Expanded Flaps in Surgical Treatment of Pressure Sores: Our Experience for 25 Years.

BACKGROUND: Because the ischial region is the main weight-bearing area in sitting, it is one of the areas most frequently affected by pressure ulcers in paraplegic patients resuming the sitting position during the subacute and chronic stages. The techniques described to date have not been able to reduce the high rates of recurrence and flap dehiscence. Other groups have described successful tissue expansion in the treatment of pressure ulcers, but to date, the long-term results of the procedure have not been reported. METHODS: The long-term follow-up of 138 reconstructions of the ischial region in patients with pressure ulcers types III to IV treated with posterior thigh expanded rotation flaps is reported. RESULTS: All patients achieved complete resolution, with adequate coverage of deeper layers, although 15.94% presented minor complications. None of these complications impeded full repair of the lesion. The 28 lesions that recurred were all reconstructed with the re-expansion of the same flap. There were no cases of flap dehiscence. CONCLUSIONS: The use of tissue expanders to treat ischial pressure ulcers, especially in patients with long life expectancy, offers important advantages over other approaches. The procedure provides abundant, high-quality tissue and may be repeated many times without creating new scars. With the use of tissue expanders, other reconstructive options can be reserved for the future.

Keratoacanthoma arising after site injection infection of cosmetic collagen filler.

INTRODUCTION: Over one million treatments in more than 40 countries have been administered Zyplast implants. Infections at collagen implant sites have occurred in fewer than one per thousand treated patients. PRESENTATION OF CASE: We present a case report of a 27-year-old man; he developed a severe granulomatous reaction in the site of resolvable collagen filler injection Zyplast, and one month later developed a cutaneous nodular lesion. Histological examination of the lesion revealed Keratoacanthoma (KA) with surgical margins free of tumor. We performed two surgical corrections within a period of six months on multiple hypertrophic skin scars of the face. Two years after the last excision, the patient continued to be free of any recurrence. DISCUSSION: Keratoacanthoma (KA) is a benign skin tumor with a quick growth pattern but may regress spontaneously. Though the exact etiology of KA is uncertain, it is found to be more frequent in elderly people, on photo-exposed skin areas and cutaneous infection site. Bovine collagen intradermal injections, though catabolized over the time in the patient, can raise several complications already described in technical literature, but we want underline that cutaneous infection near filler injection site can develope KA as described in our case report. CONCLUSION: KA must be considered as a new local unforeseeable complication of bovine collagen injection to fill facial soft tissue when occurred a face cutaneous infection. We believe that radical excision is the golden standard.

Interleukin-6 and osteoprotegerin systems in Paget's disease of bone: relationship to risedronate treatment.

Serum concentrations of interleukin-6 (IL-6), IL-6-soluble receptor (sIL-6R), IL-6 gp130-soluble receptor (sgp130), ligand of receptor activator of nuclear factor (NF)-kappaB (RANKL), and osteoprotegerin (OPG) were determined in 42 patients with polyostotic Paget's disease of bone (PDB) and acquired resistance to clodronate (M/F ratio 23:19; mean age 58.5 +/- 9.4 years) in acute phase of disease and after oral risedronate treatment (30 mg/day for 8 weeks). At baseline, pagetic patients showed higher levels of OPG, sIL-6R, and IL-6 with lower levels of sgp130 compared to 24 age- and sex-matched controls (respectively, 4.69 +/- 1.27 vs. 2.87 +/- 0.54 pmol/L; 40.89 +/- 8.61 vs. 30.98 +/- 4.24 ng/ml; 3.59 +/- 0.97 vs. 1.8 +/- 0.9 pg/ml; 327.34 +/- 43.41 vs. 411.7 +/- 79.5 ng/ml). Response to treatment is related to a significant increase of OPG levels in all patients (from 4.69 +/- 1.27 to 5.48 +/- 1.31 pmol/L). The disease remission, that is, total alkaline phosphatase (tALP) levels within the normal range after therapy, was associated with a simultaneous increase in OPG and sgp130 levels. In patients with tALP higher than the normal range after therapy, the OPG increase was associated with a parallel increase in RANKL levels. Our data suggest that serum levels of components of RANKL/OPG and IL-6 systems, before and after treatment, may be used to better define a therapeutical strategy in pagetic patients.

BsmI vitamin D receptor genotypes influence the efficacy of antiresorptive treatments in postmenopausal osteoporotic women. A 1-year multicenter, randomized and controlled trial.

Vitamin D receptor (VDR) gene polymorphisms could be considered one of the factors influencing the efficacy of the anti-osteoporotic treatments. In this multicenter, prospective, randomized and controlled trial we evaluated whether BsmI vitamin D receptor (VDR) genotypes influence the efficacy of antiresorptive treatment regimes (administered alone or in combination) in postmenopausal osteoporotic women. Using restriction endonuclease, we identified the BsmI VDR polymorphism in 1,100 postmenopausal women with osteoporosis. The women were randomized, taking account of genotype, into five treatment groups: (1) alendronate (Aln, 10 mg/day) plus raloxifene (Rlx, 60 mg/day); (2) Aln plus hormone replacement therapy (HRT, 0.625 mg/day conjugated equine estrogens plus 2.5 mg/day medroxyprogesterone acetate); (3) Aln alone; (4) HRT alone; and (5) Rlx alone. Lumbar-spine bone mineral density (BMD) and bone turnover markers were measured at study entry and after 1 year of treatment. Using the general linear model (GLM) repeated-measures procedure, the means of BMD and bone turnover markers significantly differed from baseline after a period of treatment. In particular, the mean change from baseline for BMD was -0.034 (95% confidence interval [CI]: -0.037 to -0.031, P <0.001); for serum osteocalcin (OC) it was 1.369 (95% CI: 1.289 to 1.448, P <0.001); and for urinary deoxypyridinoline (DPD) it was 1.322 (95% CI: 1.242 to 1.401, P <0.001), indicating a considerable variation before and after treatment of these indicators. In all three cases these effects appeared significantly influenced by treatments, genotypes, and the treatments*genotypes interaction term (P <0.001 each, except for the BMD and genotype effect with P =0.02), and not by the investigational centers involved in the study. In conclusion, in postmenopausal osteoporotic women, BsmI VDR genotypes influence the efficacy of antiresorptive drugs particularly when used in combination.

Association between vitamin D receptor gene polymorphisms and fasting idiopathic hypercalciuria in recurrent stone-forming patients.

OBJECTIVES: To investigate the association between fasting idiopathic hypercalciuria (IHc), defined as IHc in the fasting state associated with normal parathyroid function, and ApaI, BsmI, and FokI polymorphisms of the vitamin D receptor (VDR) gene in 159 hypercalciuric recurrent stone formers. IHc contributes to the formation of calcium kidney stones in more than one half of reported cases. METHODS: We examined 62 patients with fasting IHc (24 women, mean age 42.8 +/- 11.1 years, body mass index 25.7 +/- 4.8 kg/m2), 97 patients with absorptive IHc (41 women, mean age 43.5 +/- 10.8 years, body mass index 26.1 +/- 4.4 kg/m2), and 124 healthy control subjects (52 women, mean age 41.9 +/- 10.4 years, body mass index 25.4 +/- 5.1 kg/m2) without a history of nephrolithiasis and without IHc. The bone mass density and VDR genotype and haplotype frequencies were determined in the studied populations. RESULTS: A reduced bone mass density was observed in fasting IHc patients compared with absorptive IHc patients (P = 0.009) and control subjects (P = 0.006). The prevalence of ApaI and BsmI VDR genotypes and alleles in patients with fasting IHc was significantly different statistically (P <0.05) from that observed in patients with absorptive IHc and control subjects, and the ba haplotype was overrepresented in these patients. No statistically significant difference in the distribution of FokI VDR genotypes and alleles was found between the studied groups. CONCLUSIONS: Our results suggest a genetic association between 3' VDR alleles, fasting IHc, and reduced bone mass density in patients with recurrent stone formation.

The relationship of 3' vitamin D receptor haplotypes to urinary supersaturation of calcium oxalate salts and to age at onset and familial prevalence of nephrolithiasis.

BACKGROUND: Idiopathic hypercalciuria (IHc) and idiopathic hypocitraturia are frequently associated with calcium nephrolithiasis. We investigated the relationship of vitamin D receptor (VDR) polymorphisms (BsmI, TaqI and FokI) to urinary supersaturation of calcium oxalate salts in recurrent calcium oxalate stone formers with IHc and the clinical relevance of this relationship. METHODS: The study included 110 Caucasian stone formers with IHc and 127 unrelated healthy controls without history of nephrolithiasis. Age at onset of nephrolithiasis, familial history score (FHS) and the ion activity product of calcium oxalate salts in urine (AP(CaOx)) were tabulated. BsmI, TaqI and FokI VDR polymorphisms were evaluated in all participants. RESULTS: Patients and controls were classified as homozygous (bbTT and BBtt) or heterozygous in relation to BsmI and TaqI polymorphisms. Compared with BBtt patients, bbTT homozygous stone formers showed lower citrate excretion (1.91+/-0.89 vs 3.46+/-1.39 mmol/24 h, P = 0.004) and higher AP(CaOx) (2.02+/-0.51 vs 1.53+/-0.53, P = 0.006). Among controls, there were similar differences in citrate excretion and AP(CaOx) between the two groups, but they were not statistically significant. Compared with BBtt, bbTT patients showed lower mean age at onset of nephrolithiasis (29.7+/-12.1 vs 38.1+/-12.7 years, P = 0.008) and higher values of FHS (2.45+/-1.9 vs 0.83+/-0.7, P = 0.006). Similar results were obtained for individual BsmI and TaqI alleles. The analysis of FokI alleles was not informative. CONCLUSIONS: Recurrent calcium oxalate stone formers with IHc and the bT VDR haplotype have more aggressive kidney stone diseases as indicated by a higher familial incidence and lower mean age at onset. This clinical severity is associated with the higher urinary supersaturation of calcium oxalate salts and abnormalities of renal citrate handling.

Giant cell tumor and Paget's disease of bone in one family: geographic clustering.

Giant cell tumor is a rare complication of Paget's disease of bone. Typically, this tumor occurs in the case of polyostotic disease and only in pagetic bones. This tumor rarely has been seen in multiple family members who have Paget's disease, although Paget's bone disease clearly has a hereditary component. Our report documents four cases of polyostotic Paget's bone disease complicated by benign giant cell tumor. In two patients, the giant cell tumor also was multifocal. All patients were from one family. They were born in Avellino and reside in Campania, a Southern Italian region. The ancestors of the patients with familial giant cell tumor in Paget's bone disease were born in the same geographic area. These data suggest that a combination of environmental and genetic factors could be responsible for linkage of the patients born in Avellino with this neoplasm that is highly unusual in patients with Paget's disease of bone.

Effectiveness of alendronate treatment in postmenopausal women with osteoporosis: relationship with BsmI vitamin D receptor genotypes.

OBJECTIVE: To assess whether there is a relationship between the effectiveness of alendronate treatment in postmenopausal women with osteoporosis and BsmI vitamin D receptor (VDR) genotypes. DESIGN: Prospective baseline-controlled clinical trial. PATIENTS: Sixty-eight Italian osteoporotic women were enrolled and treated with alendronate at a dose of 10 mg/day for 12 months. MEASUREMENTS: At entry and after treatment, lumbar bone mineral density (BMD) and serum osteocalcin (OC) and urinary deoxypyridinoline/creatinine ratio (DPD-Cr) levels were evaluated. DNA was extracted from blood and analysed for the BsmI polymorphism of the VDR gene. RESULTS: The mean percentage (% +/- SD) change from baseline in lumbar BMD was significantly higher (P < 0.01) in bb than in BB BsmI VDR genotypes (7.92 +/- 4.31 vs. 3.40 +/- 1.81). No significant difference in lumbar BMD was observed in Bb VDR patients (6.01 +/- 3.89) in comparison with other groups. The mean percentage of change in serum OC and urinary DPD-Cr levels was significantly (P < 0.01) lower in individuals with bb than in those with BB BsmI VDR genotypes (-14.34 +/- 2.87 vs.-10.39 +/- 1.43 and -9.61 +/- 5.56 vs.-4.61 +/- 2.31). No significant difference in serum OC and urinary DPD-Cr levels was observed in Bb VDR patients (-12.31 +/- 2.11 and -6.52 +/- 2.65) in comparison with other groups. CONCLUSION: The different BsmI vitamin D receptor genotypes modify the pharmacological response to alendronate treatment in postmenopausal women with osteoporosis.

Raloxifene administration in post-menopausal women with osteoporosis: effect of different BsmI vitamin D receptor genotypes.

BACKGROUND: The vitamin D receptor (VDR) gene polymorphism has been considered a factor influencing the effectiveness of the anti-osteoporotic treatments. The aim of this study was to correlate the effectiveness of raloxifene treatment in post-menopausal women with osteoporosis to BsmI VDR genotypes. METHODS: Between January and August 2000, 75 Italian osteoporotic women were enrolled and treated with raloxifene at a dose of 60 mg/day. At entry and after 1 year of treatment, lumbar bone mineral density (BMD), serum osteocalcin (OC) and urinary creatinine-corrected free deoxypyridinoline (DPD) levels were evaluated. DNA was extracted from blood and analysed with restriction endonuclease BsmI for VDR gene. RESULTS: After treatment, a significant increase in lumbar BMD and a significant reduction in serum OC and urinary DPD levels were observed. The percentage of change (mean +/- SD) in lumbar BMD, and in serum OC and urinary DPD levels was significantly different in homozygous bb (1.58 +/- 0.80, -5.15 +/- 2.36 and -7.71 +/- 2.89 for BMD, OC and DPD respectively) in comparison with BB (4.13 +/- 2.26, -13.59 +/- 4.68 and -15.16 +/- 4.65 for BMD, OC and DPD respectively) BsmI VDR genotypes. Heterozygous Bb VDR patients showed an intermediate percentage (mean +/- SD) of BMD, serum OC and urinary DPD change (2.49 +/- 1.54, -8.69 +/- 2.60 and -10.52 +/- 2.56 for BMD, OC and DPD respectively) not significantly different in comparison with homozygous BB and bb. CONCLUSIONS: In post-menopausal women with osteoporosis the effectiveness of raloxifene treatment on bone metabolism seems to be controlled by different BsmI VDR genotypes.