Reliability and Versatility of Reverse Sural Island Neurofasciocutaneous Leg Flaps.

BACKGROUND: Distally based sural neurofasciocutaneous (NFC) flaps are a commonly used method for foot and ankle reconstruction given that they are much simpler and, at the same time, still efficient alternative to perforator flaps and free style free flaps. OBJECTIVE: This study aims to evaluate the reliability and versatility of reverse sural island NFC flaps as a powerful and efficient method that can be used for repair of lower leg skin defects. This method does not require microsurgical facilities or extensive training. METHODOLOGY: Patients with soft tissue defects of the distal third of the leg and ankle region received reverse sural island NFC flaps. Inclusion criteria included an absence of damage to the sural neurovascular axis or communicating perforators, absence of peripheral vascular disease, and the presence of soft tissue defects deep enough to expose tendon or bone. Patients were assessed for flap (defect) size, pedicle length and location of defects, postoperative flap survival rates, and complications. Donor sites were closed directly or skin grafted. RESULTS: Of 24 consecutive patient (20 male; 4 female), all flaps except 1 (4.16%), survived, although partial necrosis was observed in 2 patients (8.33%). The overall major complication rate was 12.50%. Epidermolysis was noted in 1 patient (4.16%). Three cases of transient venous congestion resolved without additional complications. The overall minor complication rate was 16.66%. Minimal complications were associated with healing of donor sites. CONCLUSIONS: Reverse sural island NFC flaps provide adequate and aesthetically very acceptable coverage of soft tissue defects of the distal lower leg and proximal foot with no functional impairment.

Cordylobia anthropophaga Myiasis Mimicking Hyperproliferative Skin Disorder in Traveler Returning from Sub-Saharan Africa.

Myiasis is one of the most common skin diseases found in travelers returning from tropical and subtropical regions, where humans living in or visiting the African continent are most commonly infested by C. anthropophaga during the rainy season in regions with a warm climate. Here, we present a case of furuncular myiasis caused by C. anthropophaga in a Serbian patient returning from temporary work in Kenya, where the initial histology of skin lesion mimicked hyperproliferative skin disorder.

Preclinical cerebral cryoablation in non-tumor bearing pigs.

Patients with brain metastases, the most common intracranial tumor, have an average survival ranging from a few months to 40 months, and new treatment initiatives are needed. Cryoablation is a minimally invasive, well-tolerated, and effective procedure commonly applied for treatment of renal tumors and certain other malignancies. We aimed to examine the clinical usefulness of this procedure in a step-by-step program starting with cerebral cryoablation in healthy pigs. In four terminal and four non-terminal non-tumor bearing pigs, we studied immediate and delayed effects of cerebral cryoablation. Safety was assessed by computed tomography (CT), and clinical observation of behavior, neurological deficits, and wellbeing. Effects were assessed by histological and immuno-histochemical analyses addressing structural and metabolic changes supported by additional magnetic resonance imaging (MRI) and positron emission tomography (PET) in the non-terminal animals. Using CT-guidance, cryoablation probes were successfully inserted without complications, and ice formation could be monitored real-time with CT. No animal developed neurological deficits or signs of discomfort. Histological and immunohistochemical analyses, MRI, and PET revealed profound structural and biological damage within the lesion. MRI and PET revealed no long-term damage to healthy tissue outside the cryoablation zone. Cerebral cryoablation appears to be a feasible, safe, and controllable procedure that can be monitored successfully with CT. The net effect is a dead brain lesion without damage of either nearby or remote healthy structures. Immediate changes are local hemorrhage and edema; delayed effects are perfusion defects, immune system activation, and astrogliosis.

Evaluation of healing and antimicrobiological effects of herbal therapy on venous leg ulcer: pilot study.

Venous leg ulcers represent a significant public health problem that will increase as the population ages. Numerous herbs and their extracts are potentially conducive to wound healing, including the ability to serve as an antimicrobial, antifungal, astringent, etc. A total of 32 patients with venous leg ulcers were randomized into two groups: a group with herbal therapy treatment (PT) (17 patients) and a control group (C) (15 patients). The investigation focused on five controls of parameter changes important for ulcer healing and the control of microbiological flora. Within-treatment analysis of the PT group showed that, following herbal therapy treatment, there was a significant decrease in the scores of surface leg ulcer and venous leg ulcer after week 7 of treatment (p < 0.05). In group C following topical antibiotic treatment there was no significant decrease in the surface leg ulcer. Comparing the results of decreased venous leg ulcer surface of the) PT group with the C group showed a significant difference at p < 0.05 after week 7 of treatment. The number of different types of isolated bacterial species decreased significantly (p < 0.05) after the use of herbal preparations. The results of this pilot study demonstrate the healing and antimicrobiological effects of herbal therapy on non-infected venous leg ulcer.

Single prognostic cut-off value for admission glycemia in acute myocardial infarction has been used although high-risk stems from hyperglycemia as well as from hypoglycemia (a narrative review).

All original articles and meta-analysis use the single cut-off value to distinguish high-risk hyperglycemic from other acute myocardial infarction (AMI) patients. The mortality rate is 3.9 times higher in non-diabetic AMI patients with admission glycemia ≥6.1mmol compared to normoglycemic non-diabetic AMI patients. On the other hand, admission hypoglycemia in AMI is an important predictor of mortality. Because both admission hypo- and hyperglycemia correspond to higher in-hospital mortality, this graph is recognized as "J or U shaped curve". The review suggests two cut-off values for admission glycemia for risk assessment in AMI instead of single one because hypoglycemia as well as hyperglycemia represents a high-risk factor.

[Thermal ablation of brain tumours].

The diagnosis of a malignant brain tumour is often associated with a poor prognosis. Current treatment is surgical resection followed by radio-chemotherapy. Surgical resection is most favourable in relation to survival time. Unfortunately, many patients are not suitable for surgical resection, due to inoperable tumour location or the patients' poor state. Minimally invasive thermal ablation may pose an interesting new treatment alternative. In this review, we describe the evolution, the underlying physiology and the clinical applications of cryo- and laser-induced thermal therapy of primary and secondary brain tumours.

Role of D-dimer in predicting mortality in patients with community-acquired pneumonia.

AIM: To determine whether D-dimer in patients with communityacquired pneumonia (CAP) can predict mortality risk better than standard biomarkers. METHODS: White blood cell (WBC), C-reactive protein (CRP) and D-dimer in 129 patients with CAP were analyzed. The recommended Pneumonia Severity Index (PSI) score was used to classify CAP patients into five groups according to the severity of disease (Group PSI I-V), and for predicting mortality. Additionally, the patients were divided in surviving and non-surviving group. RESULTS: White blood cell and CRP were not in correlation with the severity of CAP and the risk of mortality. The correlation between plasma D-dimer and severity of CAP was found (r=0.4993; p less than 0.001). The level of D-dimer was significantly higher in nonsurviving (2498.38 ± 1248.83 ng/mL) than in surviving patients (966.44 ± 968.73 ng/mL) (p less than 0.001). In predicting mortality risk, D-dimer showed sensitivity of 0.84 (cut of >1538 mg/mL), specificity 0.86 and AUC 0.859 (95%CI; 0.787-0.914). Pneumonia Severity Index in predicting of mortality risk for cut of > PSI III showed sensitivity of 0.92, specificity 0.62 and AUC 0.868 (95%CI; 0.797-0.921). There was no statistical difference between AUC of PSI and D-dimer (delta AUC= 0.00895) (p=0.9005). CONCLUSION: Coagulation abnormalities were presented in older patients with severe infections and comorbidity. Plasma D-dimer correlated better than standard inflammatory markers with severity of disease and risk of mortality in patients with CAP. In predicting mortality risk, D-dimer did not show difference among the PSI score.

The analysis of limbs acute ischemia during seasons on the territory of South Serbia.

The aim of this study was to examine the seasons variations in incidence of limbs acute ischemia (LAI) as well as the connection between seasons with location of LAI, old age and gender. During the three year period between January 2009 and December 2011, at the Clinic for Vascular Surgery, Clinical Center of Nis, Serbia, 167 patients were hospitalized diagnosed with limbs acute ischemia. There was no statistically significant difference in patients distribution with LAI compared with seasons (p=0.726) and months of the year (p=0.0741). There was no statistically significant difference in patients age (p=0.066), sex (p=0.923) and LAI localization (p=0.219 ) in different seasons. The absence of seasonal and monthly patterns for the AIE creation as well as its localization is followed by the absence of a connection between the age and the sex..

Tumor necrosis factor alpha gene polymorphism in serbian patients with sarcoidosis.

INTRODUCTION: Sarcoidosis is a multisystemic disease of unknown etiology. Genetic factors play a considerable role in the onset of the disease. Tumor necrosis factor alpha (TNF-a) is a proinflammatory cytokine which plays an important role in the pathogenesis of the disease and the formation of granuloma by regulating cellular proliferation and apoptosis. OBJECTIVE: The aim of this study was to investigate the role of TNF-alpha-308 G/A polymorphism in the development of sarcoidosis and to evaluate the association between the aforementioned type of polymorphism and the clinical course of the disease. METHODS: Seventy patients with sarcoidosis and 50 healthy volunteers were genotyped for the TNF-alpha-308G/A polymorphism. Polymorphism variants were examined by PCR-RFLP (polymerase chain reaction-restriction fragment length polymorphism) on the DNA isolated from blood leukocytes. RESULTS: There were no significant differences in TNF-alpha-308A allele frequency distribution between sarcoidosis patients and the control group, but the TNF-alpha-308A allele was observed significantly more frequently in the sarcoidosis patients with Löfgren's syndrome when compared with non-Löfgren's patients. CONCLUSION: We have found that the TNF-alpha-308A variant is associated with Löfgren's syndrome in Serbian patients with sarcoidosis.

Comparative analysis of autodermal graft and polypropylene mesh use in large incisional hernia defects reconstruction.

BACKGROUND: Large defects of the abdominal wall caused by incisional hernia still represent a challenging problem in plastic, reconstructive, and abdominal surgery. For their successful tension-free repair a proper selection of reconstructive material is essential. In the last decades, the use of synthetic meshes was dominant while biological autodermal grafts were rarely used. The aim of the study was to comparatively analyse efficacy and safety of autodermal graft and polypropylene mesh in surgical treatment of large abdominal wall defects. METHODS: This prospective comparative clinical study enroled 40 patients surgically treated for large incisional hernia repair in a 10-year period. The patients were divided into two equal groups consisting of 20 subjects and treated either by biological autodermal graft or by synthetic polypropylene mesh. The surgical techniques of reconstruction, duration of surgery, the occurrence of early, minor, and major (severe) and delyed complications and hospital stay were analysed. The average follow-up took 2 years. RESULTS: Statistically significant differences in demographic characteristics of patients and in size of defects were not found. The surgical technique of reconstruction with an autodermal graft was more complicated. The duration of surgery in patients treated with autodermal grafts was significantly longer. There was no statistically significant difference regarding occurrence of early, minor postoperative complications and hospital stay in our study. Two severe complications were registered in the synthetic mesh group: intestinal obstruction and enterocutaneous fistula. The recurrence rate was 10% in the autodermal graft group and 15% in the group with a synthetic mesh. CONCLUSION: Tension-free repair of large incisional hernia with autodermal grafts was unjustly neglected despite the fact that it is safe and effective. It can be applied in all cases where synthetic mesh are not indicated (presence of infection, immunodeficient patients, after radiotherapy). They are especially important in war surgery and in lack of funds when commercial grafts cannot be purchased.

A unique case of hereditary bilateral segmental neurofibromatosis on the face.

Segmental neurofibromatosis is a rare clinical finding generally with no family history and facial involvement. There are four subtypes of segmental neurofibromatosis: true segmental, localized cases with deep involvement, hereditary segmental and bilateral segmental neurofibromatosis. Here we report three patients from the same family (father, son and granddaughter) with segmental bilateral neurofibromatosis on the face. This form has not been noticed in the literature.

Application of sentinel lymph node biopsy in cutaneous basosquamous carcinoma.

Basosquamous carcinoma of the skin is a relatively rare cutaneous neoplasm that has significant metastatic potential and a metastatic rate greater than that of basal cell and squamous cell carcinoma. We describe the use of lymphatic mapping and sentinel lymph node biopsy in a 63-year-old man after identification of basosquamous carcinoma. Sentinel lymph node biopsy, which is a standard tool to detect regional lymphatic metastasis in cutaneous melanoma, has been rarely employed to detect lymphatic metastasis of basosquamous carcinoma. The approach was successful in detecting a regional lymphatic metastasis of two nodal basins with minor morbidity. Sentinel lymph node biopsy may be useful for certain high-risk lesions of basosquamous carcinoma.

Does incomplete excision of basal cell carcinoma of the eyelid mean tumor recurrence?

INTRODUCTION: Basal cell carcinoma is the most common tumor of the eyelid. In this region, reconstruction is complex and damage to healthy tissue should be minimal. OBJECTIVE: To define the relationship between margin clearance at excision and the recurrence rate of basal cell carcinoma of the eyelid. METHODS: This prospective study was conducted with 111 patients submitted to surgery for basal cell carcinoma of the eyelid between 2001 and 2003 and followed up for a period of five years. The patients were evaluated according to age, tumor site, recurrence rate and margin clearance at excision. RESULTS: No significant association was found between incomplete tumor excision and recurrence except in patients under 56 years of age, female patients and in the case of tumors of the medial canthus. CONCLUSION: A risk of recurrence in incompletely excised basal cell carcinomas of the eyelid was only confirmed in younger patients, females and for tumors of the medial canthus.

Can you combine herbal therapy with physical agents in the treatment of venous leg ulcers? Evaluation of healing and antimicrobiological effects: a pilot study.

INTRODUCTION: Venous leg ulcers are an important and common health problem. The aim of this study was to determine the effects of herbal therapies alone or in combination with physical therapy in the treatment of venous ulcers, as well as their antibacterial effects. PATIENTS AND METHODS: Our study included 60 patients (3 groups, 20 patients each) with non-infected venous leg ulcers. The patients were treated with herbal therapy alone (group HTC), with a combination of electro-ionizing radiation and herbal therapy (group ERHT) or with a combination of polarized light and herbal therapy (group PLHT). RESULTS: Surface area and score of venous leg ulcers were followed clinically at baseline and at the end of 1, 3, 5, and 7 weeks of treatment. Comparing the results within the HTC, PLHT, and ERHT groups we found that the physical agents and herbal therapy significantly accelerated the healing of venous leg ulcers and reduced bacterial flora (p < 0.05). Comparing the results between the tested groups revealed no statistically significant difference (p > 0.05). CONCLUSIONS: Our results demonstrate healing and antibacterial effects of combined physical and herbal therapies, but no superiority of the combined treatment for venous leg ulcers as compared to treatment by herbal therapy alone.

[Fasciocutaneous perforators of the lower leg--anatomic study and clinical significance].

BACKGROUND/AIM: Soft tissue defects of the lower leg, especially in its distal third, still remain a challenging problem in reconstructive surgery. The aim of this study was to examine septocutaneous system of lower leg vascularization, quantitatively and qualitatively, which is the basis of fasciocutaneous and neurocutaneous flaps. METHODS: Septocutaneous systems a. tibialis posterior and a. peroneae were examined by anatomical suprafascial lower leg microdissection of 40 fresh cadavers. Septocutaneous perforators located intermusculary, in deep crural fascia duplicature, were followed from its origin (at main arterial trunks of the lower leg) till the point they reach the deep crural fascia. The number and localization of emergence of the septocutaneous perforators were examined for both above mentioned arterial trunks, and the obtained data were documented by photographs, tables and graphics. Statistical analysis (especially cluster analysis), was used for establishing reliable septocutaneous perforators levels. RESULTS: Septocutaneous perforator systems of the lower leg have constant and reliable pattern of existance. Lower leg length was 36 cm in average, (between 33 and 43 cm). Lower leg was divided in 10 equal segments, 3.6 cm each. A. tibialis posterior and a. peronea had 5 septocutaneous perforators. Cluster analysis of a. tibialis posterior perforators (with diameter > or = 0.5 mm), discovered 5 reliable levels of septocutaneous perforators. These levels are at 3.6-10.8 cm; 14.4--21.6 cm and 25.2-28.8 cm. For a. peronea reliable perforators were found at 3.6-10.8 cm, 14.4--18 cm and 21.6-25.2 cm. Posterior tibial artery perforators had the greatest diameter (from 0.5-1.8 mm; mean value 1.14 mm and SD = 0.26 mm). A mean diameter for peroneal artery perforators was 0.9 mm. Conclusion. Existance of reliable levels of septocutaneous perforators of the lower leg enables and makes reconstruction of the soft tissue defects of the lower leg, especially its distal third and foot, much easier.

[Overview of the scoring system for cardiovascular risk estimation: role and significance of lipids].

Practical recommendations for the regulation of hyperlipoproteinemia and the prevention of coronary disease and scoring systems for coronary disease risk estimation are based on the results of epidemiologic studies and international consensus guidelines. According to the Framingham point score the risk was defined as an absolute 10 year probability of myocardial infarction and coronary death, while the PROCAM function of risk was based on cardiovascular events: fatal and non-fatal myocardial infarction and sudden coronary death. The Third European Joint Task Force and other societies for the prevention of cardiovascular diseases revise the joint European guidelines and the recommendations for national population strategies. Global coronary disease risk is nowadays in Europe based on the SCORE system. The risk is defined as an absolute 10 year probability of afatal cardiovascular event, and high risk cut-off is at 5%.

A unique case of hereditary bilateral segmental neurofibromatosis on the face / Neurofibromatose segmentar bilateral hereditária da face: caso único

Segmental neurofibromatosis is a rare clinical finding generally with no family history and facial involvement. There are four subtypes of segmental neurofibromatosis: true segmental, localized cases with deep involvement, hereditary segmental and bilateral segmental neurofibromatosis. Here we report three patients from the same family (father, son and granddaughter) with segmental bilateral neurofibromatosis on the face. This form hasn't noticed in the literature.

A neurofibromatose segmentar é um achado clínico raro, geralmente com história familiar negativa e raro envolvimento facial. Existem quatro subtipos de neurofibromatose segmentar: segmentar verdadeira, segmentar com envolvimento visceral profundo, segmentar com história familiar e segmentar cutânea bilateral. Aqui nós reportamos três pacientes de uma mesma família (pai, filho e neta) com neurofibromatose segmentar bilateral na face. Esta forma ainda não foi relatada na literatura.

[Botulinum toxin type A for the treatment of spasticity in children with cerebral palsy].

BACKGROUND/AIM: Cerebral palsy (CP) is the most common physical disability in childhood. Children have problems with motor functions as a result of limbs spasticity, which leads to severe contractures and limbs deformity. There is a growing interest in the therapeutic role of botulinum toxin type A (BTA) in CP. The aim of this study was to examine the effects of BTA on spasticity, active range of motion and functional motor outcomes in children with CP. METHODS: This study included 42 children of both sexes, aged 2-6 years, with spastic CP, divided into two groups: group I (21 child) treated with BTA and physical therapy, and group II (21 child) treated with physical therapy only. The following parameters were analyzed: spasticity; active range of motion of the hip, knee and ankle, and functional motor outcome. These parameters measurements were carried out four times in both groups: before the treatment, three, eight and 16 weeks after the beginning of the treatment. The obtained results were statistically processed and compared. RESULTS: There was no evidence of any significant difference between the groups before the treatment. After eight weeks there was a remarkable difference concerning spasticity reducing on behalf of the group I (group I -- 0.76 +/- 0.51 vs. II group -- 2.17 +/- 0.64; p < 0.0001). There was statistically significant difference concerning active range of motion increasing on behalf of the group I (hip abduction: group I --44.37 +/- 1.13(0) vs. group II -- 32.61 +/- 8.07(0),p < 0,01; knee extension: group I -- 0.77 +/- 1.82(0) vs. II group -- 14.99 +/- 7.61(0), p < 0.01; dorsiflexion of the foot: group I -- 11.50 +/- 6.08(0) vs. group II -- 8.98 +/- 7.85(0), p < 0.01). A statistically significant difference was found after 16 weeks in functional motor outcome as well, on behalf of the group I: functional motor abilities level in the group I was 1.86 vs. 2.71 in the group II, p < 0.05. CONCLUSION: Botulinum toxin type A application leads to an important spasticity decreasing, active range of motion increasing, as well as to functional abilities in children with CP.

Does incomplete excision of basal cell carcinoma of the eyelid mean tumor recurrence? / A excisão incompleta de carcinoma basocelular da pálpebra implica

INTRODUCTION: Basal cell carcinoma is the most common tumor of the eyelid. In this region, reconstruction is complex and damage to healthy tissue should be minimal. Objective: To define the relationship between margin clearance at excision and the recurrence rate of basal cell carcinoma of the eyelid. METHODS: This prospective study was conducted with 111 patients submitted to surgery for basal cell carcinoma of the eyelid between 2001 and 2003 and followed up for a period of five years. The patients were evaluated according to age, tumor site, recurrence rate and margin clearance at excision. RESULTS: No significant association was found between incomplete tumor excision and recurrence except in patients under 56 years of age, female patients and in the case of tumors of the medial canthus. CONCLUSION: A risk of recurrence in incompletely excised basal cell carcinomas of the eyelid was only confirmed in younger patients, females and for tumors of the medial canthus.

INTRODUÇÃO: O carcinoma basocelular é o tumor mais comum entre os tumores das pálpebras. Nesta região, a reconstrução é complexa e recomenda-se que haja perda mínima de tecido saudável. OBJETIVO: Para definir a relação entre margem livre de tumor na excisão e taxa de recidiva do carcinoma basocelular das pálpebras. MÉTODOS: Este estudo prospectivo incluiu 111 pacientes operados para remoção de carcinoma basocelular das pálpebras no período de 2001 a 2003, com acompanhamento subsequente de 5 anos. Os pacientes foram avaliados de acordo com a idade, localização do tumor, taxa de recidiva, e margem livre de tumor na excisão. RESULTADOS: Não se encontrou associação significativa entre a excisão incompleta do tumor e casos de recidiva, exceto em pacientes com idade inferior a 56 anos, pacientes do sexo feminino e em tumores do canto medial. CONCLUSÃO: Um risco maior de recidiva de carcinoma basocelular das pálpebras com excisão incompleta foi confirmado estatisticamente apenas em pacientes mais jovens, em mulheres, e nos tumores do canto interno.