Role of the Plastic Surgeon in Tuberculosis Treatment.

Background: Tuberculous empyema is rare. Its treatment requires oral antituberculous drugs, empyema drainage, and in severe cases, decortication and pneumectomy. In the presence of tuberculosis, lung resection has a high risk of postoperative bronchopleural fistula (BPF) and empyema. Treatment includes drainage, fistula occlusion, dead space obliteration, and infection control. Muscle flap transfer allows BPF occlusion and dead space obliteration. Methods: This report presents a case of a 63-year-old man with tuberculosis and postoperative BPF with empyema after pleural decortication and left lower lobe resection. The empyema was drained, and antituberculous drugs were started. The BPF was occluded with a latissimus dorsi and serratus anterior chimeric muscle flap, and the remaining thoracic dead space and chest wall defect were reconstructed with a pedicled pectoralis major myocutaneous flap. Results: Healing occurred uneventfully, and the patient was discharged from the hospital after 2 weeks. Conclusions: This type of thoracic defect is rare nowadays, especially in the setting of tuberculous infections. Although workhorse flaps like latissimus dorsi or pectoralis major flaps have been progressively surpassed by more elegant solutions like fasciocutaneous pedicled flaps and free flaps, they must still be considerations in the decision-making process of a reconstructive surgeon, and flap choice must be made on a case-by-case basis.

Frontotemporal Lipofilling for Plagiocephaly Sequelae.

ABSTRACT: Plagiocephaly patients generally undergo corrective surgery in the first years of life, but during their growth malformative sequelae become apparent and can have a negative psychological and social impact. Volumetric filling techniques have been used to improve social balance and minimize such negative effects.We present a case of a 25 years old male with a history of plagiocephaly corrected by 8 months of age. He kept a bilateral frontotemporal defect and we performed a lipofilling of the affected areas. The aesthetic results were very satisfactory and 6 months and 1 year after the procedure he maintained a good volumetric filling. There were no complications during or after the procedure.Lipofilling provides good contouring results and has low complication rates. Its major inconvenient is adipose tissue resorption.As illustrated by this case, this type of treatment significantly improves facial appearance, raising patients' self-esteem and quality of life.

Salvage of a Near-Total Penile Amputation following Urinary Fistulization and Carbapenemase-Producing Klebsiella pneumoniae Infection with a Composite ALT Flap and Vascularized Fascia Lata.

Reconstruction of complex penile defects is always challenging, as some defects are not possible to reconstruct with skin or mucosa grafts, and even local flaps may be precluded in complex wounds. We present a case of a 63-year-old otherwise healthy man, who underwent transurethral resection of the prostate for benign prostatic hyperplasia. After the procedure, he developed panurethral necrosis with consequent stricture. Three urethroplasties for reconstruction of the bulbar and distal urethra using buccal mucosa grafts, a preputial flap, and penile skin were performed by urology team in different institutions, but serious urinary fistulization and carbapenemase-producing Klebsiella pneumoniae (KPC) infection translated in a chronic wound, urethra necrosis, and near-total penile amputation. A composite anterolateral thigh flap and vascularized fascia lata were used with success together with a perineal urethroplasty in different stages, improving the ischemic wound condition. The extended segment of fascia lata was used for Buck's fascia replacement and circumferential reinforcement to cover the erectile bodies of the penis. The postoperative period was uneventful and after 12 months, there were no signs of recurrence or wound dehiscence. He was able and easily adapted to void in a seated position through the perineal urethrostomy that was made. To the best of our knowledge, this procedure has not been reported previously as a salvage procedure in a fistulizated and KPC infected penis, but it may be considered to avoid penile amputation in chronic infected and intractable wounds.

Signification of distal urinary acidification defects in hypocitraturic patients.

BACKGROUND AND OBJECTIVES: Hypocitraturia has been associated with metabolic acidosis and mineral disorders. The aim of this study was to investigate the occurrence of urinary acidification defects underlying hypocitraturia. MATERIALS AND METHODS: This retrospective observational study included 67 patients (32 men), aged 40.7±15.1 years with hypocitraturia (<1.67 mmol/24-h) and nephrolithiasis, nephrocalcinosis, and/or bone demineralization, referred to our center from 2000 to 2015. We aimed to assess renal distal acidification capacity, prevalence and mechanisms of urinary acidification defects. Patients with low baseline plasma HCO3- (<22 mmol/L) were studied by bicarbonate loading or furosemide/fludrocortisone tests. Patients with normal baseline plasma HCO3- had an ammonium-chloride challenge test. A normal response was a decrease in urinary pH <5.3 and an increase in urinary NH4+ ≥33 µmol/min and defined idiopathic hypocitraturia. RESULTS: Eleven patients (16.4%) had low HCO3- and overt distal acidification defect. Three had a mutation in the gene encoding AE1, 4 had Gougerot-Sjögren syndrome and no cause was found in the remaining 4 cases. Fifty-six patients (83.6%) had normal HCO3-; of those, 33 (58.9%) had idiopathic hypocitraturia. Among the 23 (41%) remaining patients, 12 were unable to increase urinary NH4+ excretion (among them, 8 were able to decrease urinary pH and 4 were not) whereas 11 were able to increase urinary NH4+ excretion but unable to decrease urinary pH. These 11 patients had higher fasting urinary calcium, reflecting bone resorption, than the other 12 patients: median 0.41 [0.24-0.47] vs. 0.22 [0.08-0.37] mmol/mmol creatinine (P = 0.04). CONCLUSIONS: Patients with hypocitraturia and normal plasma HCO3- frequently show a latent acidification defect that can be further dissected into one of several subtypes based on urinary pH and NH4+ response to the acid load. Those patients with impaired urine acidification capacity but preserved NH4+ excretion exhibit particularly high calciuria and should be identified to optimize nephrolithiasis prevention.

Blood pressure and phosphate level in diabetic and non-diabetic kidney disease: Results of the cross-sectional "Low Clearance Consultation" study.

HIGHLIGHTS: A statistically significant and moderate positive correlation was verified between systolic blood pressure and plasma phosphate concentration in the whole sample (diabetic and non-diabetic), due to the diabetic chronic kidney disease group.A statistically significant and moderate positive correlation was verified between the diastolic blood pressure and plasma phosphate concentration in the whole sample (diabetic and non-diabetic), due to the diabetic chronic kidney disease group.A statistically significant and strong negative correlation was found between diastolic blood pressure and estimated glomerular filtration rate in the diabetic chronic kidney disease group, but there was no statistically significant correlation in the whole sample (diabetic and non-diabetic). ABSTRACT: Diabetic kidney disease features certain clinical and laboratorial characteristics that differ from chronic kidney disease of other etiologies. We performed a transversal study comparing some of these characteristics and assessed potential associations among blood pressure, plasma phosphate concentration and estimated glomerular filtration rate between patients with diabetic and non-diabetic chronic kidney disease.We found a positive correlation between both systolic and diastolic blood pressure and the plasma phosphate concentration in the diabetic kidney disease group, but not in the non-diabetic group. Also, diastolic blood pressure was negatively correlated with the estimated glomerular filtration rate in the diabetic group, yet not in the non-diabetic group.In conclusion, these data support the hypothesis of a close link between systolic and diastolic blood pressure and hyperphosphatemia, as well as between diastolic blood pressure and estimated glomerular filtration rate, in patients with diabetic kidney disease. Therapeutic approaches directed at these factors might prove to be important to delay the decline of renal function in the subgroup of patients with diabetic kidney disease.

Copeptin is increased in resistant hypertension.

OBJECTIVES: The participation of vasopressin in the mechanisms of resistant hypertension is unclear. We compared plasma copeptin concentration, a surrogate marker for vasopressin secretion, between patients with resistant hypertension and those with controlled blood pressure (CBP), in a post hoc analysis of the Prise en charge de l'Hypertension Artérielle RESistante au traitement trial. METHODS: After 4-week treatment with irbesartan 300 mg/day, hydrochlorothiazide 12.5 mg/day, and amlodipine 5 mg/day (baseline), 166 patients were classified as having resistant hypertension (n = 140) or CBP (n = 26) by ambulatory BP monitoring. Patients with resistant hypertension were then randomized for 12 weeks of sequential nephron blockade (n = 74) or sequential renin-angiotensin system blockade (n = 66). Plasma copeptin concentration was measured at baseline and week 12 by immunoassay. RESULTS: Baseline plasma copeptin concentration was positively associated with male sex, plasma osmolality, BP, and negatively with glomerular filtration rate. It was higher in the resistant hypertension than in the CBP group [geometric mean 5.7 (confidence interval 95% 5.1-6.4) vs. 2.9 (2.3-3.9) fmol/ml, adjusted P < 0.0001). The relationship between plasma copeptin concentration and urinary osmolality was similar in the two groups. At 12 weeks, plasma copeptin concentration in patients whose BP was controlled by sequential nephron blockade or sequential renin-angiotensin system blockade [6.8 (5.6-8.2) and 4.3 (3.0-5.9) fmol/ml, respectively) remained significantly higher than in patients with CBP at baseline (P < 0.0001 vs. both). CONCLUSION: In patients with resistant hypertension, plasma copeptin concentrations were approximately two-fold higher than those of patients with CBP, after adjustment for plasma osmolality. This difference was not accounted for by renal resistance to vasopressin, suggesting a primary reset of osmostat.