Perioperative pain management after scapular tip free flap harvesting for head and neck reconstruction using mini-catheters to inject the local anesthetic.

PURPOSE: Although functional and esthetic results after the use of a scapular tip free flap (STFF) in head and neck reconstruction, and the related donor-site morbidity, have been extensively described, data regarding acute postoperative donor-site pain management are lacking. Purpose of this study is to explore the use of mini-catheters to administer local anesthetics for donor-site pain management after reconstruction using STFF. METHODS: Patients who underwent head and neck reconstruction using a STFF were prospectively enrolled and, through a perineural catheter placed in the donor site during the surgical procedure, a bolus of chirochaine was injected before the patient regained consciousness and at 8, 16, and 24 h postoperatively. Before and 40 min after each dose administration, donor-site pain on a numerical rating scale (NRS; 0-10) was evaluated. RESULTS: Study population consisted of 20 patients (40-88 years). At 8 h, the pain scores before and after the injection were 0-10 (mean 3.35) and 0-5 (mean 1.25), respectively. At 16 h, the pain scores before and after the injection were 0-8 (mean 2.55) and 0-4 (mean 0.55), respectively. At 24 h, the pain scores before and after the injection were 0-8 (mean 1.30) and 0-4 (mean 0.30), respectively. CONCLUSION: Statistical analysis confirmed a significant difference between the pain scores before and after administration at 8, 16, and 24 h (p < 0.001, p < 0.001, and p = 0.003, respectively). Mini-catheters for local anesthetic administration represent an effective strategy for pain control after STFF harvesting for head and neck reconstruction.

Microvascular reconstruction of the mandible with medial femoral condylar flap for treatment of mandibular non-union.

Mandibular non-union occurs in 2-9% after open reduction and internal fixation of a mandibular fracture (trauma surgery, orthognathic cases, access osteotomy for oncological purposes). The medial femoral condyle (MFC) has emerged more recently as one of the most versatile donor sites in the treatment of challenging bone reconstruction. This is the first description of MFC for treatment of mandibular non-union. A retrospective chart review was conducted for all patients who underwent reconstruction with a microvascular MFC flap for bone defects of the head and neck area between January 2015 and December 2018 at Careggi Hospital of Florence. Inclusion criteria were patients where the FMC was used for mandibular defects arising due to non-union. Seven patients presented mandibular defects reconstructed by MFC flap and were included in this investigation (two cases of segmental mandible defect due to post-traumatic non-union; two patients of pathological mandibular fracture after prolonged bisphosphonate therapy for osteoporosis; three patients with mandibular continuity loss after failed orthognathic surgeries). At one-year follow-up, all patients had satisfactory occlusion. One-year postoperative CTs revealed full osteointegration of the flaps. In conclusion, the MFC free flap is an attractive option for mandibular reconstruction. Small defects (3-5 cm) in poorly vascularized beds are the ideal target.

Orthognathic surgery for juvenile idiopathic arthritis of the temporomandibular joint: a critical reappraisal based on surgical experience.

Juvenile idiopathic arthritis (JIA) involving the temporomandibular joint (TMJ) can result in significant dentofacial deformities that may require orthognathic surgical correction. The aim of this study was to assess the functional and aesthetic results relative to stability after bimaxillary surgery with counterclockwise rotation of the occlusal plane in patients with JIA. A retrospective chart review was conducted of all patients affected by JIA who underwent orthognathic surgery between January 2000 and December 2019 at the Face Surgery Centre (Parma, Italy). Patient records were evaluated for surgical indications, complications, and outcomes. The final study sample included 13 patients (12 female, one male). The mean age of the patients was 18.6 years (range 17-26 years) at the time of surgery; 12 patients had bilateral TMJ disease. At the 1-year follow-up, all patients except one had a stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. The 1-year postoperative cone beam computed tomography (CBCT) scan revealed complete ossification at all osteotomy sites. Bilateral sagittal split osteotomy with mandibular advancement is an effective procedure with a low rate of complications for patients with JIA with stable disease confirmed by preoperative CBCT or magnetic resonance imaging.

What impact can hospitalization environment produce on the ANS functioning in patients with Unresponsive Wakefulness Syndrome? - 24-hour monitoring.

Objectives: Studies showed that the recovery of patients with Unresponsive Wakefulness Syndrome (UWS) is also correlated to the recovery of circadian rhythms. In this study, we observed the correlations between patients with UWS biometrical and ambient parameters. Methods: A dedicated monitoring system was realized to record and correlate the level of noise and luminosity with biometric Heart Rate (HR), Heart Rate Variability (HRV) and Breath Rate (BR) parameters. Eleven patients with UWS were recruited and monitored for 13 ± 7 days. Correlation of ambient and biometric parameters was analyzed by Spearman's test. Wilcoxon's test was used to compare the biometric parameters in two different moments of daily activity in the rehabilitation unit (night and day). Patients showed a moderate negative or positive correlation between biometric and ambient parameters. Results: Significant differences between night and morning (0.0001 < p ≤ 0.001) were found for HR, HRV and BR in seven, five and four patients, respectively, at Wilcoxon's test. HR and BR were higher during the night while HRV was lower. Conclusion: In patients with UWS, lower HRV and higher HR and BR during the night might be indicative of interference in sleep/wake cycles. The modifications of the environment surrounding the patient due to the unit procedures of the staff and/or some interaction modalities of the relatives may have an effect on residual endogenous mechanisms of self-regulation. However, differences between night and day in the biometrical parameters are not necessarily linked to the changes in the environment care unit.

Coma recovery scale-r: variability in the disorder of consciousness.

BACKGROUND: Despite evidence from neuroimaging research, diagnosis and early prognosis in the vegetative (VS/UWS) and minimally conscious (MCS) states still depend on the observation of clinical signs of responsiveness. Multiple testing has documented a systematic variability during the day in the incidence of established signs of responsiveness. Spontaneous fluctuations of the Coma Recovery Scale-revised (CRS-r) scores are conceivable. METHODS: We retrospectively analyzed the CRS-r repeatedly administered to 7 VS/UWS and 12 MCS subjects undergoing systematic observation during a conventional 13 weeks. rehabilitation plan. RESULTS: The CRS-r global, visual and auditory scores were found higher in the morning than at the afternoon administration in both VS/UWS and MCS subgroups over the entire period of observation. The probability for a VS/UWS subject of being classified as MCS at the morning testing at least once during the 13 weeks. observation was as high as 30%, i.e., compatible with the reported misdiagnosis rate between the two clinical conditions. CONCLUSIONS: Multiple CRS-r testing is advisable to minimize the risk of misclassification; estimates of spontaneous variability could be used to characterize with greater accuracy patients with disorder of consciousness and possibly help optimize the rehabilitation plan.

Closed reduction of the isolated anterior frontal sinus fracture via percutaneous screw placement.

Fractures of the frontal sinus are a common maxillofacial trauma and constitute 5-15% of all maxillofacial fractures. Conventional surgical approaches include the coronal flap, direct cutaneous incision, and endoscopic techniques. Minimally invasive techniques have recently been described for the reduction of the isolated anterior frontal sinus fracture via a closed approach. The medical records and radiological findings of all patients who underwent surgical treatment for anterior frontal sinus fractures from January 2009 to December 2013 at the study hospital in Florence, Italy, were reviewed. The final study sample consisted of 15 patients (13 males and two females) with isolated anterior frontal sinus fractures who were treated with closed reduction using percutaneous screws. The mean age was 32.1 years. The skin incisions healed without any visible scarring, and no depressions of the frontal sinuses were evident in the postoperative period. Computed tomography scans performed at 6 months postoperatively showed adequate reduction of the displaced fragments. This closed technique is a good option for displaced isolated fractures of the anterior frontal sinus. However, the technique is not adequate for complex fractures of the frontal sinus.

A study of the reliability of the Nociception Coma Scale.

OBJECTIVE: In this study, we investigated the reliability of the Nociception Coma Scale which has recently been developed to assess nociception in non-communicative, severely brain-injured patients. DESIGN: Prospective cross-sequential study. SETTING: Semi-intensive care unit and long-term brain injury care. SUBJECTS: Forty-four patients diagnosed as being in a vegetative state (n=26) or in a minimally conscious state (n=18). INTERVENTIONS: Patients were assessed by two experts (rater A and rater B) on two consecutive weeks to measure inter-rater agreement and test-retest reliability. MAIN MEASURES: Total scores and subscores of the Nociception Coma Scale. RESULTS: We performed a total of 176 assessments. The inter-rater agreement was moderate for the total scores (k = 0.57) and fair to substantial for the subscores (0.33 ≤ k ≤ 0.62) on week 2. The test-retest reliability was substantial for the total scores (k = 0.66) and moderate to almost perfect for the subscores (0.53 ≤ k ≤ 0.96) for rater A. The inter-rater agreement was weaker on week 1, whereas the test-retest reliability was lower for the least experienced rater (rater B). CONCLUSIONS: This study provides further evidence of the psychometric qualities of the Nociception Coma Scale. Future studies should assess the impact of practical experience and background on administration and scoring of the scale.

Surgical approach to isolated bilateral orbital floor fractures.

Isolated bilateral orbital floor fractures are uncommon and are rarely described in the scientific literature. They are usually seen in association with naso-ethmoidal fractures, zygomatic fractures, or fractures of the middle third. We report our experience in the management of a patient presenting bilateral isolated orbital floor fracture. The difficulties in management of these fractures are due to the lack of an uninjured contralateral side for intraoperative comparison.

Cystic gastrointestinal stromal tumors of the pancreas simulating cystoadenocarcinoma. Report of three cases and short review of the literature.

Gastrointestinal stromal tumors (GISTs) represent a distinct subset of mesenchymal tumours of the gastrointestinal tract. They are more common in the stomach and small intestine, and are characterized by the proliferation of spindle or epithelioid cells and by the expression of CD117. Extra-gastrointestinal stromal tumors are rare and only 13 cases of pancreatic GISTs have been reported in the literature, only 1 of which presented as a cystic lesion. Mutational analysis of KIT and Platelet derived growth factor receptor-α genes was performed only in two out of the 13 cases. We report 3 cases of cystic GISTs of the pancreas, radiologically mimicking a cystoadenocarcinoma. Routine histopathology and molecular characterization of the tumours have been performed. In two of them, molecular analysis showed unusual genetic alterations (the internal repeat of codon 502 and 503 in exon 9 of the KIT gene and the KIT exon 9 single nucleotide substitution c.1427G⟩T). Pancreatic GIST should be included in the differential diagnosis of both cystic and solid masses of the pancreas. The diagnosis should be accomplished by a combination of radiology, histology, immunohistochemistry and molecular biology. The evaluation of CD117 expression and the sequence analysis of KIT and Platelet derived growth factor receptor-α gene is mandatory for therapy.

Efficacy and safety of maxillomandibular advancement in treatment of obstructive sleep apnoea syndrome.

To assess the effectiveness of maxillomandibular adavancement for treatment of adults with obstructive sleep apnoea, we report the results obtained after maxillomandibular advancement. A group of 16 patients were studied before surgery, at 6 months after surgery and at followup. The analysis included: upper airway endoscopy during Mueller's manoeuvre, lateral cephalometry, polysomnography and Epworth Sleepiness Scale. The results of surgical treatment were divided into "surgical success" and "surgical cure". The former was defined as an AHI < 20 events/hour and a > 50% reduction in AHI after surgical procedure, while the latter was defined as an AHI < 5 events/hour after surgical procedure. At follow-up, all patients had AHI < 20 events/hour with a surgical success rate of 100%. The surgical cure rate was 37.5%, with 6 patients having an AHI < 5 events/hour. Surgical success and long term stability of outcomes confirm the efficacy and safety of MMA for treatment of obstructive sleep apnoea syndrome. However, a continuous follow-up of these patients is necessary to control their lifestyle and to detect possible relapse.

Intraoral extra-mucosal fixation of fractures in the atrophic edentulous mandible.

Atrophy of the mandible leads to a decrease in the bone mass, making it more vulnerable to fractures. A direct relationship has been demonstrated between the height of the bone in the area of the fracture and the incidence of postoperative complications of bone healing. Basic principles of fracture management in both edentulous and non edentulous patients are open reduction and internal fixation with osteosynthesis of the fracture to achieve restoration in terms of aesthetics and functionality. Several authors have discussed the advantages and disadvantages of the transoral and extraoral approaches. Between January 2007 and June 2011, 13 patients affected by bilateral fractures of atrophic mandibles were treated by extra-mucosal intraoral stabilization with satisfactory results. This approach reduces the risks of damage of the marginalis mandibulae nerve with low operation time, while avoiding unsightly scars.

Vacuum-assisted closure therapy in reconstructive surgery.

In 1997, supported by experimental work, Argenta published a clinical report describing a variety of complicated wounds whose treatment responded successfully to negative pressure dressings using a vacuum-assisted closure system (VAC) (Kinetic Concepts Inc., San Antonio, TX). This system has been successfully used in the fields of orthopaedics and traumatology, general surgery, plastic and reconstructive surgery and gynaecology/obstetrics for a large variety of complicated wounds located in several regions, particularly in the torso and extremities. To the best of our knowledge, the use of the VAC therapy in treating free flaps surgical wounds has not been discussed in the literature. Since 2009 at the Novara Major Hospital, we have been using the VAC therapy in selected cases for difficult and complicated wounds of the maxillofacial region. The purpose of this study is to describe and discuss three cases undergoing VAC therapy followed by loco-regional flaps in the management of exposed bone after fibular free flap. The advantages and disadvantages of VAC therapy in treating complicated wounds have been reported by several studies; compared with conventional wet-to-dry dressings, this system eliminates interstitial oedema, exudates and debrides while increasing blood perfusion leading to a more rapid promotion of wound healing with less bacterial loading. Although surgical debridement, wet-to-dry dressing changes and antibiotic treatment are the mainstay in managing maxillofacial wounds, VAC therapy can be used to obtain primary closure or to prepare the wound bed until definitive reconstruction is carried out. In our opinion, the VAC technique is an innovative therapy, and at our institution represents the standard of care for the majority of complicated wounds.

Human decidual natural killer cells as a source and target of macrophage migration inhibitory factor.

The human uterine mucosa of early pregnancy is largely populated by CD56(bright) natural killer (NK) cells (uterine (u) NK cells). The specific functions of these cells are still unknown, but their interaction and response to foetal trophoblasts are thought to be important for the establishment of a successful pregnancy. The study reported herein shows that uNK cells respond to, and produce, macrophage migration inhibitory factor (MIF), a cytokine highly expressed in the human placenta and in the cyclic and pregnant endometrium. Recombinant human MIF reduced in a dose-dependent manner the cytolytic activity of purified uNK cells against K562 cells. RT-PCR, Western blot analysis and ELISA demonstrated the synthesis and secretion of the cytokine by uNK cells. Double immunofluorescence staining showed the presence of MIF in uterine CD56 + cells. Finally, neutralization of the endogenous cytokine by a polyclonal antibody resulted in a sharp increase in the cytolytic activity of uNK cells. These findings indicate the existence of a previously unrevealed paracrine and autocrine action of MIF on uNK cells and support its contribution to the immune privilege at the maternal-foetal interface.

Identification of urocortin mRNA and peptide in the human endometrium.

Urocortin is a 40-amino acid peptide belonging to the corticotropin-releasing factor (CRF) family. In human reproductive tissues, urocortin expression has been previously demonstrated in the ovary, in the placenta and fetal membranes and in pregnant uterine tissues, while no data are available on the expression of the peptide in the nonpregnant uterus. In this study, urocortin expression was evaluated by both immunohistochemistry and reverse transcription-polymerase chain reaction, in human uterine tissues and cells at different phases of the menstrual cycle. Urocortin was immunolocalized in endometrial epithelial and stromal cells, as well as in the myometrium, and in vascular smooth muscle cells. No differences between proliferative and secretory phase were observed. These results were confirmed by reverse transcription-polymerase chain reaction analysis of isolated endometrial epithelial and stromal cells, and myometrial specimens. These findings open new questions on the roles played by urocortin in the human uterus.

Gonadal malignant germ cell tumors express immunoreactive inhibin/activin subunits.

OBJECTIVE: Inhibin and activin are proteins produced by ovarian granulosa cells and testicular Sertoli cells and are members of the transforming growth factor-beta superfamily. Since increased circulating levels of immunoreactive inhibin were detected in women with malignant ovarian tumors, they were proposed as tumor markers for ovarian carcinoma. Immunohistochemical studies later confirmed the presence of inhibin and activin subunits in granulosa cell tumors and epithelial ovarian cancer, as well as in Sertoli and Leydig cell testicular cancer. However, there is discrepant information on the detection of inhibin and activin in malignant germ cell tumors (MGCT). The aim of the present study was to evaluate the immunohistochemical expression of the inhibin/activin alpha, betaA and betaB subunits in ovarian and testicular MGCT specimens using polyclonal antisera. METHODS: The ovarian tissue samples were composed of 19 MGCT, including dysgerminoma (n=18) and yolk sac tumor (n=1). The testis specimens included classic seminomas (n=20), embryonal carcinomas (n=7), choriocarcinomas (n=2), and yolk sac tumor (n=1). RESULTS: Ovarian and testicular malignant germ cell tumors expressed positive staining for inhibin/activin alpha, betaA and betaB subunits, with some variations between and within individual tumors: while ovarian dysgerminomas were diffusely positive for alpha, betaA and betaB, testicular tumors expressed alpha and betaB subunits, whereas betaA staining was weak. CONCLUSIONS: The present results show positive staining for inhibin/activin subunits in ovarian and testicular MGCT, suggesting a possible role in tumorigenesis with the resultant clinical implication.

Macrophage migration inhibitory factor in the human endometrium: expression and localization during the menstrual cycle and early pregnancy.

Macrophage migration inhibitory factor (MIF) was discovered as an activated T-lymphocyte-derived protein that inhibits the random migration of macrophages in vitro. Subsequently, knowledge of the physiological actions of MIF was extended to include its role as a proinflammatory cytokine that affects several functions of macrophages and lymphocytes. Previous reports have suggested an involvement of MIF in reproduction. However, no data are currently available on the presence of this cytokine in the human endometrium. In this study, the expression and tissue localization of MIF was evaluated in specimens of cycling endometrium, first trimester placenta bed biopsy, and isolated endometrial glands by Western blot analysis, immunohistochemistry, ELISA, and reverse transcription-polymerase chain reaction. The results demonstrated that MIF is expressed in human endometrium across the menstrual cycle and in early pregnancy. Immunohistochemical localization identified the protein in glandular epithelium, in stromal and predecidualized stromal cells of cycling endometrium, as well as in the decidua of first-trimester placenta. The proinflammatory features and specific actions of MIF on lymphoid cells suggest its potential involvement in several aspects of endometrial physiology.

Macrophage migration inhibitory factor in prostatic adenocarcinoma: correlation with tumor grading and combination endocrine treatment-related changes.

BACKGROUND: Macrophage migration inhibitory factor (MIF) is a ubiquitary cytokine whose expression has been investigated in tumors, showing a correlation between tumor aggressiveness and production of this protein by neoplastic cells. The aim of our study was to correlate MIF expression with tumor grade (Gleason scoring system) and histopathological changes after combined endocrine treatment (CET) of prostate adenocarcinoma. METHODS: We analyzed MIF immunoreactivity in 124 paired needle biopsies and radical prostatectomy specimens from 62 prostate cancer patients, of which 20 had been treated with CET. RESULTS: In untreated prostates, MIF expression significantly correlated with tumor grading, being stronger in low-grade than in high-grade adenocarcinoma. In treated prostates, histopathological changes also correlated with MIF immunoreactivity, but not in a significant manner. CONCLUSIONS: The results of the current study demonstrated that with histological dedifferentiation, prostate adenocarcinoma cells show a reduced MIF expression. This finding may be the consequence of a reduced MIF synthesis or the result of an enhanced and altered secretion by tumor cells into the surrounding stroma. The consequent abnormal interaction between MIF and environmental factors might influence tumor growth and diffusion. On the other hand, the minor but not significantly reduced MIF expression by tumor cells after CET seems to exclude a hormonal regulation of MIF secretion.

Progestin regulation of 11beta-hydroxysteroid dehydrogenase expression in T-47D human breast cancer cells.

This study examined the enzymatic characteristics and steroid regulation of the glucocorticoid-metabolizing enzyme 11beta-hydroxysteroid dehydrogenase (11beta-HSD) in the human breast cancer cell line T-47D. In cell homogenates, exogenous NAD significantly increased the conversion of corticosterone to 11-dehydrocorticosterone, while NADP was ineffective. There was no conversion of 11-dehydrocorticosterone to corticosterone either with NADH or NADPH demonstrating the lack of reductase activity. In keeping with these results, RT-PCR analysis indicated a mRNA for 11beta-HSD2 in T-47D cells, while 11beta-HSD1 mRNA levels were undetectable. In T-47D cells treated for 24 h with medroxyprogesterone acetate (MPA), 11beta-HSD catalytic activity was elevated 11-fold, while estrone (E(1)), estradiol (E(2)) and the synthetic glucocorticoid dexamethasone (DEX) were ineffective. The antiprogestin mifepristone (RU486) acted as a pure antagonist of the progestin-enhanced 11beta-HSD activity, but did not exert any agonistic effects of its own. In addition, RT-PCR analysis demonstrated that MPA was a potent inducer of 11beta-HSD2 gene expression, increasing the steady-state levels of 11beta-HSD2 mRNA. Taken together, these results demonstrate that 11beta-HSD2 is the 11beta-HSD isoform expressed by T-47D cells under steady-state conditions and suggest the existence of a previously undocumented mechanism of action of progestins in breast cancer cells.