Microsurgical Reconstructions for Head and Neck Cancers in Elderly Aged >80 Years: An Analysis of Surgical Outcomes and Quality of Life.

BACKGROUND: The rising incidence of primary head and neck (H&N) cancers in the elderly presents a dilemma regarding the appropriateness of complex surgery in this assumed frail age group. With limited data on surgical morbidity, survival, and patient quality of life (QOL), this analysis aimed to broaden the understanding of safety and effectiveness of microsurgical treatment in very elderly H&N cancer patients. METHODS: A prospective database analysis was used to evaluate surgical outcomes (morbidity, survival, and QOL) in all patients aged 80 years and older undergoing microsurgical reconstruction for cutaneous and intra-oral H&N cancers between 2004 and 2014. Outcomes were assessed for their association with surgical, tumour, and patient variables. Comorbidities were categorized by the ACE27 index and postoperative morbidity by the Clavien-Dindo scoring system. QOL was analyzed using the UW-QOLv4. RESULTS: Of 720 microsurgical reconstructions, 96 patients were identified. Median survival was 25 months. The ACE27 index was the only variable significantly associated with survival with a 5-year survival of 59.2 % in the least comorbid group versus 19.7 % in the most comorbid group (p 0.015). ACE-27 showed influence on socioemotional QoL scores. Physical QOL scores were influenced by tumour and operative factors. Patients were found to value physical QOL over socioemotional. CONCLUSIONS: Microsurgical reconstructions are well tolerated in the very elderly patients and should be considered predominantly based on comorbidity. Tumour stage, flap type, and cancer site should still form part of the preoperative counseling due to their implication on postoperative physical function.

Scrotal calcinosis: a very rare multiple clinical presentation.

Scrotal calcinosis (SC) is a rare benign disease that affects patients in childhood or early adulthood. It is characterized by slow-growing yellowish-white nodules consisting of deposits of calcium and phosphates, within the scrotal skin. The nodules vary in number, and can be solitary or grouped. Owing to the age of onset and anatomical location, SC may be a source of embarrassment and lead to social isolation. Because of its rarity, the aetiology of SC is still controversial. We report a very rare case of an SC in a 59-year-old white man who presented with multiple nodules with different clinical patterns in the scrotum, which had been present for > 42 years. Despite the rarity and the multiple long-lasting lesions, surgical excision of the scrotal nodules can offer a very good aesthetic outcome in a single procedure even under local anaesthesia.

Is infrared thermography (IRT) a possible tool for the evaluation and follow up of Emery-Dreifuss muscular dystrophy? A preliminary study.

HYPOTHESIS: The hypothesis of this work is that infrared thermography could become a valid tool for the diagnosis and follow-up of the Emery-Dreifuss disease due to putative temperature changes produced by a constant degenerative evolution of this muscular dystrophy. TESTING THE HYPOTHESIS: To justify this hypothesis we proposed a pilot study with 2 brothers affected of Emery-Dreifuss who present a very different age, with the principal objective to evidence a possible evolution of this pathology. Acquisition and comparison of images of computerized axial tomography (CT) and thermography (IRT) of the distal limbs in 2 affected brothers. DATA AND DISCUSSION: Important image correlations in the region of the thighs and the posterior region of the legs have been highlighted. The comparison between the CT and the thermography showed how the first results are encouraged and promising and open a possible new line of research on the evaluation and follow-up of this disease. Despite this, a larger number of studies are needed to validate the thermography as a diagnostic technique and follow-up of this pathology.

Extracorporeal shock wave therapy for management of chronic ulcers in the lower extremities.

Management of chronic ulcers in the lower extremities is still a challenge for patients and health providers. Recent studies showed extracorporeal shock waves (ESW) as effective in stimulating growth factors, inducing angiogenesis and healing of fractures and injuries. This study was planned to investigate the opportunity of introducing the ESW in the treatment of chronic wounds. Thirty consecutive patients with chronic posttraumatic, venous and diabetic ulcers, unresponsive to conservative or advanced dressing treatments, were counseled about the use of ESW as alternative treatment for their wounds. Thirty-two wounds were treated and 16 wounds healed completely within six sessions of ESW. In all of the nonhealed wounds, decrease of the amount of exudates, increased percentage of granulation tissue compared with fibrin/necrotic tissue and decrease of wounds' size were statistically significant after four to six sessions of ESW (p < 0.01). Significant decrease of pain was reported (p < 0.001). Comparison with a control group of 10 patients with chronic ulcer treated on the basis of regular dressings confirmed the statistical significant improvement in the healing process (p < 0.01). ESW therapy seems to be a safe, feasible and cost-effective treatment for chronic ulcers in the lower extremities. Further research and clinical trials are necessary to evaluate dose and time intervals of sessions to standardize a protocol of treatment in the management of chronic wounds.

Squamous cell carcinoma of the lateral nail fold.

The digital nail complex is occasionally involved by squamous cell carcinoma. The published literature has either been indiscriminating of the site of origin of this tumour within the nail complex or has concentrated attention on the nail bed as the site of pathology. Tumours originating in the lateral nail fold can be clearly differentiated from those of the nail bed itself. This study identifies six cases of squamous cell carcinoma arising in the lateral nail fold. While surgical convention remains to amputate the digital tip for squamous cell carcinoma of any part of the nail complex, the dermatological literature identifies that local surgery can be curative for these tumours, when presenting early and without bone involvement, although offering no discussion of reconstruction. Reconstruction is desirable and methods of achieving this following local excision of lateral nail fold tumours are illustrated in this series.

The results of immediate re-repair of zone 1 and 2 primary flexor tendon repairs which rupture.

This study reports the outcome of immediate re-repair of primary flexor tendon repairs in zones 1 and 2 of the fingers which had ruptured. Between June 1989 and May 2003, a total of 62 fingers in 61 patients presented with ruptured flexor tendon repairs within 48 hours from rupture. Immediate re-repair and rehabilitation was carried out in 44 fingers (71%) in 43 (70%) patients. Thirty-six patients completed the 8-week therapy programme after re-repair in 37 fingers. Nine (24%) had excellent, 10 (27%) good, 5 (14%) fair and 13 (35%) had poor results when assessed by the original Strickland method. Five fingers in five patients ruptured the re-repair. Poor results and second ruptures were particularly common after re-repair of ruptured tendon repairs in the little finger. In the light of these findings, a policy for dealing with ruptured primary flexor tendon repairs in the fingers is suggested.

Skin involvement in Dupuytren's disease.

UNLABELLED: Whether the palmar skin has a role in the development, propagation or recurrence of Dupuytren's disease remains unclear. Clinical assessment for skin involvement is difficult and its correlation with histology uncertain. We prospectively biopsied the palmar skin of consecutive patients undergoing single digit fasciectomy (for primary Dupuytren's disease without clinically involved skin) and dermofasciectomy (for clinically involved skin or recurrence) in order to investigate this relationship. We found dermal fibromatosis in 22 of 44 patients (50%) undergoing fasciectomy and 41 of 59 patients (70%) undergoing dermofasciectomy. Dermal fibromatosis appeared to be associated with greater preoperative angular deformity, presence of palmar nodules and occupations involving manual labour. Dermal fibromatosis exists in the absence of clinical features of skin involvement and we hypothesize that the skin may have a greater role in the development and propagation of Dupuytren's disease than previously thought. LEVEL OF EVIDENCE: III.

[The presence of nucleotide sequences of the hepatitis B virus in the serum of HBsAg-negative blood donors in Sardinia]. / Presenza di sequenze nucleotidiche del virus dell'epatite B nel siero dei donatori di sangue HBsAg negativi in Sardegna.

The presence of HBV DNA was assessed in the serum samples from 878 HBsAg negative Sardinian blood donors. They were composed of 481 (55%) donors selected because of abnormal serum alanine aminotransferase (ALT) levels during routine testing of their blood donation, and of 397 donors (45%) selected on the basis of normal serum ALT activities. HBV DNA sequences were detected in 37 (7.7%) out of 481 subjects with abnormal ALT and in 2 (0.5%) out of 397 subjects with normal ALT. Anti-HBc was detected in 199 (41%) of the 481 subjects with abnormal ALT and in 81 (20%) out of 397 subjects with normal ALT. Among the 39 subjects positive for serum HBV DNA, 12 (31%) were positive for anti-HBc, while 27 (69%) were negative for all serological HBV markers. These data show in Sardinia, where HBV infection is endemic, there is a high frequency of HBsAg negative HBV DNA positive individuals in whom multiplication of HBV may occur without conventional serological HBV markers, suggesting the possible existence of HBV-like viruses which may be responsible for some of the presumed non-A non-B hepatitis.

[The presence of nucleotide sequences of the hepatitis B virus in peripheral lymphocytes of patients with acute hepatitis B]. / Presenza di sequenze nucleotidiche del virus dell'epatite B nei linfociti periferici di pazienti con epatite acuta di tipo B.

Hepatitis B virus (HBV) DNA sequences were assessed in 26 patients with acute type B hepatitis, using dot-blot hybridization technique from peripheral blood mononuclear cells (PBMC), during different phases of the illness. At clinical presentation, 15% of patients showed HBV-DNA sequences in PBMC, while serum HBV-DNA was detected in 58% of patients. During clinical improvement 50% of patients had HBV-DNA in PBMC but only 11.5% were positive for serum HBV-DNA. Twenty-three (88.5%) patients recovered and cleared HBV-DNA from serum and from PBMC; three (11.5%) patients with acute hepatitis progressing to chronicity showed persistently HBV-DNA sequences in serum and in PBMC. In conclusion, our study shows that HBV-DNA sequences may be found in PBMC, transiently in patients with acute hepatitis followed by recovery, persistently in patients with acute hepatitis progressing to chronicity.

[Spontaneously regressive ulcerative colitis: the result of contraceptive agents?]. / Colite ulcéreuse spontanément régressive: conséquence des anti-conceptionnels?

PIP: 4 cases of ulcerative colitis are reported. The patients were all young women who had been on oral contraceptives (OCs) for at least 1 year. All cases regressed spontaneously without treatment. The association between OCs and gastrointestinal effects must be better clarified.^ieng

The propeller flap for chronic osteomyelitis of the lower extremities: a case report.

The goals of the treatment of chronic osteomyelitis are infection eradication with systemic antibiotic therapy and local management with radical excision of the infected tissue and obliteration of the remaining dead space. Adequate debridement and coverage with a well-vascularised tissue are mandatory for successful outcomes. Use of muscle covering for chronic osteomyelitis in the lower extremities is considered the best procedure. However, there have been instances where debridement of the bone tissue did not leave a deep cavity along the leg bones and fasciocutaneous flaps can be used in these instances to cover the defect and to restore function without recurrence of the disease. Recently, free non-muscle flaps have been used and assessed for chronic osteomyelitis or covering of exposed bone. Perforator flaps have been shown to be well vascularised due to a structural haemodynamic enhancement. In the light of these findings we report a successful case of chronic osteomyelitis of the right fibula treated with excision of the affected tissue and covering with a propeller flap. Instead of free flap covering, in order to optimise surgical reconstruction, reducing the operative time, donor and recipient site morbidity and risk of total flap failure, local perforator flaps and particularly the propeller flap may be indicated in the treatment of chronic osteomyelitis in selected patients when the defect is limited and there is no need to fill a deep bone cavity or a dead space. To our knowledge, this the first report of the use of a propeller flap in the treatment of chronic osteomyelitis in the lower extremities.

Flap size/flow rate relationship in perforator flaps and its importance in DIEAP flap drainage.

The vascular architecture within a perforator flap is different from a conventional muscle or myocutaneous flap. The purpose of this paper is to understand the correlation between flow rate and flap size in perforator flaps. With extrapolation of these data, we have provided an indirect analysis of the venous drainage and its correlation with flap size. A prospective study was planned. Twenty-five patients were enrolled in this study: six patients were operated on using an anterolateral thigh (ALT) flap and 19 using a deep inferior epigastric artery perforator (DIEAP) flap. One month postoperatively, echo-colour-Doppler measurements were performed on pedicle and perforator arteries to calculate blood flow rate in the flaps. A correlation between weight and flow rate was analysed. Spearman rho statistic was calculated. A linear regression model was made from patient data of flow rate/flap weight and predicted values of flow per flap weight were calculated. Then, flow rate values of veins of various diameters were estimated using Hagen-Poiseuille's formula. Our data show that flow rate measured postoperatively on flap arteries is significantly correlated with flap weight [rho(23 d.f.)=0.725, P<0.01 (two-tailed)]. Moreover, we have calculated the minimum size of veins able to drain flaps of increasing weights with different patterns, i.e. our data show that veins of 1.30, 1.50 and 1.75 mm diameter could safely drain flaps of, respectively, 300, 500 and 900 g in weight. This can be useful preoperatively to estimate the risk of flap congestion and in planning additional drainage.

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals.

Many techniques have been described to create an aesthetic and functional neo-phallus after penile amputation or in female-to-male transsexuals. Microsurgical free-flap phalloplasty seems to be the preferred method of penile reconstruction. For many years the radial forearm free flap has been considered the best procedure, but other flaps have been attempted to minimize donor site morbidity and optimize outcome. Pedicled flaps are considered to be reliable and to decrease the risk of total failure. Recently, a one-stage non-microsurgical technique was described for phallic reconstruction in a young male patient. We report successful total phallic reconstruction in a female-to-male transsexual patient using an island pedicled anterolateral thigh (ALT) flap. Urethral reconstruction was left as a possible further procedure due to patient's preference. A malleable soft silicone penile prosthesis was inserted within the flap and the lateral cutaneous femoral nerve stump was sutured to the dorsal clitoris branch from the pudendal nerve for flap sensation. After 6 months, the patient demonstrated successful aesthetic and functional reconstruction referring to satisfactory sexual activity. To our knowledge, this is the first report of an innervated island pedicled ALT flap used for female-to-male penile reconstruction in a transsexual patient. The pedicled ALT flap may be a reliable option to avoid visible scarring at the donor site on exposed parts of the body, and reduce the risk of total flap failure from microsurgical procedures for reconstruction of a neo-phallus in this increasing population of patients.