Intraoperative superficial inferior epigastric vein preservation for venous compromise prevention in breast reconstruction by deep inferior epigastric perforator flap.

OBJECTIVE: The aim of this study was to analyze our technique of intraoperative venous compromise management based on conservation of the superficial inferior epigastric vein (SIEV), and to undertake a retrospective review of our series of breast reconstructions by deep inferior epigastric perforator (DIEP) flap, followed by a review of other techniques reported in the literature. MATERIALS AND METHODS: This retrospective study involves 198 breast reconstructions by DIEP flap performed between January 2010 and September 2017. Our surgical technique is related in detail, with a focus on venous compromise management. Operative time, re-intervention rate, hospital stay, and complications were all noted and analyzed, and a literature review dealt with other techniques of prevention and management of flap venous congestion. RESULTS: Among breast reconstructions by DIEP, 7.5% contained an episode of intraoperative venous compromise, as opposed to 6.5% postoperatively. The SIEV was used in 65% of cases of venous congestion. In our series, 15.1% of cases presented postoperative complications, and we observed a 2.5% flap failure rate (2%: venous thrombosis; 0.5%: arterial thrombosis). In all patients for whom venous drainage augmentation was performed, the flaps survived without partial loss. While average length of hospital stay in the group having undergone intraoperative secondary anastomosis was 7.5 days, in the group having undergone postoperative secondary anastomosis, it was 13.5 days. CONCLUSION: In cases of intraoperative venous congestion, while a second venous anastomosis may immediately increase duration of an initial intervention by 1hour and 45minutes, it is nonetheless likely to pronouncedly decrease need for surgical revision, cases of failure, rate of partial necrosis and overall hospital stay.

Surgical approaches in neck dissection: Comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach.

BACKGROUND: Surgical approaches in neck dissection: comparing functional, oncologic and aesthetic aspects of transverse cervicotomy to Paul André's approach. METHODS: This single-center retrospective study compares a new transverse incision for cervicotomy to the classical approach described by Paul André in neck dissections. The evaluation criteria were: number of lymph nodes analyzed, operative time, complications, patient satisfaction and aesthetic aspects of the scar. RESULTS: A total of 34 patients were included in this study, from September 2009 until January 2015. The number of lymph nodes analyzed is not affected by this new approach compared to the classical one (P=0.9). The scar has a significantly more discreet appearance in the transverse cervicotomy group (P=0.023) likewise; patient satisfaction is higher in this group (P=0.006). CONCLUSIONS: Aesthetic and functional impairment can be reduced using this new transverse cervical approach hidden in the natural creases of the neck described by Langer.

Reconstruction of an anterior chest wall radionecrosis defect by a contralateral latissimus dorsi flap: A case report.

INTRODUCTION: Soft tissue and bone radionecrosis are rare but serious complications may occur late after radiotherapy. CASE REPORT: We report the case of an 86-year-old woman with a history an infiltrating ductal carcinoma of the left breast, treated by total mastectomy, left axillary dissection and adjuvant radiotherapy. Eighteen years later, the first radionecrosis lesions appeared and grew progressively in a 6-month period. These lesions are deep, involving the anterior aspect of the 4th to the 6th ribs and infiltrating the chest wall to the left cardio-thoracic space communicating largely with the pericardium. During axillary dissection, the neurovascular pedicle of the left latissimus dorsi muscle had been severed. The first part of the operation consisted of performing a left side parietectomy of the thoracic wall with a large resection of pericardial tissue and a small myocardial patch. The second step consisted of repairing the thoracic wall defect with a contralateral musculocutaneous latissimus dorsi flap. CONCLUSION: Due to its significant axis of rotation, the latissimus dorsi muscle flap must be considered in the therapeutic algorithm for covering of contralateral anterior chest wall defects.

Using free flaps for reconstruction during infections by mucormycosis: A case report and a structured review of the literature.

BACKGROUND: Mucormycosis is a very rare infection caused by fungi from the order Mucorales, it rarely involves the skin. We report a case of necrotizing fasciitis of the upper limb which required an aggressive surgical debridement, antifungal therapy and coverage of the defect with a free DIEP flap, a review of the literature was also done regarding indications of reconstruction with free flaps. CASE PRESENTATION: Here we present a case of cutaneous mucormycosis of the right upper limb in a 49-year-old immunocompetent woman after having an open fracture associated with massive contamination during a motor vehicle collision. In early postoperative period, she had multiple skin necrotic lesions. Serial surgical debridements were performed and ended up with interscapular-thoracic amputation associated with a total mastectomy. Following diagnosis confirmation of mucormycosis infection, the patient was started on antifungal therapy for several months. After disease control, the large defect was successfully covered by a DIEP flap. CONCLUSION: Cutaneous mucormycosis requires antifungal therapy along with aggressive debridement, reconstruction by a free flap seems to be a good solution to cover these large defects.

Canine echinococcosis: genetic diversity of Echinococcus granulosus sensu stricto (s.s.) from definitive hosts.

Canids, particularly dogs, constitute the major source of cystic echinococcosis (CE) infection to humans, with the majority of cases being caused by Echinococcus granulosus (G1 genotype). Canine echinococcosis is an asymptomatic disease caused by adult tapeworms of E. granulosus sensu lato (s.l.). Information on the population structure and genetic variation of adult E. granulosus is limited. Using sequenced data of the mitochondrial cytochrome c oxidase subunit 1 (cox1) we examined the genetic diversity and population structure of adult tapeworms of E. granulosus (G1 genotype) from canid definitive hosts originating from various geographical regions and compared it to that reported for the larval metacestode stage from sheep and human hosts. Echinococcus granulosus (s.s) was identified from adult tapeworm isolates from Kenya, Libya, Tunisia, Australia, China, Kazakhstan, United Kingdom and Peru, including the first known molecular confirmation from Gaza and the Falkland Islands. Haplotype analysis showed a star-shaped network with a centrally positioned common haplotype previously described for the metacestode stage from sheep and humans, and the neutrality indices indicated population expansion. Low Fst values suggested that populations of adult E. granulosus were not genetically differentiated. Haplotype and nucleotide diversities for E. granulosus isolates from sheep and human origin were twice as high as those reported from canid hosts. This may be related to self-fertilization of E. granulosus and/or to the longevity of the parasite in the respective intermediate and definitive hosts. Improved nuclear single loci are required to investigate the discrepancies in genetic variation seen in this study.

Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model.

BACKGROUND: The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation. OBJECTIVE(S): To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change. METHODS: An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed. RESULTS: Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change. CONCLUSIONS: Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

Bacterial, viral and fungal genital tract infections in Palestinian pregnant women in Gaza, Palestine.

BACKGROUND: Pregnant women may be at high risk to be infected with one of sexually transmitted diseases. Of the sexually transmitted infections childbearing women, Chlamydia trachomatis, Human papilloma virus (HPV) and Candida albicans are of special importance. OBJECTIVE: To determine the prevalence of Chlamydia trachomatis, Human papilloma virus (HPV) and Candida albicans among pregnant women attending child and mother health center in Gaza. METHODS: The present study included 423 pregnant women aged 16 to 50 years old, who were attending child and mother care center in Gaza. Their complaints included vaginal discharge and signs suggestive of acute and chronic cervicitis. Detection of Chlamydia trachomatis, Human papilloma virus and C. albicans was carried out using standard methods. RESULTS: The prevalence of Chlamydia trachomatis was 35(8.3%), Human papilloma virus 55(13%) and Candida albicans 22(5.2%). Chronic cervicitis was highly correlated to HPV. The pregnant women >50 years of age were found to be the highest group infected with C. trachomatis, Human papilloma virus and C. albicans. Different results were obtained when STIs were correlated to years where some improvement in primary healthcare and private clinics had been established as has been noticed lately in Gaza Strip, beside the easy accessible to these services for women. CONCLUSION: It is concluded that these sexually transmitted infections are common among pregnant women in Gaza and that these need more investigations using advanced techniques.

Nipple reconstruction after implant-based breast reconstruction in radiated patients: A new safe dermal flap.

INTRODUCTION: After implant-based breast reconstruction, the nipple reconstruction technique must be carefully chosen, especially in patients with a history of radiotherapy. When the contralateral nipple is not available, using a classical dermal-fat local flap may lead to the implant exposure, and consequently, removal. We describe here a simple nipple reconstruction technique, using a strictly dermal local flap and evaluate its complication rate. PATIENTS AND METHODS: All patients who underwent our technique for nipple reconstruction between January 2012 and April 2015 were included in this retrospective study. We described our surgical technique and noted the occurrence of postoperative complications. RESULTS: Forty-nine nipples, in 47 patients with a history of radiotherapy, were reconstructed with our technique. The mean age was 53 years old (range 27-78 years old). The average time between radiotherapy and nipple reconstruction was 42.5 months (range from 4.6 to 274.8 months). The mean follow-up was 30.9 months (range from 6 to 47 months). No implant exposure occurred. Regarding the nipple flap, two partial flap loss and one infection occurred, the whole complication rate was 6.1%. Regarding nipple projection, it was quite low (between 2 and 5 mm) after 6 months, but remained stable. CONCLUSION: Our strictly dermal local flap technique for nipple reconstruction is a safe procedure and represents a good alternative to composite contralateral nipple graft in irradiated patients with an implant-based reconstructed breast.

Synovial cysts of the lumbar facet joint.

A study of 42 synovial cysts arising from the lumbar facet joint is presented. Intraspinal cysts caused radicular pain and cauda equina syndrome in 11 patients. In a series of 1,400 lumbar laminotomies for a herniated disk, 31 incidental nodules arising from the exposed facet as paraarticular masses were found and excised. The limited number of reports in the orthopedic and neurosurgical literature has not dealt adequately with the etiology or incidence of these benign lesions. The neuroradiologic appearance and histopathologic findings are briefly discussed.

Intrinsic 'soft-start' polymerisation shrinkage-kinetics in an acrylate-based resin-composite.

OBJECTIVES: A resin-composite based on multi-acrylate monomers was to be evaluated for any differences in the setting shrinkage-strain kinetics relative to more conventional formulations based on di-methacrylate monomers. METHODS: Four resin-composites were examined for shrinkage-strain over time periods up to 60 min, from initial irradiation, using a 'bonded disk' measurement device. One material was evaluated with a standard and also a two-level (low to high) blue light irradiation regime. The test material (Solitaire), and the other two controls were studied under fixed-(normal) level irradiation by blue light. Measurements were made at 23 and 37 degrees C. RESULTS: The low-high light irradiation applied to one di-methacrylate composite led to a highly significant (p < 0.001) reduction in shrinkage-strain to a minimal level for the initial 0.2 min. The fixed-level irradiation with the acrylate-composite also led to a formally identical, but intrinsic 'soft-start' shrinkage-delay regime; significant at p < 0.001. Di-methacrylate composites under the same fixed-level light regime did not exhibit shrinkage delay. Both di-methacrylate and multi-acrylate composites exhibited increases in the range 18-29% in final equilibrium shrinkage-strain by increase of specimen temperature. SIGNIFICANCE: Reductions in the rate of initial shrinkage of light-cured restoratives may have clinical benefits for restoration bond-integrity nearly as important as reductions in the final equilibrium shrinkage-strain. This may be achieved either by special light irradiation regimes (low to high, or ramped) or in favourable cases by novel monomer-composite formulations and setting chemistry (e.g. Solitaire). The bonded disk shrinkage-strain measurement technique is suitable for the elucidation of such rapid kinetic and temperature-dependent events during photo-polymerisation setting processes.

Photo-polymerization shrinkage-stress kinetics in resin-composites: methods development.

OBJECTIVES: Studies of free shrinkage-strain kinetics on restoratives have begun to multiply. However, there have been fewer investigations of the more difficult problem of concurrent stress-kinetic measurements. The aim was to outline design parameters for a new methodology for this problem, amenable especially to light-cured materials, and to present illustrative results for a range of restorative composites. METHODS: Absolute values of stress measurable for a given material and geometry are dependent upon the stiffness of the measurement system. In an infinitely stiff system, the measured stress would also tend towards infinity. Real teeth and their cavities are not infinitely stiff; they have elastic and visco-elastic compliance. Consequently, it is important that some minimal, but essentially constant compliance be allowed, whatever the final or time-dependent modulus of the material may be. This goal has been realised by measurement of the time-development, for a disk-geometry specimen (phi=10, h approximately 1.0 mm) of stress (S(r)), with a calibrated cantilever beam-geometry load cell. A novel specimen-holder design was used for this purpose, held in a rigid base assembly. Specimen thicknesses (or gap-widths) of 0.8 and 1.2 mm were specifically investigated on four representative resin-composites. Concurrent measurements were made of the end-displacement of the cantilever load cell, relative to a lower glass plate retaining the specimen. RESULTS: Load-calibration of the cantilever load cell gave an end-displacement per unit stress of circa 6 microm/MPa. This compares with literature values for cuspal compliance or displacement of circa 20 microm. Re-normalisation of the stress-data was implemented. This was accomplished assuming Hooke's law behavior at each instant and equivalent to a stiffer system, with a correction (multiplier) factor of 4 on the raw-stress values. For the materials examined, resultant maximum-stress levels determined were circa 5-8 MPa Stress-levels obtained at 1.2mm thickness were slightly higher (11-15%) than the level of stress obtained at 0.8 mm thickness. This is attributable to the greater mass of material undergoing shrinkage at 1.2 mm, offset slightly by the different C-factors. SIGNIFICANCE: The new device is a practical and self-contained system for rapid and accurate measurement of stress-kinetics in photo-polymerising and also self-cure materials.

18q+, the progeny of a balanced translocation t(1;18)mat: case report with necropsy findings.

A female infant with additional genetic material on the long arm of chromosome 18 is described. Cytogenetic studies of the infant and her mother showed that the altered region resulted from an unbalanced translocation of part of the long arm of chromosome 1. This chromosomal abnormality has not been reported previously, according to a recent registry of abnormal chromosome patterns. The patient had hydrops fetalis and multiple congenital abnormalities, involving the cardiovascular, respiratory, and skeletal systems, together with unusual facies. External features, radiological findings, and gross and microscopical examination at necropsy are presented and compared with previously reported cases of related but dissimilar chromosomal abnormalities.

Swab cultures accurately identify bacterial pathogens in diabetic foot wounds not involving bone.

AIMS: Current clinical practice assumes swab cultures from wounds are unreliable. However, this assumption is based upon data culled only from wounds in which osteomyelitis and/or gangrene were present. This study aimed to re-evaluate the accuracy of swab cultures vs. deep tissue cultures in diabetic wounds of varying depth and severity. METHODS: A total of 60 infected diabetic foot wounds were cultured. Two specimens were taken from each wound: superficial swab before debridement and deep tissue specimen towards the end of surgical debridement. RESULTS: In 37 wounds (62%), the micro-organisms isolated from the swab specimen and those isolated from the deep tissue specimen were identical. In another 12 wounds (20%), the swab culture contained all micro-organisms isolated from the deep tissue culture, but also contained additional micro-organisms. Analysis according to the depth of the wound, demonstrated that swabs identified all micro-organisms isolated from the deep tissue specimens in 36/40 wounds (90%) that did not extend to bone as opposed to 13/20 wounds (65%) that extended to bone. CONCLUSIONS: Swab cultures are valuable in identifying pathogens in diabetic foot wounds when bone is not involved. When surgical debridement is contraindicated or delayed, swab cultures can be used to select appropriate antibiotic therapy.

Decreased secretion of Th2 cytokines precedes Up-regulated and delayed secretion of Th1 cytokines in activated peripheral blood mononuclear cells from patients with insulin-dependent diabetes mellitus.

Recent evidence suggests that autoimmune animal diabetes is associated with an imbalance between the Th1 and Th2 arms of the cellular immune system. However, limited data is available regarding the Th1/Th2 imbalance in human Insulin dependent diabetes mellitus (IDDM) patients. Therefore, we examined the peak levels, secretory pattern and total cytokine production (calculated as the area under the curve, AUC) of the Th1 cytokines, IL-2 and IFN-gamma, and Th2 cytokines, IL-4 and IL-10, from stimulated peripheral blood mononuclear cells, from 17 IDDM patients and 24 normal controls. In contrast to controls, diabetic patients were characterized by an early, uniformly low secretion of Th2 cytokines, followed by a late increased secretion of Th1 cytokines. This resulted in significant differences in secretory patterns of IFN-gammaIL-2, IL-4 and IL-10 between the two groups; P<0.001, P<0.005, P<0.005 and P<0.001, respectively. No correlation was found in the diabetic patients between any profiles of the cytokines and their various clinical parameters, including age, gender, disease duration, insulin requirements or glycated hemoglobin levels. In conclusion, our data provides the first comprehensive evidence for an independent and persistent impairment of both Th1 and Th2 cytokine secretory patterns in IDDM patients.

Prevalence of intestinal parasites among school children in Gaza City, Gaza Strip.

A total of 489 stool specimens were collected from school children aged 6-11 years. The target area is overcrowded, with improper sewage disposal system and low socioeconomic standards. A questionnaire was designed to include relevant informations. Each stool specimen was processed by the direct smear microscopy, zinc sulphate flotation technique and formol-ether sedimentation technique. The present study revealed an overall prevalence at 27.6%. Six parasites were detected. Giardia lamblia (62.2%) was the most frequent species found, followed by Ascaris lumbricoides (20.1%) then, Entamoeba histolytica (13.3%). The prevalence of these parasites was found to be related to age, socioeconomic and sanitation conditions. Most of the other parasitic infections were of mild intensity. There is an urgent need to correct the present situation by improving the living conditions, providing facilities for the population such as modern housing, proper sewage disposal system, health education and execution of survey programs for parasites to treat the infected persons.

Intestinal parasites in relation to haemoglobin level and nutritional status of school children in Gaza.

The prevalence of intestinal parasites and their relations to anaemia and nutritional status among school children aged 6-11 years in Gaza was studied. The target area is overcrowded with improper sewage disposal system and low socioeconomic levels. Anaemia was assessed by haemoglobin level (Hb) and nutritional status by anthropometric measurements including weight for age (WA), weight for height (WH) and height for age (HA). Intestinal parasites were found to be prevalent in Gaza. The overall prevalence was 24.5%. Giardia lamblia (62.2%) was the most common parasite detected particularly in age group 6-7 years, followed by Ascaris Iumbricoides (20.0%), then Entamoeba histolytica (18.0%). Parasitosis was generally declining with older age groups for both sexes. In general, the prevalence of anaemia was more common in the younger children. Malnutrition was found to be prevalent among children. Infected children of age group 8-9 years showed higher incidence of low WA than non infected ones. The prevalence of stunting and wasting among infected children of the youngest group was greater than that observed for controls. Regarding sex, no specific trend that relates the prevalence of anaemia with sex. Malnutrition was more prevalent among females than males.