Breast Reconstruction using the Anterior Approach Scarless Latissimus Dorsi Muscular flap: A Single Center Retrospective Study.

Introduction: Scarless latissimus dorsi (LD) flap is a breast reconstruction technique, which allow to cover the lower pole of implant with a large portion of the LD muscle without skin paddle; it represents a surgical solution that transpose vascularized tissue avoiding the failure of breast reconstruction, following necrosis of mastectomy skin flaps. Material and Method: A retrospective review of patients undergoing immediate or delayed breast reconstruction using scarless LD flap reconstructions was performed. Clinical data obtained from follow-up visits were recorded. To evaluate breast shape contentment and patient satisfaction, the patients were requested to answer the Breast-Q, version 2.0 reduction module postoperative scales questionnaire at the 12-month follow-up. Results: We performed 19 scarless LD flap reconstructions between September 2019 and June 2022. The surgical time in average (considering minutes ± SD) was 130 (±15) minutes. The aesthetic assessment was good/excellent in 83% of patients. This was statistically significant (P=0.0). Conclusions: The scarless LD flap reconstruction is a valid and reliable solution, which has the advantage to reduce the risk of exposed prosthesis if native skin necrosis occurs.

Obsessive-Compulsive Disorder as an Epiphenomenon of Comorbid Bipolar Disorder? An Updated Systematic Review.

BACKGROUND: Bipolar disorder (BD) and obsessive-compulsive disorder (OCD) comorbidity is an emerging condition in psychiatry, with relevant nosological, clinical, and therapeutic implications. METHODS: We updated our previous systematic review on epidemiology and standard diagnostic validators (including phenomenology, course of illness, heredity, biological markers, and treatment response) of BD-OCD. Relevant papers published until (and including) 15 October 2023 were identified by searching the electronic databases MEDLINE, Embase, PsychINFO, and Cochrane Library, according to the PRISMA statement (PROSPERO registration number, CRD42021267685). RESULTS: We identified 38 new articles, which added to the previous 64 and raised the total to 102. The lifetime comorbidity prevalence ranged from 0.26 to 27.8% for BD and from 0.3 to 53.3% for OCD. The onset of the two disorders appears to be often overlapping, although the appearance of the primary disorder may influence the outcome. Compared to a single diagnosis, BD-OCD exhibited a distinct pattern of OC symptoms typically following an episodic course, occurring in up to 75% of cases (vs. 3%). Notably, these OC symptoms tended to worsen during depressive episodes (78%) and improve during manic or hypomanic episodes (64%). Similarly, a BD course appears to be chronic in individuals with BD-OCD in comparison to patients without. Additionally, individuals with BD-OCD comorbidity experienced more depressive episodes (mean of 8.9 ± 4.2) compared to those without comorbidity (mean of 4.1 ± 2.7). CONCLUSIONS: We found a greater likelihood of antidepressant-induced manic/hypomanic episodes (60% vs. 4.1%), and mood stabilizers with antipsychotic add-ons emerging as a preferred treatment. In line with our previous work, BD-OCD comorbidity encompasses a condition of greater nosological and clinical complexity than individual disorders.

Symmetrization in primary tip rhinoplasty after resection of the cephalic portion of the lower-lateral cartilage.

Background: The cephalic trim allows the remodeling of the alar cartilages by removing the cranial portion of the lower-lateral cartilages; this resection determines raising the tip of the nose through its rotation. The objective of this study is to demonstrate how a greater symmetry of the lower-lateral cartilages after resection of the cephalic portion is obtainable by introducing a specific additional surgical time into the procedure. Methods: Between June 2016 and December 2021, forty-six patients underwent primary rhinoplasty with the cephalic portion of the alar cartilage resection. After the cephalic trim symmetry of the nose tip was then assessed through a specific additional surgical maneuver in 23 patients (Group A), whereas in 23 patients, the evaluation of symmetry was performed according only to the surgeon's personal judgment (Group B). Preoperative and postoperative pictures were evaluated in the symmetry of the two sides of the faces considering anthropometric measurements and the judgment by ten plastic surgeons uninvolved in this study. Results: None of the patients had completely symmetric values. Objectively, the degree of asymmetry in Frankfurt's plane, considering RMLLA (midline-lateral alar margin ratio), was significantly decreased in Group A. Subjectively, more patients in Group A who were judged with asymmetrical face before rhinoplasty were evaluated with a symmetrical face after rhinoplasty than those in Group B. Conclusions: We believe that in closed rhinoplasty, the symmetry of the postoperative sides of the face is increased by performing an easily replicable intraoperative maneuver as described.

Reversed distal laterodigital adipofascial flap for nail-bed reconstruction.

BACKGROUND: Lesions of the distal phalanges of the fingers frequently involve the nail bed. There are few therapeutic options for nail-bed reconstruction and they often lead to painful scars and onychodystrophy. We present our experience with the distal adipofascial laterodigital reverse flap. METHODS: Fifteen patients (average age 46.33 years, range 28-73) with tumors or traumatic injuries (crush injuries, nail avulsion, and partial fingertip amputations) of the nail bed, underwent digital reconstruction through the distal adipofascial laterodigital reverse flap from June 2018 to August 2019. The size of the fingertip defect covered with the flap was ranged between 1.1 × 1.1 and 1.6 × 1.2 cm (average size 1.4 × 1.2 cm). The flap was harvested enrolling subcutaneous tissue from the lateral aspect of the middle and distal phalanx from the less damaged side. RESULTS: The average size of the harvested flaps was 1.3 × 1.2 cm (range 1.1 × 1.0 to 1.4 × 1.1 cm). All adipofascial flaps survived entirely and the nail bed healed in all patients, with an average healing time of 21 days and a subsequent regrowth of the nail. The follow up ranged from 6 to 12 months, with a mean of 7 months. CONCLUSIONS: The distal reverse adipofascial flap provides a very versatile and reliable coverage of the distal finger and its nail bed. It is a rapid and reproducible surgical procedure with poor morbidity for the donor site. LEVEL OF EVIDENCE: IV.

Evaluating the Quality of Online Patient Information for Prepectoral Breast Reconstruction Using Polyurethane-Coated Breast Implants.

Background: An increasing number of patients are using online information regarding medical issues; however, the Internet is not subject to content ratings or filters. Unreliable information found on the web can heavily influence patients to the extent that it can lead to wrong decisions in the choice of treatment. In our daily experience we meet more informed patients and given the increasing use of polyurethane-coated implants in breast reconstruction in Europe, we wondered about the level of information available online. Our study aims to assess the quality of information available online on breast reconstruction with polyurethane-coated implants. Materials and Methods: Assuming that the most used search engines are Google and Yahoo, we used a search strategy to identify online information regarding prepectoral breast reconstruction with polyurethane-coated implants. The selected websites were divided into 5 groups (practitioners, hospitals, healthcare portals, professional societies, and encyclopedias), and the quality of information was assessed by using an expanded version of the Ensuring Quality Information for Patients (EQIP) tool, which is a checklist applicable to all existing types of information. Results: Fifty-six websites were selected and were categorized into 5 groups: 17 practitioners, 9 hospitals, 13 healthcare portals, 7 professional societies, 10 encyclopedias. The average score was 17 points (range: 12 - 25). We found 13 reliable websites with a score higher than 20 using the expanded version of the EQIP tool, whereas 43 were deemed unreliable, as they scored lower. Conclusion: Proper communication between surgeon and patient is crucial in the therapeutic choice, as the available online information presently is scarce and can lead to wrong decisions if not properly verified.

Gender dysphoria: Quality of online information for gender reassignment surgery.

An ever-increasing number of patients are using the Internet to learn about medical conditions. This study aimed to evaluate the quality of Internet-based patient information on gender reassignment surgery for people who suffer from gender dysphoria. Twenty websites identified using Google and Yahoo search engines were selected and evaluated based on the modified Ensuring Quality Information for Patients (EQIP) instrument (36 items). The EQIP tool comprises 36 questions to which the answer can be "yes" or "no". The final score for each website can be between 0 and 36. An overall score of 26 or above was considered high, because it co-related to the 72nd percentile. The average of the scores turned out to be 22.5 points, lower than our target; 7 (35%) sites were rated higher than the average and 13 (65%) were rated lower. The assessment of the websites included in the study showed a lack of information about the sequence of the medical procedures, perioperative criticalities and qualitative risks and side-effects descriptions. The overall quality of published information on gender reassignment surgery is very low. We believe that the Internet should not be used as the main source of medical information, and physicians should maintain the leadership in guiding patients affected by gender dysphoria. Level of Evidence: Level IV, case study.

The use of the internal pudendal artery perforator flap after abdominoperineal reconstruction: A single center study.

Abdominoperineal resection (APR) is still a valuable option in the presence of cancer recurrences or salvage surgery. Primary perineal closure after conventional APR curries a high rate of wound complications. A multidisciplinary approach with perineal soft tissue reconstruction surgical time improves the immediate and long-term prognosis of these patients. The aim of the study is to report our experience with the use of the internal pudendal artery perforator flap in perineal region reconstruction after APR. We performed 11 perineal region reconstructions after conventional APR between September 2016 and December 2020. In 8 cases the reconstruction was performed on previously irradiated tissues while in 2 cases the radiotherapy was carried out on the perineal tissues solely for adjuvant therapy. A rotation perforating flap was harvested in 8 cases, an advance island flap in 2 cases, and a propeller type in one case. All 11 flaps survived with no immediate postoperative major complications. Only one case showed dehiscence of the donor site wound healed with conservative treatment. Average hospitalization time was 11 days internal pudendal artery perforator flap represents a valid and reliable reconstructive solution after APR showing low complication rates and minimal donor site morbidity even in patients with previous radiotherapy.

Sociodemographic and Clinical Correlates Associated with the Frequent Service Users in an Italian Psychiatric Emergency Department.

BACKGROUND: The aim of the present study is to identify the main sociodemographic and clinical correlates associated with frequent service users (FSUs) in an Italian psychiatric emergency department. METHODS: This study is an observational and prospective clinical investigation. All subjects (N = 549) consecutively admitted to the Psychiatric Inpatient Unit of the IRCCS Ospedale Policlinico San Martino ((Genoa, Italy) were recruited over a period of 18 months. RESULTS: On average, FSUs were more likely to be single (75.0% vs. 64.0, p = 0.001), younger (38.79 years ± 14.68 vs. 45.94 years ± 16.94, p = 0.028), with an earlier onset (20.15 years ± 7.22 vs. 29.33 years ± 15.96, p < 0.001), and longer length of hospitalisation (13.65 days ± 12.40 vs. 9.89 ± 10.15, p = 0.006) compared to non-FSUs. While bipolar disorder was the most common primary diagnosis in both FSUs and non-FSUs, cluster B personality disorder was particularly elevated in FSUs (30.3% vs. 10.4%, p < 0.001). Furthermore, FSUs were more prone to substance use disorder (63.6% vs. 40.0%, p < 0.001), particularly cannabis (45.5% vs. 15.3%, p < 0.001), cocaine (33.3% vs. 10.4%, p < 0.001), and heroin (19.7% vs. 5.8%, p < 0.001), and were more likely to have non-suicidal self-injuries (21.2% vs. 6.8%, p < 0.001). FSUs were significantly more likely to be discharged against medical advice (18.2% vs. 5.6%, p < 0.001) or to have at least one escape attempt from the psychiatric ward (12.1% vs. 0.8%, p < 0.001). CONCLUSIONS: Specific clinical and social profiles of patients who repeatedly utilised the services of a psychiatric emergency department have been identified. Our findings can be used to develop suitable structures to support and reintegrate FSUs into society and work life.

Surgical Delay of Nipple Areola Complex: A Powerful Technique to Extend the Indication of Nipple-Sparing Mastectomy.

BACKGROUND: Surgical delay (SD) techniques, performed before the nipple sparing mastectomy (NSM), are procedures conceived to improve the blood supply to the nipple-areola complex (NAC) in order to overcome the ischemic risk. The aim of the study is reporting our experience with SD of the NAC in the setting of NSM, identify the rate of nipple and skin necrosis and other complications and to evaluate patient satisfaction with cosmetic outcome. PATIENTS AND METHODS: A retrospective review of female patients, who underwent NSM and breast reconstruction between the July 2014 and the July 2019, was performed at the Breast Unit of San Giovanni-Addolorata Hospital in Rome. Eighty-nine NSM after SD procedure were performed in 66 patients. In all cases immediate breast reconstruction was performed with a direct to implant technique and polyurethane implants in prepectoral plan were used in all reconstructions. RESULTS: We registered only 1 case of total NAC necrosis and 3 skin flap necrosis. Furthermore, patient satisfaction with breast reconstruction resulted excellent or good in 23 cases and good in 36 cases; the external plastic surgeon considered the breast reconstruction excellent or good in 63 cases. CONCLUSION: We support the thesis that SD techniques may expand indications for NAC sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications. Microabstract This is the largest single center series on surgical delay of nipple areola complex providing interesting data on follow-up and complication rates and we support the thesis that surgical delay techniques may expand indications for nipple-areola complex sparing mastectomy and immediate breast reconstruction in women with known risk factors for local complications.

COVID-19 Impact on the Italian Community-based System of Mental Health Care: Reflections and Lessons Learned for the Future.

Despite the unprecedented wave of research and publications sparked by the recent pandemic, only few studies have investigated the impact of COVID-19 on the Italian community-based system of mental health care. We aimed to summarize the available evidence from the literature also considering what we have learned from our daily clinical practice. As hospital care was restricted by COVID-19, although reducing their opening hours and activities, Community Mental Health Centers promoted continuity of care for at-risk populations, supporting them to cope with loneliness and hopelessness during quarantine and self-isolation. Ensuring continuity of care also remotely, via teleconsultation, lowered the risk of psychopathological decompensation and consequent need of hospitalization for mental health patients, with satisfaction expressed both by patients and mental health workers. Considering what we have learned from the pandemic, the organization and the activity of the Italian community-based system of mental health care would need to be implemented through 1) the promotion of a "territorial epidemiology" that makes mental health needs visible in terms of health care workers involved, 2) the increase of mental health resources in line with the other European high-income countries, 3) the formalization of structured initiatives of primary care and mental health cooperation, 4) the creation of youth mental health services following a multidimensional and multidisciplinary approach and encouraging family participation, 5) the promotion of day centers, to build competence and self-identity within a more participatory life, and programs geared to employment as valid models of recovery-oriented rehabilitation.

Central mucoepidermoid carcinoma of the mandible deriving from odontogenic cyst: A case report and review of the literature.

Mucoepidermoid Carcinoma (MEC) it can origin from a mandibular odontogenic cyst. We report the case of a 63-year-old man with MEC of the right retromolar trigonum of the mandibula. We performed a wide mandibular excision and immediate reconstruction with a fibula bone free flap.

Reconstruction of hypopharyngeal defects with anterolateral thigh free flap: A single-center retrospective analysis.

INTRODUCTION: Reconstruction of expanded hypopharyngeal defects following laryngo-hypopharyngectomy for surgical treatment of primary is still a challenge for head and neck surgeons. Tradiotionally, jejunal or radial forearm flaps are the common reconstructive choice. Recently, the anterolateral thigh (ALT) free flap has served for pharyngoesophageal reconstruction. The goal of this work is to describe a retrospective analysis about a five-year single-center experience in the reconstruction of post-operative hypopharyngeal defects with ALT free flap. METHODS: A single-center retrospective study was performed, including patients treated for patients who underwent tumor surgery involving hypopharynx with ALT free flap reconstruction from 2015 to 2020. Exclusion criteria were paediatric (0-18 years) patients, and the absence of follow-up. RESULTS: The study included 23 adult patients. The mean size of the flap was 90 cm2 (range 60-130 cm2). The mean time required to harvest the antero-lateral tight flap was 70 min (range 35-120 min). The median age was 46.3 years (SD 15.81, range: 19-84 years), with a gender female prevalence (F = 48, M = 33). Mean follow-up was 77.7 months (min 4-max 361, SD 72.46). One patient (4.4 %) showed a hypopharyngeal stenosis. CONCLUSION: ALT free flap represents a successful and versatile reconstructive option for hypopharyngeal defects extended to oropharynx and/or larynx following total laryngectomy with circumferential or partial hypopharyngectomy, regardless of the functional and aesthetic results, with minimal donor-site complication.

Bipolar Disorder and Polysubstance Use Disorder: Sociodemographic and Clinical Correlates.

Introduction: Patients with bipolar disorder (BD) often show comorbidity with substance use disorder (SUD) with a negative impact on clinical course, prognosis, and functioning. The role of polysubstance use disorder (polySUD) is understudied. The aim of the present paper is to evaluate the sociodemographic and clinical characteristics associated with BD and comorbid SUD, focusing on polySUD, in order to phenotype this specific group of patients and implement adequate treatment and prevention strategies. Methods: A cross-sectional study was conducted involving 556 patients with a primary diagnosis of BD (376 without SUD, 101 with SUD, and 79 with polySUD). A semi-structured interview was administered to collect sociodemographic variables, clinical characteristics, and pharmacological treatment. ANOVA and chi-square tests were used to compare the three groups. Significantly different variables were then inserted in multivariate logistic regression. Results: Patients affected by BD and polySUD were younger, and more frequently males and single, than patients with SUD or without SUD. Indeed, the prevalence of patients affected by BD and polySUD living in residential facilities was higher than in the other groups. Moreover, earlier age at onset, higher prevalence of psychotic and residual symptoms, involuntary hospitalization, and a family history of psychiatric disorders were associated with polySUD in patients suffering from BD. Lastly, patients with BD and polySUD were more likely to take four or more medications, particularly benzodiazepines and other drugs. At the multinomial regression, younger age, male gender, early age at onset, psychotic and residual symptoms, positive family history of psychiatric disorders, and use of benzodiazepines remained significantly associated with polySUD in patients with BD. Conclusion: Our findings show a specific profile of patients with BD and polySUD. It is important to conduct research on this topic in order to adopt specific therapeutic strategies, minimize the use of polypharmacy, and aim at full remission and mood stabilization.

Quality of online information about migraine headache surgery.

Migraine headache is a debilitating disease that can lead to severe functional limitations and is the most common primary headache. In more than 30% of cases conservative therapies do not allow the control of symptoms or cause side effects. Peripheral nerve surgery should be considered in non-responsive chronic migraine or suspected peripheral origin. Nowadays Web has become one of the most important sources of knowledge for patients: the information available on the web is not subject to a control of the sources reliability but can influence the patient. The aim of the study is to evaluate the quality of information accessible on the Web about the surgical treatment of migraine headache. "Headache OR migraine treatment", "headache OR migraine surgery" were the keywords used on two main search engines (Google and Yahoo). Among the first 50 websites, 26 were suitable and we divided them into five groups (practitioners, hospitals, healthcare portals, professional societies, encyclopedias). We applied the expanded EQIP (Ensuring Quality Information for Patients) scale: the EQIP scale consists of 36 questions with three sections (content, identification data and structure). Although the overall average score was relatively high (22 out of 36), many lacks information were highlighted: overall, readability was not satisfactory in communicating information regarding migraine and its surgical treatment. Readability should be tested before medical online publication, in order to provide for its correct use by the patient and improving migraine knowledge.

The use of preauricular skin flaps in the treatment of ear malignancy in elderly patients.

BACKGROUND: The ear is one of the face areas most affected by skin cancers, and the surgical reconstruction is often challenging because of tumor- and patient-related factors. Reconstructive options are essentially skin flaps and grafts or their combinations. The use of preauricular translocation (PAT) flap for auricular reconstructions is constantly increasing. AIM AND METHODS: This retrospective study reports the comparison between the PAT flap and the full-thickness skin grafts (FTSGs) for surgical auricular defect reconstruction in elderly population (≥65 years) that typically shows poor compliance in the postoperative wound care management. RESULTS: A total of 52 FTSGs (Group A) and 39 PAT (Group B) were performed between April 2007 and July 2020. The aim was to investigate, compare, and define advantages and disadvantages of both techniques. Visual Analogue Scale (VAS) was used to evaluate the overall patients' satisfaction. The mean surgical and healing times were longer in Group A (p < 0.05). No complications occurred in the PAT group, and all the flaps survived. In the FTSG group, the overall complication rate was 17.3% (four partial and three total graft failure, and two graft infections). T test was used to compare the VAS scores: Patients with PAT flap were more satisfied than those with FTSG (p < 0.05). CONCLUSIONS: Preauricular translocation flap is a reproducible, safe, and quick option for auricular defects reconstruction in the ≥65 years population, associated with an easier patient management, high patient satisfaction, and excellent aesthetic result.

Application of Machine Learning for Fenceline Monitoring of Odor Classes and Concentrations at a Wastewater Treatment Plant.

The development of low-cost sensors, the introduction of technical performance specifications, and increasingly effective machine learning algorithms for managing big data have led to a growing interest in the use of instrumental odor monitoring systems (IOMS) for odor measurements from industrial plants. The classification and quantification of odor concentration are the main goals of IOMS installed inside industrial plants in order to identify the most important odor sources and to assess whether the regulatory thresholds have been exceeded. This paper illustrates the use of two machine learning algorithms applied to the concurrent classification and quantification of odors. Random Forest was employed, which is a machine learning algorithm that thus far has not been used in the field of odor quantification and classification for complex industrial situations. Furthermore, the results were compared with commonly used algorithms in this field, such as artificial neural network (ANN), which was here employed in the form of a deep neural network. Both techniques were applied to the data collected from an IOMS installed for fenceline monitoring at a wastewater treatment plant. Cohen's kappa and Normalized RMSE are used as specifical performance indicators for classification and regression: the indicators were calculated for the test dataset, and the results were compared with data in the literature obtained in contexts of similar complexity. A Cohen's kappa of 97% was reached for the classification task, while the best Normalized RMSE, namely 4%, for the interval 20-2435 ouE/m3 was obtained with Random Forest.