Metastatic Renal Cell Carcinoma to the Soft Tissue 27 Years after Radical Nephrectomy: A Case Report.

Background and Objectives: Approximately 20-40% of patients affected with renal cell carcinoma (RCC) develop either distant metastatic or locally recurring disease following radical nephrectomy. Soft tissue, skin, and the central nervous system are less common metastatic sites. We present the case of a patient who has received a diagnosis of RCC; it was found that she had no metastases at the time of nephrectomy but had metastases in the soft tissue and subcutaneous tissue of the scalp 27 years later. As far as we can tell, this is the longest period elapsed between primary renal tumor and subcutaneous/soft tissue metastasis; moreover, this case is the first report of a combined soft tissue/subcutaneous metastasis from RCC. Case presentation: A 73-year-old woman underwent right radical nephrectomy 27 years earlier for clear cell renal cell carcinoma (CCRCC). She presented at our unit because she noticed swelling in the left temporal region; after radiological exams, a benign lesion was suspected. The patient underwent surgical eradication, but the massive bleeding did not allow the removal of the lesion. A biopsy of the mass was performed and the histological examination was consistent with RCC metastases. Conclusions: Metastases from renal cell carcinoma to the subcutaneous and soft tissues are rare. It is essential to take into account RCC metastases in the differential diagnostic of the new starting mass of the head and neck, and the necessity for close and continuous surveillance of patients diagnosed with renal cancer even after a long disease-free period should be emphasized.

Reply to De Luca et al. Comment on "Marra et al. Metastatic Renal Cell Carcinoma to the Soft Tissue 27 Years after Radical Nephrectomy: A Case Report. Medicina 2023, 59, 150".

We appreciated the comments of De Luca and colleagues [...].

Acellular dermal matrix in breast augmentation surgery: A systematic review.

Background: The use of acellular dermal matrix (ADM) in breast reconstruction was described for the first time in 2000s. Recently, ADMs have been used not only in reconstructive surgery but also in cosmetic breast surgery for both primary and revision indications. Therefore, the matrices represent an important support to recent surgical techniques for breast augmentation in treatment or prevention of complications. Conversely, ADMs can affect operative times, costs, and additional complications related to their placement. A review of the literature was carried out to evaluate the efficacy, safety, and indication for the use of these matrices in cosmetic breast surgery. Methods: A literature review was conducted including manuscripts published up to April 2023 on breast augmentation using ADM. PubMed and MEDLINE were the databases used for research. The keywords used were "Breast augmentation" and "Acellular Dermal Matrix." Non-English language articles have been excluded. Results: The initial search for "breast augmentation" yielded 7900 results, which were further reviewed for "Acellular Dermal Matrices" in breast augmentation, selecting 74 articles. Following further screening, 12 articles were included in the review. A total of 787 patients were treated with breast augmentation and ADM placement. The main indication was capsular contracture (60%). Conclusions: The current evidence from the published scientific literature, albeit limited, suggests the indication for the use of ADM in revision surgery, to support the prosthetic pocket, to minimize the risk of capsular contracture and its recurrence.

Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy.

Background: Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods: This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results: All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found (p = 0.002 and p < 0.00001, respectively). Conclusions: A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.

Giant thigh lipomas: from a case report to a guide for the surgical approach.

The issue of international migration and health has received increased attention since its rise due to empirical studies on the immigrant paradox. Less examined has been research focused on countries in the Global South with growing immigrant population share and contentious debates on implications. Using data from the longitudinal National Income Dynamics Study (NIDS) (2008-2017) and panel logistic regression this study focused on evaluating whether reported physical health, mental health, and life satisfaction are all associated with immigrant status in South Africa. Accounting for several sociodemographic factors, results emanating from analysis showed no significant evidence of association between overall immigration status and self-reported health or life satisfaction. This however did not apply to depression as immigrants were found to be significantly less likely to report depressive level scores. Interestingly, preference to migrate was also found to be significantly associated with depression, and life satisfaction. Further evaluation amongst racial groups showed that African immigrants are also significantly more likely to report better health than non-immigrant counterparts. This study argues for the need of contextualisation of the immigrant paradox as evidence thereof varies dependent on specific outcomes and communities. The importance of other associated social determinants of wellbeing is also highlighted since gender, race, age, class, education, relationship status, location, and behavioural factors were found to be significantly associated with wellbeing. Policies should thus be aimed at reducing structural inequalities in broad whilst also introducing social programmes that reduce behavioural or lifestyle activities that have negative implications on wellbeing.

Ultramicronized Palmitoylethanolamide and Luteolin: Drug Candidates in Post-COVID-19 Critical Illness Neuropathy and Positioning-Related Peripheral Nerve Injury of the Upper Extremity.

Coronavirus disease 2019 (COVID-19) is the most dramatic pandemic of the new millennium and patients with serious infection can stay in intensive care unit (ICU) for weeks in a clinical scenario of systemic inflammatory response syndrome, likely related to the subsequent development of critical illness polyneuropathy (CIP). It is in fact now accepted that COVID-19 ICU surviving patients can develop CIP; moreover, prone positioning-related stretch may favor the onset of positioning-related peripheral nerve injuries (PNI). Therefore, the urgent need to test drug candidates for the treatment of these debilitating sequelae is emerged even more. For the first time in medical literature, we have successfully treated after informed consent a 71-year-old Italian man suffering from post-COVID-19 CIP burdened with positioning-related PNI of the left upper extremity by means of ultramicronized palmitoylethanolamide 400 mg plus ultramicronized luteolin 40 mg (Glìalia), two tablets a day 12 hours apart for 6 months. In the wake of our pilot study, a larger clinical trial to definitively ascertain the advantages of this neuroprotective, neurotrophic, and anti-inflammatory therapy is advocated.

Combining gemcitabine and MSC delivering soluble TRAIL to target pancreatic adenocarcinoma and its stroma.

Pancreatic ductal adenocarcinoma (PDAC) still has a poor response to therapies, partly due to their cancer-associated fibroblasts (CAFs). Here, we investigate the synergistic impact of a combinatory approach between a known chemotherapy agent, such as gemcitabine (GEM), and gene-modified human mesenchymal stromal/stem cells (MSCs) secreting the pro-apoptotic soluble (s)TRAIL (sTRAIL MSCs) on both PDAC cells and CAFs. The combo significantly impacts on PDAC survival in 2D and 3D models. In orthotopic xenograft models, GEM and sTRAIL MSCs induce tumor architecture shredding with a reduction of CK7- and CK8/18-positive cancer cells and the abrogation of spleen metastases. A cytotoxic effect on primary human CAFs is also observed along with an alteration of their transcriptome and a reduction of the related desmoplasia. Collectively, we demonstrate a promising therapeutic profile of combining GEM and sTRAIL MSCs to target both tumoral and stromal compartments in PDAC.

The Overwhelming Postsplenectomy Sepsis: Role of Plastic Surgeon.

The overwhelming post-splenectomy infection (OPSI) is a feared late complication of splenectomy, with high morbidity and a mortality rate of up to 50%. Although the management of this syndrome is the duty of clinical physicians, the interest of plastic surgeons in OPSI is related to the injury that can occur in tissues with an end circulation, such as the limb extremities, nasal tip, and lips. In the management of OPSI, surgical techniques are not highlighted. The role of the plastic surgeon can be fundamental for the prevention of further extension of the necrotic tissue, improving as much as possible the vascularization around it. Moreover, a critical role in the management of OPSI is avoiding superinfection of the necrotic areas by combining different techniques and methods, such as surgical debridements, negative pressure wound therapy, and conservative treatment. Last but not least, functional and aesthetic restoration of the injured parts is of paramount importance for the final outcome. In this article, we describe the management of two unvaccinated patients with necrosis of the extremities after OPSI.

Factors influencing final rendering in areola tattoo reconstruction: a statistical analysis.

BACKGROUND AND AIM: Reconstruction of the nipple-areola complex announces the end of breast reconstruction process, sometimes difficult to live for the patient, and significantly improves the perception of body image. In literature there are no studies addressing the possible influencing factors of the final rendering of areola reconstruction with tattoo. The aim of the present study was to evaluate all the factors which could influence the yield and the final result of the nipple areola complex pigmentation. METHODS: 97 patients who underwent areolar tattooing between January 2018 and February 2020 were retrospectively reviewed. Breast reconstruction timing and personal history, as well as surgical details were recorded. RESULTS: Mean age was 52 years old (range 29-71), almost the totality of cases was women including even 2 men (one with Poland syndrome and one post mastectomy). 27 patients needed bilateral tattooing. 22 had history of adjuvant radiotherapy, 16 received neoadjuvant chemotherapy and 4 adjuvant chemotherapy. In the logistic regression analysis, radiotherapy resulted a risk factor for retattooing (p<0.05) while the autologous breast reconstruction resulted a protective factor for retattooing. Neo - and adjuvant chemotherapy were not statistically significant. CONCLUSIONS: Tissue thickness, sex, reconstructive technique and history of radiotherapy could influence the final result in areola reconstruction with tattoo, and must be taken into account to obtain the best result, knowing when the pigmentation has to be repeated.

Radial forearm flap versus antero-lateral thigh flap in oral soft tissue reconstruction: update and statistical analysis on our 77 consecutive cases for an objective selection criteria.

BACKGROUND AND AIM: The radial forearm free flap (RFFf) and the antero-lateral thigh flap (ALTf) are considered the "key flaps" for oral cavity reconstruction. Nowadays, the literature lacks of an objective and standardized decision-making algorithm for the flap choice. The aim of this study is to describe a decision-making algorithm concerning the more appropriate flap, RFFf or ALTf, in the reconstruction of intra-oral soft tissues based on the volumetric analysis of the defect with a pre-operative Magnetic Resonance Imaging (MRI), updating our previous surgical experience. METHODS: We conducted a retrospective observational study including 77 patients who underwent microsurgical reconstruction with RFFf or ALTf after tumor resection of the soft tissues in the oral cavity. During follow-up, patients were evaluated using the UW-QOL questionnaire. RESULTS: Analyzing the scores of the UW-QOL questionnaire based on the size of the tumor on preoperative MRI we found that for tumor volume <50cc and between 50-70cc, the patients reconstructed with RFFfobtained statistically significant better scores compared to the ALTf group, while for tumor volume >70cc, the patients reconstructed with ALTf reported statistically significant better scores. CONCLUSIONS: Pre-operative RMI-guided volumetric assessment of oral cancer plays a key role in the planning of adequate soft tissue reconstruction and can objectively help surgeons in the correct choice of the flap (RFFf vs. ALTf) for each case based on preoperative tumor size, suggesting for defects <50cc and between 50 and 70 cc a reconstruction with RFFf, while for defects >70cc a reconstruction with ALTf.

Adipose-derived stromal vascular fraction (SVF) for the treatment of androgenic alopecia (AGA): a systematic review.

BACKGROUND AND AIM: Androgenetic alopecia (AGA) is a common chronic, hereditary, cutaneous and androgen-dependent condition. Low self-esteem and negatively impact quality of life are often consequences of AGA. Clinical treatment of AGA using SVF (Stromal vascular fraction) has been effective. In fact, hair follicle is affected by various environment factors and one of the most important factors is the vascularity of the scalp which is itself affected bySVF. METHODS: During October 2022 we carried out a systematic review to identify all scientific publications discussing about hair loss treatment with stromal vascular fraction or adipose stem cell. We selected 140 articles. After screening process, we kept 9 articles complying with inclusion criteria.  Results: No serious adverse events were reported in all studies. Despite standardized protocol was not found, all studies reported a statistically significant increase in the number (density) of hair after SVF treatment. Two studies found a significant improvement at pull test. An increase of hair diameter was noticed after treatment. The combination between medical therapy and SVF proved to be advantageous. CONCLUSIONS: SVF is nowadays at the center of studies in the field of regenerative medicine due to its potential applications in many branches of medicine and surgery. The initial results are very promising but furthermore studies are necessary to establish a methodical and systematic research capable of demonstrating its real benefits and the creation of homogenous treatment protocols.

Reconstruction of Complex Anterior Chest Wall Defects: The Lasagna Technique.

Background: Sternal tumors are rare, comprising only 0.94% of all bone tumors, with the majority being sarcomas. An extensive composite defect is often the result of surgical resection. Reconstruction of this anatomical area is a challenge for plastic surgeons. Reconstruction must fulfil two different tasks: restoration of soft tissues and stabilization of the chest wall. Both are well defined, and many techniques have been historically proposed. Methods: We present the case of a 66-year-old man affected by sternal metastasis of lung non-small cell carcinoma with sarcomatoid features. After wide tumor resection, a large defect was created. Results: The patient underwent a complex multilayer reconstruction that combined multiple techniques: Gore DualMesh to reconstruct the pericardial plane and protect the heart muscle, omental flap to facilitate integration of the mesh, titanium bars to recreate chest wall stability, and bilateral pectoralis muscle flaps to cover hardware. This multilayer reconstruction was named the "lasagna technique." Conclusions: Due to the rarity of primary malignancies of the sternum, it is difficult to standardize a therapeutic approach. For this reason, it is necessary to customize the surgical treatment by combining several techniques and materials. Our lasagna technique may be considered a valuable option in treating these complex reconstructive cases.

Novel bioprinted 3D model to human fibrosis investigation.

Fibrosis is shared in multiple diseases with progressive tissue stiffening, organ failure and limited therapeutic options. This unmet need is also due to the lack of adequate pre-clinical models to mimic fibrosis and to be challenged novel by anti-fibrotic therapeutic venues. Here using bioprinting, we designed a novel 3D model where normal human healthy fibroblasts have been encapsulated in type I collagen. After stimulation by Transforming Growth factor beta (TGFß), embedded cells differentiated into myofibroblasts and enhanced the contractile activity, as confirmed by the high level of α - smooth muscle actin (αSMA) and F-actin expression. As functional assays, SEM analysis revealed that after TGFß stimulus the 3D microarchitecture of the scaffold was dramatically remolded with an increased fibronectin deposition with an abnormal collagen fibrillar pattern. Picrius Sirius Red staining additionally revealed that TGFß stimulation enhanced of two logarithm the collagen fibrils neoformation in comparison with control. These data indicate that by bioprinting technology, it is possible to generate a reproducible and functional 3D platform to mimic fibrosis as key tool for drug discovery and impacting on animal experimentation and reducing costs and time in addressing fibrosis.

Cubital Tunnel Syndrome Temporally after COVID-19 Vaccination.

Coronavirus disease 2019 (COVID-19) is the most dramatic pandemic of the new millennium. To counter it, specific vaccines have been launched in record time under emergency use authorization or conditional marketing authorization and have been subjected to additional monitoring. The European Medicines Agency recommend reporting any suspected adverse reactions during this additional monitoring phase. For the first time in the available medical literature, we report a left cubital tunnel syndrome in a 28-year-old right-handed healthy male after seven days from the first dose of Spikevax® (formerly Moderna COVID-19 Vaccine). Histochemistry for Alcian Blue performed on the tissue harvested from the cubital site reveals myxoid degeneration of the small nerve collaterals, a clear sign of nerve injury. It still remains unclear why the syndrome occurs in a localized and not generalized form to all osteofibrous tunnels. Today, modified messenger ribonucleic acid vaccines as Spikevax® represent an avantgarde technological platform with a lot of potential, but one which needs careful monitoring in order to identify in advance those patients who may experience adverse events after their administration.

Clinical Evaluation of the Efficacy and Tolerability of Rigenase® and Polyhexanide (Fitostimoline® Plus) vs. Hyaluronic Acid and Silver Sulfadiazine (Connettivina® Bio Plus) for the Treatment of Acute Skin Wounds: A Randomized Trial.

OBJECTIVES: Compare the efficacy and tolerability of Connettivina® Bio Plus (Group A) gauze and cream, and Fitostimoline® Plus (Group B) gauze and cream for the treatment of acute superficial skin lesions. DESIGN: Single-center, parallel, randomized trial. A block randomization method was used. SETTING: University of Salerno-AOU San Giovanni di Dio e Ruggi d'Aragona. PARTICIPANTS: Sixty patients were enrolled. All patients fulfilled the study requirements. INTERVENTION: One application of the study drugs every 24 h, and a six-week observation period. MAIN OUTCOME MEASURES: Efficacy and tolerability of the study drugs. RESULTS: In total, 60 patients (Group A, n = 30; Group B, n = 30) were randomized; mean age was 58.5 ± 15.8 years. All patients were included in the outcome analysis. Total wound healing was achieved in 17 patients undergoing treatment with Connettivina® Bio Plus and 28 patients undergoing treatment with Fitostimoline® Plus. The greater effectiveness of the latter was significant (p = 0.00104). In Group B, a significantly greater degree of effectiveness was observed in reducing the fibrin in the wound bed (p = 0.04746). Complications or unexpected events were not observed. CONCLUSIONS: Both Connettivina® Bio Plus and Fitostimoline® Plus are secure and effective for treating acute superficial skin lesions. Fitostimoline® Plus was more effective than Connettivina® Bio Plus in wound healing of acute superficial skin lesions, especially if fibrin had been observed in the wound bed.

Establishing a comprehensive search strategy for Indigenous health literature reviews.

BACKGROUND: Appropriate search strategies are essential to ensure the integrity and reproducibility of systematic and scoping reviews, as researchers seek to capture as many relevant resources as possible. In the case of Indigenous health reviews, researchers are met with the special challenge of creating a search strategy that can encompass this large, diverse population group with no universally agreed upon identification criteria. MAIN BODY: With an aim to promote improved review methodologies that uphold standards of justice, autonomy, and equity for Indigenous peoples and other heterogeneous populations, we describe critical gaps and approaches to close them. We report organizational and transparency issues around how Indigenous populations are indexed in several major databases, and draw on examples of published reviews and protocols to demonstrate the challenges inherent to creating a comprehensive search strategy. CONCLUSIONS: The conduct and communication of results from health literature research on global Indigenous populations are compromised by challenges of methodology that are rooted in the complexities inherent to defining Indigenous peoples. These challenges must be urgently addressed to improve this important field of inquiry moving forward.