Prosthetically guided mandibular reconstruction using a fibula free flap: three-dimensional Bologna plate, an alternative to the double-barrel technique.

The fibula free flap represents the gold standard for mandibular reconstruction. However, when harvested as a single barrel, this flap does not allow the native mandibular height to be restored, which is required for implant-supported dental rehabilitation of the patient. The aim of this study was to present a new design for a patient-specific three-dimensionally printed reconstructive plate (3DBO-PSI) that positions the fibula bone at the height of the resected mandibular alveolar bone while restoring the mandibular profile to ensure a correct morphological outcome. Twenty patients were enrolled prospectively between January 2019 and May 2022. All patients underwent a segmental mandibular resection and prosthetically guided reconstruction making use of a fibula free flap supported by the 3DBO-PSI. The mean follow-up period was 20 months. All microvascular and implant-related complications were recorded. Microvascular failure occurred in two patients. No PSI-related complications were recorded during the postoperative follow-up. The proposed reconstructive method was found to be reliable and reproducible. In all treated patients, the bony flap appeared to be adequately positioned to maintain the preoperative intermaxillary relationship, as planned. To date, dental rehabilitation has been completed in seven patients.

Parametrizing the genioplasty: a biomechanical virtual study on soft tissue behavior.

PURPOSE: Sliding genioplasty is used to surgically correct a retruded or misaligned chin: in this procedure, an osteotomy is performed and the bony segment is repositioned. In this study we investigate the effect of surgical parameters (bony segment movement, osteotomy design) on postop soft tissue changes in a patient cohort. METHODS: Seven patients were retrospectively recruited. Cone beam computed tomography data were obtained and soft tissue and bone shape reconstructions were performed. 3D models were created and surgical cuts were replicated according to postop scans. Each model was imported in ANSYS 2019R1 (Ansys Inc, USA) for simulation: the effect of variation in osteotomy plane as well as extent of bony segment movement were assessed by means of design of experiment: surgical parameters were varied in a surgically acceptable range and the soft tissue predictions were evaluated as displacement output of five craniometric landmarks. RESULTS: Simulation results show the overall changes of the lower third of the face are sensitive to changes in horizontal and vertical displacement of the bony segment as well as segment rotation. No significant changes in the soft tissue response were to attribute to the osteotomy design. CONCLUSIONS: Our results are consistent with experimental findings reported in the literature: when planning genioplasty in orthognathic surgery, particular focus on the segment movement (horizontal translation, vertical translation and rotation), rather than on the design of the osteotomy itself, should be considered.

Bilateral cleft lip and palate without premaxillary protrusion is associated with lethal aneuploidies.

OBJECTIVE: To investigate the clinical implications of two categories of fetal bilateral cleft lip and palate (BCLP): with premaxillary protrusion and with a flattened profile. METHODS: This was a retrospective study of fetuses with a prenatal diagnosis of BCLP at the Department of Obstetrics and Gynecology of the University of Bologna in the period 1991-2005. RESULTS: BCLP was diagnosed prenatally in 14 cases (mean gestational age at diagnosis, 21 (range, 12-36) weeks). In nine of these, there was a premaxillary pseudomass; in the remaining five, the profile was flat. Associated structural and/or chromosomal anomalies were found in two of the nine with a premaxillary pseudomass and in all five of those with a flat profile (P = 0.02). All fetuses with a flat profile had aneuploidies (three trisomy 18, one trisomy 13, one trisomy 8 mosaic), as did one of the nine with a premaxillary pseudomass. Eight of the pregnancies were terminated, including three of those with a premaxillary pseudomass and all five of those without. All continuing pregnancies resulted in live births, although one neonate affected by Krabbe's disease died shortly after birth. CONCLUSIONS: Our findings suggest that a third of cases of BCLP diagnosed in utero have a flat profile and these are at high risk of lethal aneuploidies.

Characteristics of Type 2 diabetic patients cared for by general practitioners either with medical nutrition therapy alone or with hypoglycaemic drugs.

The essential role of medical nutrition therapy (MNT) for people with diabetes is widely recognised, and its exclusive use is recommended in mild diabetes according to a stepwise therapeutic approach. We describe the characteristics of MNT-treated Type 2 diabetic patients (vs drugs) cared for by general practitioners (GPs) in order to check that appropriate differences did exist between the two groups, by auditing the data from our local shared-care program for diabetes. We had 16,000 diabetic patients (out of 630,000 inhabitants); 6,800 of them (42.5%) cared for by GPs. Thirty-one percent (2,079 out of 6,800 patients cared for by GPs) were treated with MNT and 69% with drugs. The MNT-treated patients (vs drugs) were younger (66.1 +/- 10.7 vs 67.7 +/- 11.0 yr, p<0.01), had shorter disease duration (8.2 +/- 6.6 vs 11.2 +/- 7.6 yr, p<0.01), lower HbA1c (7.0 +/- 1.1 vs 7.8 +/- 1.6%, p<0.01) and body mass index (BMI) (28.6 +/- 4.6 vs 29.0 +/- 4.9 kg/m2, p<0.01). They had less prevalence of high blood triglycerides (25.4% vs 29.0%, p<0.01). MNT-treated patients had less micro-albuminuria (5.3% vs 8.8%, p<0.01); less retinopathy both non-proliferant (6.5% vs 11.1%, p<0.01), and pre-proliferant (6.8% vs 12.7%, p<0.01), and proliferant (7.0% vs 12.9%, p<0.01); less peripheral neuropathy (3.9% vs 8.3%, p<0.01); and diabetic foot (1.0% vs 2.0%, p<0.01). They had less chronic heart failure (2.7% vs 4.6%, p<0.01), and claudicatio intermittens (3.3% vs 5.3%, p<0.01). In conclusion, the Type 2 diabetic patients cared for by GPs using MNT appropriately had a less severe form of diabetes.

Audit of a shared-care program for persons with diabetes: baseline and 3 annual follow-ups.

In Italy, data on shared-care programs for diabetes are lacking. We described the characteristics of type 2 diabetic population assisted in general practice and evaluated 3 years of follow-up outcomes and performance indicators in a shared-care program in Modena, Italy (1998-2001); only well-controlled diabetic patients were considered. Forty-nine percent of territorial GPs adhered to the project (257 out of 521) and 77% of them sent 6409 paired baseline and follow-up datasheets. Altogether, 97.8% patients had type 2 diabetes, mean age 68.6+/-11.7 years, disease duration 9.6+/-7.5 years, BMI 28.6+/-4.8 kg/m2, HbA(1c) 7.6%+/-1.6%, 16.1% of them were disabled. Among the non-disabled patients, 23.6% had optimal glycemic control (HbA(1c) < or =6.5%); at baseline the prevalence of micro- and macrovascular diabetic complications was: 8.2% microalbuminuria and 2.4% macroalbuminuria plus nephropathy, 11.0% nonproliferative and 3.0% preproliferative retinopathy, 7.0% neuropathy, 1.8% diabetic foot; 8.5% angina, 6.9% TIA or stroke, 6.3% infarction, 5.2% intermittent claudication, 4.1% heart failure. Among the disabled patients 27.9% had optimal glycemic control, but they had more diabetic complications. The performance indicators significantly improved over the 3-year study period: glycemic control indicators increased from 66%-75% to 83%-90% and micro- and macrovascular indicators from 59%-65% to 75%-81%. The outcome indicators also improved: mean HbA(1c) value changed from 7.6%+/-1.6% to 7.3%+/-1.3% and the percentage of people with HbA(1c)< or =6.5% significantly improved over time. Similar trends were observed in both disabled and non-disabled diabetic patients.

A diagnosis of left ventricular hypertrophy on ECG is associated with a high cardiovascular risk: findings from a 40- to 69-year-old cohort in general practice.

OBJECTIVE: Left ventricular hypertrophy (LVH) is an independent cardiovascular (CV) risk factor in both sexes. We studied if a diagnosis of LVH on electrocardiogram (ECG) was associated with a 'high CV risk condition' among 40- to 69-year-old individuals cared for by GPs. METHODS: We studied 4250 individuals, 5.4% of whom had LVH. Cross-sectional frequencies, and age- and gender-adjusted statistical differences have been calculated. RESULTS: All the study variables were significantly worse for 'LVH' than 'non-LVH' individuals (except smoking). The 'LVH' had both a mean '5-year CV risk' significantly greater than 'non-LVH' individuals (27.0% versus 8.6%), and a significantly higher prevalence of a '5-year CV risk >15%' (89% versus 15%). CONCLUSIONS: A diagnosis of LVH on ECG among the adult individuals of an opportunistic cohort from general practice was associated with a 6-fold greater prevalence of a 'high CV risk condition'.

Sonography of pregnancies with first-trimester bleeding and a small intrauterine gestational sac without a demonstrable embryo.

OBJECTIVE: This was a prospective observational cohort study to evaluate the outcome and prognostic criteria of pregnancies with first-trimester bleeding and a gestational sac

Changes in long-term glycemic control and performance indicators in a cohort of type 2 diabetic patients cared for by general practitioners: findings from the "Modena Diabetes Project".

BACKGROUND AND AIM: General practitioners (GPs) are being increasingly asked to play a key role in the shared care of people with diabetes mellitus, but data concerning the effects of this in Italy are still scarce. We therefore evaluated the 4-year follow-up changes in outcomes and performance indicators in type 2 diabetic patients cared for by GPs in the framework of the "Modena Diabetes Project". METHODS AND RESULTS: Seventy-four percent of the local GPs participating in the project (387 out of 521) sent 5260 paired baseline and follow-up datasheets. The baseline characteristics of the type 2 diabetic patients (49.6% male) were a mean age of 67.3+/-11.2 years, a mean disease duration of 10.9+/-7.4 years, a mean BMI of 28.7+/-4.8 kg/m2, and a mean HbA1c level 7.56+/-1.52%. After four years follow-up, the individual before/after match-paired outcomes revealed an improvement in glycemic control: HbA1c levels significantly decreased to 7.39+/-1.31%, and the percentage of patients with HbA1c level of <6.5% significantly increased from 15.7% to 22.1%. There was also a significant decrease in body weight (from 78.3+/-14.8 to 77.6+/-14.6 kg) and BMI (from 28.8+/-4.8 to 28.5+/-4.9 kg/m2). The time trends of glycemic control significantly improved during the 4-year follow up, but those of the body weight and BMI values did not. Furthermore, the percentages of performance indicators matching the expected rate of recurrence per each year of follow-up significantly improved during the study period. CONCLUSIONS: Long-term glycemic control and the performance indicators relating to the type 2 diabetic patients participating in our shared care programme progressively improved.

Lymphotropic herpes virus (EBV, HHV-6, HHV-8) DNA sequences in HIV negative Castleman's disease.

Aim-To evaluate the possible involvement of lymphotropic herpes viruses in Castleman's disease.Methods-Archival formalin fixed, paraffin wax embedded biopsy specimens from 16 HIV negative patients (11 with localised and five of multicentric disease) were studied. Epstein-Barr virus (EBV), human herpes virus-6 (HHV-6) and human herpes virus-8 (HHV-8) DNA was detected using PCR. PCR was also used to characterise the EBV genomes and the clonal status of the lesions.Results-EBV sequences were identified in nine (56%) cases. The main EBV genotype detected was type 1. Two (12%) cases were positive for both HHV-6 and EBV sequences. HHV-8 sequences were detected in one case of localised Castleman's disease, the sequence of which differed from that of the HHV-8 prototype. No clonal immunoglobulin gene rearrangements were found.Conclusions-EBV DNA was detected in a substantial proportion of cases, suggesting that it may have a role in the pathogenesis of Castleman's disease, unlike HHV-6 which was detected rarely. This is the first report of HHV-8 specific sequences in the localised from of the disease.

Transvaginal sonography vs. hysteroscopy in the preoperative staging of endometrial carcinoma.

The aim of this study was to evaluate the diagnostic accuracy of transvaginal sonography vs. hysteroscopy in the preoperative staging of endometrial carcinoma, in order to establish the most appropriate surgical therapy. Transvaginal sonography and hysteroscopy were used preoperatively in 67 women with histologically proven endometrial carcinoma. Deep myometrial invasion (> 50%) was present at postoperative pathology in 26/67 (39%) women and spread to the cervix occurred in 11/67 (16%) women. Transvaginal sonographic examination was initially directed at assessing myometrial invasion, which was correctly predicted in 52/67 (78%) women. Transvaginal sonography demonstrated a sensitivity of 88% (23/26) and a specificity of 71% (29/41) for deep invasion, with a positive predictive value (PPV) of 66% (23/35) and a negative predictive value (NPV) of 91% (29/32). The accuracy of transvaginal sonography in detecting cervical involvement was 82% (55/67), and that of hysteroscopy was 72% (48/67): transvaginal sonography was slightly less sensitive (54% vs. 64%), but more specific (87% vs. 73%) than hysteroscopy. When cervical invasion was present, the PPVs of transvaginal sonography and hysteroscopy were 46% (6/13) and 32% (7/22), respectively, while the NPV was 91% for both techniques (49/54; 41/45). Our data show that the accuracy of transvaginal sonography was comparable with that of hysteroscopy in detecting cervical involvement. Therefore, in the majority of cases, when both techniques showed that disease was limited, the appropriately limited type of surgery would be performed. Conversely, detection of a myometrial invasion of > 50% or an extension to the cervix would lead to an unnecessarily extensive operation if this was the sole criterion used for making the decision.

Anaplastic large cell lymphoma (CD30+/Ki-1+). Analysis of 35 cases followed at GISL centres.

Between January 1988 and June 1992, 35 patients with primary anaplastic large cell lymphoma (ALCL)CD30+ were referred to one of the institutions participating in GISL (Gruppo Italiano per lo Studio dei Linformi). 16 patients were treated with ProMACE-CytaBOM, two with MACOP-B, one with CHOP and one with LSA2-L2. As of November 1990, all newly diagnosed patients were treated with MOPP/EBV/CAD hybrid. 27 (77%) cases of ALCL CD30+ and 8 (23%) cases of Hodgkin's-related (HR) lymphoma CD30+ were diagnosed. Extranodal disease was present in 22 cases (63%), and 8 patients (23%) had primary bone marrow involvement. Twenty-three complete remissions (CR) (66%), six partial remissions (PR) (17%) and six no remissions (NR) (17%) were achieved with induction therapy. Results achieved with ProMACE-CytaBOM and MOPP/EBV/CAD hybrid were comparable. The overall response rate (CR+PR) was 85% for patients with classic ALCL CD30+ and 87% for those with HR lymphoma CD30+. The 3 year estimated overall survival rate was 66% and the 3 year relapse free survival rate was 65% for the entire group. The only significant favourable prognostic factor was the achievement of CR with initial therapy. Our findings suggest that ALCL (CD30+/Ki-1+) has a clinical outcome similar to aggressive non-Hodgkin's lymphoma (NHL). The use of an anthracycline-containing regimen will provide a change of cure in approximately 65% of cases.

Cytogenetic conversion in a case of polycythaemia vera treated with interferon-alpha.

Polycythaemia vera is a clonal disorder of the haemopoietic stem cell causing a pathologic expansion of the erythroid and sometimes the megakaryocytic and myeloid elements. In order to avoid the possible mutagenic effects of radioactive phosphorus, alkylating agents and hydroxyurea, since 1988 alpha-IFN has been used for the treatment of PV and has been shown to induce and maintain haematological remission. We describe a 24-year-old PV patient with chromosomal abnormalities who achieved not only a reduction of the proliferation of erythroid elements and reticulin content in the bone marrow, but also a complete cytogenetic remission after IFN treatment.

[Noma in a patient with acute leukemia allergic to penicillin]. / Noma in paziente con leucemia acuta allergica alla penicillina.

Noma has virtually disappeared from Europe, but is still found in certain parts of Africa, South America and Asia. In our case the etiologic agent was Pseudomonas aeruginosa sensitive to antibiotic therapy that we used (pefloxacin and netilmicin). Another characteristic aspect of our case is the rapid infaust evolution. In this report will be discuss the pathogenesis and the reason of the failure of the antibiotic therapy especially in immunodeficiency patients.

[Efficacy of erythropoietin in anemia of patients with immuno-lymphoproliferative disease]. / Efficacia dell'eritropoietina nell'anemia dei pazienti con malattie immuno-linfoproliferative.

Anemia is a common complication of lymphoproliferative syndromes. The exact pathogenic mechanism of this anemia is unclear. Many patients require progressive and persistent blood transfusions. We treated 10 patients (8 with multiple myeloma, 1 with non Hodgkin Lymphoma, 1 with chronic lymphocytic leukemia) by administering low doses of recombinant human erythropoietin (60 U/kg 3 times a week s.c.). All patients presented anemia with hemoglobin levels less than 10 gr/dl; renal function was not impaired (serum creatinine levels less than 1.2 mg/dl or creatinine clearance greater than 60 ml/min). A response was defined as an increase of hemoglobin level of at least 2 gr/dl or stop of red-cell transfusion within the first 3 months of treatment. Nine patients (90%) responded to treatment with a significant increase in the hemoglobin concentration. Two patients presented a cerebral stroke not correlated with erythropoietin administration.

Accuracy of transvaginal ultrasound and serum hCG in the diagnosis of ectopic pregnancy.

Transvaginal ultrasound was performed upon admission of 127 patients with a clinical suspicion of ectopic pregnancy in association with human chorionic gonadotropin (hCG) determination. Failure to visualize with sonography an intrauterine gestational sac with an hCG level superior to 1000 mIU/ml identified 25/42 tubal pregnancies with a positive predictive value of 86% and a specificity of 93%. Abnormal adnexal findings occurred in 95% of the ectopic pregnancies. Extrauterine gestational sacs with or without embryos could be confidently detected in 19 ectopic pregnancies (45%). A complex adnexal mass was seen in 19 cases and yielded a positive predictive value of 90% (19/21). Adnexal gestational sacs and complex masses were seen more frequently in those ectopic pregnancies with an hCG level above 1000 mIU/ml but the difference was not significant (100% versus 78%). Simple adnexal cysts were found more frequently in intrauterine pregnancies, and fluid in the cul-de-sac was also not indicative of ectopic pregnancy (positive predictive value, 29%). Transvaginal ultrasound has a primary role in the diagnosis of ectopic pregnancy. The combined use of uterine and adnexal sonography associated with elevated hCG levels allows a definitive diagnosis in the vast majority of cases at a very early stage, when the chances for a successful conservative treatment are greater.