall quality of life.

[Acute poisoning with organophosphoric esters. A case in a 24-year-old patient]. / Intossicazione acuta da esteri organofosforici. Un caso in una paziente di 24 anni.

A case of acute organophosphate poisoning (Malatox P20) in a 24-year-old woman, is reported. The signs and symptoms of acute poisoning are described and a rational approach to specific treatment is discussed.

[Optic fiber endoscopy in childhood with facial mask]. / Endoscopia a fibre ottiche in età infantile con maschera facciale.

Flexible fibroscopy is the method of choice in the diagnosis of upper airway (UA) pathologies. Some Authors believe that it should be carried out under local anaesthesia even in children less than one year of age. In this article, the Authors report on their experience with general anaesthesia, using an airway mask that simultaneously allows the flexible endoscope to be inserted and the patient to be ventilated. The study was carried out in the period 2000-2001 in 32 subjects, 18 males and 14 females between 2 and 12 months of age who presented different degrees of stridor and dyspnoea. 18 patients were affected by laryngomalacia, 6 presented bilateral paralysis of the vocal cords, 3 had a paralysis of the left vocal cord, 3 were suffering from congenital anomalies of the epiglottis and 2 had normal larynx from the point of view of morphology and motility. The method described is easy to perform and allows the subglottid area to be carefully evaluated, prolonging, if necessary, procedure time without risking hypoventilation-induced hypoxemia; carrying out the examination on a sedated patient furthermore reduces the likelihood of complications. The Authors therefore recommend that in all infants under one year of age, endoscopy of the upper airways be effected under general anaesthesia with an airway mask, reserving the execution of the same procedure under local anaesthesia to cases involving older children.

[The non-recurrent inferior laryngeal nerve. Surgical experience]. / Il nervo laringeo inferiore non ricorrente. Esperienza chirurgica.

During the performance of 1018 thyroid operations, 1497 recurrent laryngeal nerves were identified and exposed. Of the 773 visualized nerves on the right side, 2 were found to be non recurrent (0.26%). This abnormality may represent a pitfall during thyroidectomy even for very experienced thyroid surgeons. We emphasize that the exposure and preservation of this vital structure is the standard of care and an essential component of routine dissection in thyroid surgery.

[Drainage in thyroid surgery]. / Il drenaggio nella chirurgia della tiroide.

Bleeding represents a rare complication of thyroid surgery but when it occurs it may be life-threatening. To prevent this complication drainage is widely used. However no study has demonstrated the drains' value and recent reports have questioned its benefits. Therefore we have analyzed our experience of a 10 year-period in which 1.217 thyroidectomies were performed by the same surgical team and prophylactic routine drainage was always adopted. In 13 patients (1.06%) a benign hematoma occurred with spontaneous remission. In 6 patients the bleeding was severe and compressive hematoma occurred; it required surgical re-exploration. Such a complication is unusual in the neck surgery (0.49% in the authors' series) performed by experienced surgeons and when life-threatening hematomas do occur they depend on various uncontrolled factors and drainage is often not helpful. Otherwise a meticulous haemostatic technique is necessary and patients should be observed very closely during the few first hours following surgery on the thyroid gland. Therefore on the basis of the analysis of their series, although it is not always possible to prove the benefit of the drainage, the authors suggest its indication in the neck surgery, as in other fields with dead space, to remove blood and secretions reducing postoperative complications. They have never observed wound infections and patients were discharged within 72 hours.

[Hyperthyroidism and carcinoma of the thyroid gland]. / Ipertiroidismo e carcinoma della tiroide.

The incidence of thyroid carcinoma in hyperthyroidism varies considerably from as low as 0.3% to as high as 16.6% with a higher rate in toxic nodular goiters. Occult thyroid carcinoma (< 1.5 cm or microscopic foci) is the rule and only a few tumors are suspected preoperatively with ultrasonography or fine needle aspiration or 131 I scan. In 408 patients who underwent surgery for hyperthyroidism in our Surgery Department from January 1967 through December 1994 the incidence of thyroid carcinoma was 5.6% (23 cases). In detail, a neoplasm occurred in 5 cases of Graves' disease (specific incidence: 3.8%), in 13 cases of toxic nodular goiter (12.5%) and in 5 cases of hyperfunctioning adenomas (2.8%). 19 cancers were papillary (12 in toxic nodular goiter, 3 in Graves' disease, 4 in hyperfunctioning adenomas), three were follicular (1 in Graves' disease, 1 in toxic nodular goiter, 1 in hyperfunctioning adenomas) and 1 medullary in Graves' disease. A papillary carcinoma was diagnosed preoperatively on fine needle aspiration with ultrasonography in only two patients with Graves' disease and confirmed by postoperative histological examination on permanent section. We do not believe in the frozen-section examination intraoperatively because it's not diagnostical for follicular lesions and evaluates rarely capsular invasion. Twenty patients received total thyroidectomy and four of them also lymphoadenectomy. Three patients received emithyroidectomy: in two cases for occult papillary carcinoma and in the last case for local cancer invasion (T4N0M0). Twenty patients are alive and with no evidence of cancer recurrence. Mean follow-up is 59.6 months. Our retrospective study shows a progressive increase of the incidence of coexisting thyroid malignancy and hyperthyroidism especially in toxic nodular goiter, probably related to extended surgical indications. Our findings do confirm that, even in the presence of hyperthyroidism, all thyroid nodules require careful diagnostics for exclusion of malignancy.

Pancreatectomy and metabolic alterations.

The authors describe problems about anaesthesia management in peri- and post-operative periods in seven patients undergoing total pancreatectomy. They underline that metabolic alterations in these cases show, until now, some unsolved problems. Sometimes artificial pancreas is very useful in post-operative management of these patients.