The Effect of Intraoperative Radiotherapy on Healing and Complications After Sacrectomy and Immediate Reconstruction.

INTRODUCTION: Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT. METHODS: A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps. RESULTS: Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy. CONCLUSIONS: Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT.

Circumferential Pharyngoesophageal Reconstruction and Total Larynx Preservation with Extra-anatomical Free Flaps.

Reconstruction of total circumferential pharyngeal defects following caustic or stenosant lesions of the pharynx present major challenges with respect to minimizing surgical morbidity and restoring functional deficits. With recent advances in microvascular free tissue transfer, the options for pharyngeal reconstruction have multiplied in order to maximize swallowing and voice. There is long experience in the reconstruction of the pharynx and the cervical esophagus in oncological patients after total pharyngolaryngectomy, but there are not many publications concerning circumferential pharyngeal reconstruction preserving the larynx. Here, we discuss 2 new techniques for total circumferential pharyngeal reconstruction respecting swallowing and voice by means of extra-anatomical bypasses (visceral or fasciocutaneous), upholding the larynx in its original placement.

Comparing Efficacy and Costs of Four Facial Fillers in Human Immunodeficiency Virus-Associated Lipodystrophy: A Clinical Trial.

BACKGROUND: The objective of this study was to evaluate and compare the safety and effectiveness of four different dermal fillers in the treatment of facial lipoatrophy secondary to human immunodeficiency virus. METHODS: The authors conducted a clinical trial including 147 patients suffering from human immunodeficiency virus-induced lipoatrophy treated with Sculptra (poly-L-lactic acid), Radiesse (calcium hydroxylapatite), Aquamid (polyacrylamide), or autologous fat. Objective and subjective changes were evaluated during a 24-month follow-up. Number of sessions, total volume injected, and overall costs of treatment were also analyzed. A comparative cost-effectiveness analysis of the treatment options was performed. RESULTS: Objective improvement in facial lipoatrophy, assessed by the surgeon in terms of changes from baseline using the published classification of Fontdevila, was reported in 53 percent of the cases. Patient self-evaluation showed a general improvement after the use of facial fillers. Patients reported being satisfied with the treatment and with the reduced impact of lipodystrophy on their quality of life. Despite the nonsignificant differences observed in the number of sessions and volume, autologous fat showed significantly lower costs than all synthetic fillers (p < 0.05). CONCLUSIONS: Surgical treatment of human immunodeficiency virus-associated facial lipoatrophy using dermal fillers is a safe and effective procedure that improves the aesthetic appearance and the quality of life of patients. Permanent fillers and autologous fat achieve the most consistent results over time, with lipofilling being the most cost-effective procedure.

New Refinements in Greater Omentum Free Flap Transfer for Severe Secondary Lymphedema Surgical Treatment.

Lymphedema is a chronic debilitating disease, affecting a considerable part of the population; it results from impairment of the lymphatic system. It is highly prevalent among patients subjected to axillary and groin nodal dissection after surgery for breast cancer, abdominopelvic surgery, and lymphadenectomy after melanoma surgery. Interestingly, among the surgical treatment options for lymphedema, groin lymph node transfer is gaining popularity; however, in some cases, dissection at this site can cause significant morbidity, including possible development of iatrogenic lymphedema. To avoid these complications, new donor nodal groups are being proposed (eg, submental or supraclavicular). We have used the greater omentum as a lymph node and lymph vessel donor site. Dissection of the omentum is easy to perform and can even be done in patients who have undergone previous abdominal surgeries. We present refinements in the surgical technique for free omentum transfer in the management of secondary lymphedema: the first free omental flap dissection performed laparoscopically and the use of a primary flap as the recipient pedicle of a free greater omentum flap for anatomical repair after chest osteoradionecrosis and simultaneous functional repair of chronic lymphedema.

Invasive basal cell carcinoma in a xeroderma pigmentosum patient: facing secondary and tertiary aggressive recurrences.

Xeroderma pigmentosum (XP) is characterized by photohypersensitivity of sun-exposed tissues and several thousand-fold increased risk of developing malignant neoplasms of the skin and eyes. Inherited molecular defects in nucleotide excision repair genes cause the autosomal recessive condition XP. A 56-year-old woman with XP presented with an extensive multirecurrence basal cell carcinoma in the left naso-orbital region. At the time of the first visit, the patient had already received several interventions with local reconstructive techniques, a full course of radiotherapy, and bilateral neck dissection. A large tumor resection and free flap reconstruction were performed. Three years 9 months afterward, an aggressive recurrence occurred, and a second resection was needed. A new free flap was transferred, and microvascular anastomoses were done to the pedicle of the previously transferred flap. Nine months later, the patient returned with frontal bone tumoral lesions, and third microsurgical intervention was done. At that time, the reconstruction was practiced by a composite chimeric flap with a rib portion. Its pedicle was anastomosed to the one of the second free flaps. The objective of this article was to report the authors' experience concerning a unique case of XP requiring a complex reconstruction of the anterior skull base. Xeroderma pigmentosum patients need an early diagnosis and removal of cutaneous tumor lesions as some of them behave aggressively, especially those affecting the face. Free flaps are good solutions for reconstruction and should proceed from non-sun-exposed areas of the body. If reconstructed areas are highly radiated and/or skin tumors affect deep anatomical areas, complications are frequent.

Motivos para dejar de fumar en España en función del sexo y la edad / Reasons for smoking cessation in Spain by gender and age

ObjetivoAnalizar los motivos para dejar de fumar ligados al sexo y a la edad del paciente fumador que desea abandonar el consumo de tabaco.MétodosEstudio multicéntrico transversal sobre 1.634 fumadores atendidos en consultas de atención primaria y especializada de España, que tras preguntarles explícitamente muestran su deseo de abandonar el consumo de tabaco. Se recopilaron datos sociodemográficos, antecedentes del consumo de tabaco y motivos del deseo de cesar el consumo. Se realizó un análisis descriptivo.ResultadosLa media de edad fue de 45,6 años (desviación estándar±12,0 años). Los varones representaban el 55,9% de la población estudiada. La mayoría (35,2%) tenía estudios por encima del grado secundario. El motivo argumentado para abandonar el tabaquismo por el 63,9% de los varones y el 81,1% de los mayores de 60 años fue la indicación médica; el 60,7% de las mujeres buscaba prevenir enfermedades. El hecho de representar un papel ejemplar para los hijos subyacía en el 31,6% de los fumadores de 31 a 45 años, y los motivos estéticos en el 11,4% de aquellos entre 18 y 30 años.ConclusionesLa indicación médica promueve la voluntad de cesación tabáquica en los varones, mientras que con su decisión las mujeres pretenden representar un papel ejemplar para los hijos, prevenir enfermedades o mejorar su estética. A mayor edad, mayor porcentaje de pacientes que deciden dejar de fumar por indicación médica. El adulto de mediana edad alega querer ser un ejemplo para sus hijos, mientras que los jóvenes actúan movidos por principios estéticos(AU)

ObjectiveTo analyze gender- and age-related motivations among smokers wishing to quit.MethodsWe performed a multicenter cross-sectional study in 1,634 smokers attended by general practitioners and specialized physicians in Spain who, after being explicitly asked about their intention to quit smoking, expressed a desire to do so. Sociodemographic data, history of smoking and motivations for cessation were collected. A descriptive statistical analysis was performed.ResultsThe mean age was 45.6 years (SD±12.0 years). Fifty-six percent were men. A total of 35.2% had studied beyond high school. The main motivation expressed by 63.9% of men and 81.1% of smokers older than 60 years old was medical advice; 60.7% of women were motivated by disease prevention; 31.5% of smokers aged between 31 and 45 years old wanted to be a good role model for their children and 11.4% of those aged between 18 and 30 were motivated by esthetic reasons.ConclusionsMen tend to be motivated by medical advice, while women are motivated by a desire to be a role model for their children, to prevent diseases or improve their appearance. The greater the age, the greater the percentage of patients motivated by medical advice. Middle-aged adults want to be good role models for their children while young patients are motivated by esthetic concerns(AU)

[Reasons for smoking cessation in Spain by gender and age]. / Motivos para dejar de fumar en España en función del sexo y la edad.

OBJECTIVE: To analyze gender- and age-related motivations among smokers wishing to quit. METHODS: We performed a multicenter cross-sectional study in 1,634 smokers attended by general practitioners and specialized physicians in Spain who, after being explicitly asked about their intention to quit smoking, expressed a desire to do so. Sociodemographic data, history of smoking and motivations for cessation were collected. A descriptive statistical analysis was performed. RESULTS: The mean age was 45.6 years (SD+/-12.0 years). Fifty-six percent were men. A total of 35.2% had studied beyond high school. The main motivation expressed by 63.9% of men and 81.1% of smokers older than 60 years old was medical advice; 60.7% of women were motivated by disease prevention; 31.5% of smokers aged between 31 and 45 years old wanted to be a good role model for their children and 11.4% of those aged between 18 and 30 were motivated by esthetic reasons. CONCLUSIONS: Men tend to be motivated by medical advice, while women are motivated by a desire to be a role model for their children, to prevent diseases or improve their appearance. The greater the age, the greater the percentage of patients motivated by medical advice. Middle-aged adults want to be good role models for their children while young patients are motivated by esthetic concerns.

Left ventricular geometric patterns after 1 year of antihypertensive treatment.

Left ventricular hypertrophy increases the risk for cardiovascular target organ damage, myocardial infarction, and stroke. The authors assessed the patterns of ventricular adaptation in 107 essential hypertensives whose treatment had been withdrawn and its modification after 1 year of hypertension treatment. Blood pressure decreased from 158+/-17/96+/-12 mm Hg to 137+/-15/83+/-10 mm Hg (mean +/- SD; p<0.001); 45% of the patients (49 of 107) had their blood pressure controlled below 140 mm Hg and 90 mm Hg. Although a significant decrease of left ventricular mass index was found in the study, the percentage of patients with normal left ventricular geometry at the completion of the study increased by only 9% (27% to 36%, p>0.05). Left ventricular mass geometry improved in 31% of the patients, remained unaffected in 51%, and worsened in 18%. The data suggest that even while suboptimal antihypertensive treatment reduces left ventricular mass index, either left ventricular hypertrophy or concentric remodeling remains present in a significant number of patients at the end of a 1-year treatment period. The authors conclude that these patients should be considered as a subgroup at high risk and should be treated more aggressively.

High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension.

OBJECTIVE: To determine causes of treatment resistance in patients with refractory hypertension, and to estimate the prevalence of true resistant hypertension. METHODS: We studied 50 consecutive patients referred with refractory hypertension after exclusion of hypokalemia and stenosis of the renal artery. Ambulatory blood pressure monitoring was performed in all patients to detect white-coat effect. The patients were hospitalized, antihypertensive drugs were withdrawn and a screening for secondary hypertension was performed. In addition, these patients, and a control group of essential hypertensives controlled with three antihypertensive drugs, underwent a OGTT with 75 g of glucose. RESULTS: Primary normokalemic hyperaldosteronism was diagnosed in seven patients. Two patients had a pheochromocytoma and six had white-coat effect. The 35 remaining patients with true resistant hypertension shown significant differences in serum insulin and HOMA IR when compared with the control group. CONCLUSIONS: These findings show that among normokalemic treatment-resistant hypertension, the presence of hyperaldosteronism and pheochromocytoma is quite high. Moreover, treatment resistance in hypertensive patients appears to be associated with insulin resistance.

Propuesta de un programa de selección de residentes de ortopedia con base en un perfil ocupacional

Las instituciones con programas de especialización en Ortopedia en el pais al igual que otras organizaciones realizan procedimientos de selección como parte integral de sus actividades académicas y administrativas. En términos de las prácticas más generalizadas, en el proceso de admisión actual de Residentes se omiten aspectos importantes de selección, al tiempo que la información obtenida sobre los candidatos resulta insuficiente utilizada para efectos de una decisión confiable de aceptación o rechazo de un aspirante; un factor determinante de esta situación es la ausencia de unidad de criterio en cuanto a habilidades y características esperadas para un satisfactorio desempeño profesional. El presente artículo pone a consideración de la comunidad ortopédica, a nivel de hipótesis de trabajo, factores considerados como esenciales dentro de esta profesión. Se toman en cuenta 3 áreas: a) Aptitudes psicofísicas que miden la predisposición a desarrollar la habilidad quirúrgica b) Habilidades intelectuales, miden la capacidad para la adquisición y el manejo de un badaje conceptual propio de la ortopedia.c) Características de personalidad que favorecen el ajuste a la profesión. La relevancia del perfil ocupacional de Ortopedia se remite a la posibilidad de estructurar un proceso de selección de Residentes que faciliten a las directivas de los diferentes programas tomardecisiones confiables sobre los aspirantes a los mismos