Physical properties of Scarpa's fascia.

Preservation of Scarpa's fascia has improved clinical outcomes in abdominoplasty procedures and in other body contour surgeries. However, the physical properties of Scarpa's fascia have not yet been described, and grafts are still underexplored. Fresh surgical specimens from five female patients subjected to classical abdominoplasty were dissected and analyzed. A grid was drawn on the fascia surface, dividing it into equal upper and lower halves; four Scarpa's fascia samples (30 × 10 mm) were collected from each half, 40 mm apart. The thickness was measured with a caliper. A strain/stress universal testing machine was used for mechanical tests. Twenty-five samples were obtained (nine from the upper half, 16 from the lower). The average thickness was 0.56 ± 0.11 mm. The average values for stretch, stress, strain, and Young's Modulus were, respectively, 1.436, 4.198 MPa, 43.6%, and 23.14 MPa. The upper half showed significantly greater thickness and strain values (p = 0.020 and p = 0.048; Student's t-test). The physical and biomechanical properties of Scarpa's fascia can make it a donor area for fascial grafts as an alternative to fascia lata, as it is always available and has minimal donor-site morbidity. Further studies are needed to validate this statement. It seems advantageous to use the lower half of the abdomen instead of the upper part as a donor site.

Dissection Technique for Abdominoplasty With Scarpa Fascia Preservation: Comparative Study on Avulsion Technique Versus Diathermocoagulation.

BACKGROUND: Many strategies have been developed to lower the high complication rate associated with a full abdominoplasty. The dissection technique may have a role to achieve this goal. OBJECTIVES: The present study compared 2 different dissection techniques to perform a full abdominoplasty with Scarpa fascia preservation: avulsion technique and electrodissection. METHODS: A retrospective observational cohort study was performed in 2 health institutions from January 2005 to January 2019. A total of 251 patients were involved: 122 patients submitted to abdominoplasty employing the avulsion technique (Group A) and 129 with diathermocoagulation (coagulation mode) (Group B). The latter was further divided into group B1 (57 patients with device settings according to surgeon's preferences) and B2 (72 patients with a specific regulation aiming at minimal tissue damage). Several variables were analyzed: population characteristics, time of hospital stay, time to drain removal, total and daily drain output, emergency department visits, readmission, reoperation, and local and systemic complications. RESULTS: The general characteristics of both groups did not statistically significantly differ except for previous abdominal surgery. The diathermocoagulation group had a significantly lower length of hospital stay and time to drain removal. Moreover, these advantages were maximized when electrocautery was conducted with a specific low-voltage setting as significant differences were found. The other outcomes were identical. CONCLUSIONS: Limiting the extension of electrodissection with the avulsion technique did not present any advantage. Utilizing diathermocoagulation (coagulation mode) during a full abdominoplasty with Scarpa fascia preservation, especially when it is aimed at minimal tissue damage, reduces patients' time with drains.

Reconstruction of a near total ear amputation with a neurosensorial radial forearm free flap prelaminated with porous polyethylene implant and delay procedure.

When an auricular defect is caused by high-energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year-old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A "printed" ear made of silicone, based on the patient's CT-scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.

Facial allotransplantation procurement using a transparotid approach: a new anatomical model.

BACKGROUND: Full face transplantation is a complex procedure and a detailed plan is needed. Coaptation of motor nerve branches at more distal sites instead of the level of the main trunk is highly desirable, but may be difficult to find, are thin, fragile and have limited length for safe and tension-free coaptation. In addition, nerve grafts may be necessary. In this study, the technical feasibility of facial allotransplantation procurement using a transparotid approach was investigated. METHODS: Three mock cadaver dissections were performed, procuring full face transplants with en bloc facial nerve dissection. The facial nerve (main trunk, temporofacial/cervicofacial divisions, and individual facial branches) was elevated en bloc as part of the allograft, dissected out from the parotid completely, and left as loose attachments to the allograft specimen. RESULTS: Full face transplantation with en bloc facial nerve dissection was technically feasible, allowing for more proximal or distal nerve section, and to achieve the desired length and diameter for appropriate matching during nerve coaptation. CONCLUSION: This technique follows principles of targeted nerve reinnervation. It allows to select the level of facial nerve section to the temporofacial and cervicofacial divisions or final branches, with further adaptation to the remaining recipient's anatomic structures, and avoiding the need for nerve grafts; it also excludes the parotid gland (reduces bulk). Despite a small increase in the time required for dissection, this disadvantage may be compensated by an improved functional recovery.

Chimeric flaps and "their variations": different options for immediate reconstruction of massive facial defects.

The reconstruction of massive head and neck defects is a difficult challenge, requiring restoration of bone, skin, and oral lining. Their complex three-dimensional nature often dictates the need of more than a single osteocutaneous flap for intra- and extra-oral reconstruction.Conventional reconstructive options can be considered, but there is no single ideal osteocutaneous free or pedicled flap providing an unlimited length of bone and skin paddle, or that could orient the skin paddle independently of the vascularized bone. The surgeon should then be aware of more complex options for reconstruction of extensive three-dimensional defects, namely chimeric free flaps and "their variations." They can be stratified in three types, either based on their intrinsic vasculature-perforated-based, branch-based, or whether they are prefabricated (surgical junction by microanastomosis).Despite morbidity and not perfect matching in terms of skin texture and pliability, these techniques are a good alternative in the presence of partial defects, especially in the context of immediate oncological reconstruction, where facial transplantation is not considered.

Use of Infrared Thermography for Abdominoplasty Procedures in Patients with Extensive Subcostal Scars: A Preliminary Analysis.

Subcostal scars may increase the risk of healing complications in abdominoplasty. The authors evaluated the use of thermography as a potential tool for patient selection and surgery planning to avoid complications and improve abdominoplasty outcomes. Two candidates for abdominoplasty procedures who presented with extensive subcostal scars were submitted to an infrared thermography protocol at all phases of the procedure: preoperative, intraoperative, and postoperative at 1 and 6 months. The preoperative thermography for both patients revealed near-normal abdominal wall perfusion. The thermograms captured intraoperatively during flap elevation did not show perfusion deficits on the upper abdominal flap. At 1 month and 6 months postoperative, dynamic thermography for both patients showed normal to near-normal perfusion. The procedures had a complication-free course with a good aesthetic result. Plastic surgeons may be reluctant to perform a full abdominoplasty in patients with a previous subcostal incision. In this preliminary analysis, we raise the potential usefulness of thermography for patients with recent subcostal scars and/or important comorbidities as a strategy for adequate patient and technique selection, avoiding possible complications. Future studies, with an increased number of patients and adequate statistical analysis, may allow us to validate the utility of thermography in these cases and reassure that the presence of previous extensive subcostal scars may not be a contraindication for a full abdominoplasty, especially if they are not recent.

Classic Versus Scarpa-sparing abdominoplasty: An infrared thermographic comparative analysis.

BACKGROUND: Scarpa fascia preservation during abdominoplasty has been shown to have several clinical advantages. The mechanisms behind its efficiency have been the subject of several studies. Three theories have been proposed, relating to mechanical factors, lymphatic preservation, and improved vascularization. This study aimed to further investigate the possible vascular impact of Scarpa fascia preservation by using a thermographic analysis. METHODS: A single-center prospective study was conducted, involving 12 female patients randomly and equally assigned to one of two surgical procedures: classic (Group A) and Scarpa-sparing abdominoplasty (Group B). Dynamic thermography was applied before and after surgery (one and six months), and two regions of interest (ROIs) were considered. The latter had the same location on every sample, and corresponded to areas where different surgical planes had been used. Static thermography was applied intraoperatively, and four ROIs were considered, located over Scarpa and over the deep fascia. The respective thermal data were analyzed. RESULTS: The general characteristics of both groups were identical. Preoperative thermography demonstrated no differences between groups. Intraoperative higher thermal gradients between lateral and medial ROIs were observed in Group B (P = 0.037, right side). Dynamic thermography at one month demonstrated a trend for better thermal recovery and better thermal symmetry (P = 0.035, 1-min mark) in Group B. No other differences were found. CONCLUSION: Dynamic thermography presented a better response when Scarpa fascia was preserved: stronger, faster, and more symmetric. Based on these results, improved vascularization may have a role in explaining the clinical efficiency of a Scarpa-sparing abdominoplasty.

Hepatitis E in a Portuguese cohort of human immunodeficiency virus positive patients: High seroprevalence but no chronic infections.

Introduction: Hepatitis E virus (HEV) infection causes zoonotic hepatitis in Europe, with a higher risk of complications in immunocompromised hosts. HEV natural history in human immunodeficiency virus (HIV) positive patients is not fully understood, and its prevalence is unknown. Objectives: To study the seroprevalence of HEV and prevalence of chronic HEV in HIV-positive patients from Porto, Portugal. Methods: We randomly selected patients from the cohort of HIV-positive patients followed in our hospital. We performed an enzyme-linked immunosorbent assay to search for immunoglobulin G for HEV. When the absorbance/cut-off was inferior to 3.5, the test was repeated, and a confirmatory test executed in that sample. For reactive tests and for immunosuppressed patients (CD4 count < 200/mm3) with nonreactive test, a polymerase chain reaction (PCR) test was also performed. Results: We included 299 patients. The mean age was 48 and 75.3% were men. Regarding HIV infection, the median follow-up time was 10 years, the acquisition was mainly heterosexual contact, and 94% were on antiretroviral therapy. Seventy-six patients (25.4%) had reactive immunoglobulin G (IgG) hepatitis E serology. Patients with a reactive test were older (statistically significant difference). Otherwise, there was no difference between groups concerning birthplace, rural residence, chronic viral hepatitis coinfection, or cirrhosis. Nadir and actual TCD4+ lymphocyte counts did not differ significantly from patients with HEV reactive and nonreactive serology. Gamma-glutamyl-transferase (GGT) was higher in patients with reactive IgG HEV. All serum HEV PCR tests were negative. Conclusions: Seroprevalence of HEV was 25.4% in HIV-positive patients. Older age and higher GGT correlated to HEV reactive IgG test. No cases of current hepatitis E were found.

Ear replantation after human bite avulsion injury.

Traumatic auricular amputation due to human bite is not a common event, but it constitutes a difficult challenge for the reconstructive surgeon. Microsurgery can be performed in some cases, but replantation of a severed ear without microsurgery can be a safe alternative. We present a case of a 44-year-old male individual who was involved in a fight and sustained a human bite, resulting in almost a complete amputation of his right ear. The Baudet technique has been used successfully. It is a simple technique and very reliable because it allows a great surface of contact between the graft and the vascular bed, substantially increasing its odds of survival in cases presenting with high risk of infection such as human bite injury. It also produces excellent aesthetic results.

Benzodiazepine Use in Opioid Maintenance Treatment Programme: Risks and Clinical Outcomes.

INTRODUCTION: The co-association of benzodiazepines and opioids is associated with an increased risk of overdose, death, and poorer psychosocial prognosis. The aim of this study is to characterize the prevalence, pattern of use, and primary clinical outcomes in benzodiazepines users in a public opioid maintenance treatment unit. MATERIAL AND METHODS: We conducted a cross-sectional study involving 236 patients treated with opioid substitutes (methadone and buprenorphine). We conducted a descriptive, bivariable, and multivariable analysis to determine clinical differences between benzodiazepines users and non-users. RESULTS: The prevalence of consumption of benzodiazepines was 25.4% (60). The benzodiazepines were obtained with a medical prescription (49.8%) or on the black market (42.6%). The most prescribed benzodiazepine was diazepam (29.1%), and the main reasons were to relieve insomnia (27.7%) or anxiety (26.9%) and to enhance the psychoactive effects of other drugs (19.7%). Regarding the clinical outcomes, we highlight: a very high prevalence of hepatitis C (51.7%); severe ongoing consumption of psychoactive drugs (73.7%); and a high rate of depression and anxiety (> 60%), significantly higher in the benzodiazepines-user group. In the multivariable analysis of benzodiazepine use, we found alcohol consumption (OR 0.482; IC 95% 0.247, 0.238) had a negative association and having hepatitis C (OR 2.544, IC 95% 1.273, 5.084) or anxiety symptoms (OR 5.591; IC 95% 2.345, 13.326) had positive associations. DISCUSSION: Our results suggest the BZD users had a complex drug addiction problem and underline the importance of adequately addressing BZD use, contemplating psychological and psychiatric approach in this particular population. CONCLUSION: Past or current use of benzodiazepines is associated with poor clinical and psychiatric outcomes. A multidisciplinary approach with a focus on infectious diseases and mental health is critical in order to enhance the treatment effectiveness and overall prognosis.

Introdução: A co-associação entre benzodiazepinas e opióides associa-se a risco aumentado de overdose, morte e pior prognóstico psicossocial. Pretendemos determinar a prevalência, o padrão de consumo e as principais co-morbilidades do uso de benzodiazepinas, em utentes sob tratamento de manutenção opióide. Material e Métodos: Conduzimos um estudo transversal, envolvendo 236 doentes tratados com substitutos opióides (metadona e buprenorfina). Realizou-se uma análise descritiva, bivariável e multivariável das características clínicas entre os usuários de benzodiazepinas e os não-usuários de benzodiazepinas. Resultados: A prevalência do uso de benzodiazepinas foi de 25,4% (60). A obtenção de benzodiazepinas foi através de prescrição médica (49,8%) ou mercado negro (42,6%). A substância mais prescrita foi o diazepam (29,1%), e as principais razões para a toma foi insónia (27,7%), ansiedade (26,9%), e para potenciar os efeitos psicoativos de outras drogas (19,7%). No que respeita aos resultados clínicos sublinhamos: prevalência elevada de hepatite C (51,7%); elevado consumo continuado de substâncias psicoativas (73,7%); elevada taxa de depressão e ansiedade (> 60%), significativamente mais elevada nos utilizadores de benzodiazepinas. Na análise multivariável para o uso de benzodiazepinas, verificámos que o consumo de álcool (OR 0,482; IC 95% 0,247, 0,238) tem associação negativa; a hepatite C (OR 2,544; IC 95% 1,273, 5,084) e a ansiedade (OR 5,591; IC 95% 2,345, 13,326) tiveram associações positivas. Discussão: Os resultados obtidos sugerem que os utilizadores de BZD têm um problema complexo de dependência de drogas e sublinham a importância de abordar adequadamente o uso de BZD, contemplando uma abordagem psicológica e psiquiátrica nesta população em particular. Conclusão: O uso de benzodiazepinas, no passado ou atualmente, associa-se a piores indicadores físicos e psiquiátricos. A abordagem multidisciplinar com foco nas doenças infeciosas e na saúde mental é uma necessidade crítica para a efetividade do tratamento e prognóstico global.

Dynamics of a Dual SARS-CoV-2 Lineage Co-Infection on a Prolonged Viral Shedding COVID-19 Case: Insights into Clinical Severity and Disease Duration.

A few molecularly proven severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases of symptomatic reinfection are currently known worldwide, with a resolved first infection followed by a second infection after a 48 to 142-day intervening period. We report a multiple-component study of a clinically severe and prolonged viral shedding coronavirus disease 2019 (COVID-19) case in a 17-year-old Portuguese female. She had two hospitalizations, a total of 19 RT-PCR tests, mostly positive, and criteria for releasing from home isolation at the end of 97 days. The viral genome was sequenced in seven serial samples and in the diagnostic sample from her infected mother. A human genome-wide array (>900 K) was screened on the seven samples, and in vitro culture was conducted on isolates from three late samples. The patient had co-infection by two SARS-CoV-2 lineages, which were affiliated in distinct clades and diverging by six variants. The 20A lineage was absolute at the diagnosis (shared with the patient's mother), but nine days later, the 20B lineage had 3% frequency, and two months later, the 20B lineage had 100% frequency. The 900 K profiles confirmed the identity of the patient in the serial samples, and they allowed us to infer that she had polygenic risk scores for hospitalization and severe respiratory disease within the normal distributions for a Portuguese population cohort. The early-on dynamic co-infection may have contributed to the severity of COVID-19 in this otherwise healthy young patient, and to her prolonged SARS-CoV-2 shedding profile.

Change in the Prevalence and Social Patterning of First-and Second-Hand Smoking in PORTUGAL: A Repeated Cross-Sectional Study (2005 and 2014).

Between 2005 and 2007, important reinforcements of the tobacco legislation have been implemented in Portugal, which may have affected smoking patterns. The aim of this study was to measure the change in prevalence of first- and second-hand smoking (SHS) among adults, and its socio-demographic patterning in Portugal from 2005 to 2014. Data from the last two Portuguese National Health Interview Surveys (2005 and 2014) were used. The changes in daily smoking and SHS were measured using Poisson regressions, stratifying by sex and survey year. The inequalities were measured using relative inequality indexes (RII). From 2005 to 2014, there was a reduction in SHS (75%-54% among men, and 52%-38% among women), and a reduction in smoking among men (27%-26%), and an increase among women (9%-12%). SHS reduction was more marked among less privileged people. Among Portuguese men, inequalities in daily smoking have increased slightly, while among women the gap favoring low-educated reduced. Between 2005 and 2014, SHS decreased, but not daily smoking, particularly among women. Additionally, socioeconomic inequalities in smoking increased. Future policies should simultaneously tackle smoking and SHS prevalence, and their socioeconomic patterning. More comprehensive policies such as comprehensive national (non-partial) bans, combined with price increases could be more effective.

Aortic Prosthesis-Associated MDR Pseudomonas Infections as a Diagnostic and Therapeutic Challenge.

Endovascular prostheses are used to treat life-threatening conditions such as ruptured aortic aneurysms. Prosthetic infection cause significant morbidity and mortality, posing important diagnostic and therapeutic challenges. It is particularly difficult to diagnose and, in the era of multidrug resistance (MDR), these type of infections may become even more difficult to treat. Herein, we reported a case of a secondary prosthetic endovascular infection following repeated bacteremia episodes from a urinary source. This case illustrates an MDR Pseudomonas aeruginosa aortic infection that was difficult to diagnose with no oral antibiotic treatment options.

Schizophyllum commune sphenoidal sinusitis as presentation of a non-Hodgkin Lymphoma.

Schizophyllum commune is a basidiomycetes worldwide distributed that has emerged as cause of invasive infections in immunosuppressed patients. We present a case of a man who was simultaneously diagnosed with a small cell non-Hodgkin lymphoma and a sphenoid sinusitis by S. commune. Intraoperative observation and histology description were crucial to consider an alternative diagnosis to mucormycosis suggested by the MRI. The diagnosis was made based on PCR identification and sequencing.

Botulism disguised as parotitis.

Botulism is an acute toxin-mediated neuroparalytic syndrome caused by some Clostridium species. It typically presents itself as an acute symmetric descending paralysis of cranial and peripheral nerves, which can potentially evolve to respiratory failure and death. We report a case of botulism diagnosed in a patient presenting with a parotitis probably due to xerostomia, even though he had already sought medical assistance for blurred vision and dysphagia. The neurological symptoms resolved without administration of antitoxin and botulism diagnosis was confirmed with identification of both toxins B and F in patient's serum. We aim to illustrate the need for a high clinical suspicion for the diagnosis of botulism and to report an atypical case of botulism with the production of toxins B and F, the latter being of rare occurrence.

Abdominoplasty with Scarpa Fascia Preservation: Randomized Controlled Trial with Assessment of Scar Quality and Cutaneous Sensibility.

BACKGROUND: Scarpa fascia preservation during abdominoplasty has been shown to reduce complications associated with the traditional technique. As an extension of a previously published randomized controlled trial, this study aims to clarify whether preservation of Scarpa fascia during abdominoplasty has an influence on scar quality or sensibility recovery. METHODS: This was a single-center clinical trial, involving 160 patients randomly assigned to one of two surgical procedures: classic full abdominoplasty (group A) and abdominoplasty with preservation of Scarpa fascia (group B). Patients were later convoked to assess scar quality and abdominal cutaneous sensibility. Scar quality was evaluated through the Patient and Observer Scar Assessment Scale. Cutaneous sensibility was measured on the upper and lower abdomen, using light touch, Semmes-Weinstein testing (5.07/10-g monofilament), and a 25-gauge needle. RESULTS: A total of 99 patients (group A, 54 patients; group B, 45 patients) responded to contact, with a mean follow-up time of 44 months. Concerning scar quality, Patient and Observer Scar Assessment Scale scores were similar between groups. On the upper abdomen, there was a statistically significant difference between groups on cutaneous sensibility, on the examination with the Semmes-Weinstein 5.07/10-g monofilament (group A, 79.6 percent; group B, 93.3 percent; p = 0.046) and pain (group A, 90.7 percent; group B, 100 percent; p = 0.044). No statistically significant differences were found between groups on the lower abdomen. A considerable proportion of patients (two-thirds) still presented sensibility alterations in the subumbilical area 3½ years after abdominoplasty. CONCLUSION: Scarpa fascia preservation during abdominoplasty does not influence scar quality, but it improves sensibility recovery in the supraumbilical area. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.