ALGORITHM OF PARTIAL BREAST RECONSTRUCTION WITH PEDICLED PERFORATOR FLAPS

INTRODUCTION: The authors present an algorithm of partial breast reconstruction following quadrantectomy that allows to restore the breast volume defect with the use of pedicled perforator flaps. MATERIAL AND METHODS: Between March 2009 and May 2010, at the Plastic and Reconstructive Institute of University of Palermo, pedicled perforator flaps were used to integrate volume and/or breast skin in 12 patients after benign and malignant breast tumors. The flaps used were based on perforators of the thoraco-dorsal artery (TDAP) and of the intercostal arteries (ICAP). TDAP flaps were used to reconstruct defects in any breast quadrant, while ICAP perforator were used to reconstruct lateral and central inferior pole defects. RESULTS: All flaps survived completely. Breast size, shape and volume were satisfactorily restored. Contralateral breast procedure to adjust symmetry were not necessary. Donor sites scars were well hidden in the inframammary fold or under the brassiere. CONCLUSIONS : Partial breast reconstruction can be performed, in selected patients, with pedicled perforator flaps to restore both volume, shape and skin envelope. Donor site scars are negligible and better with the anterior ICAP because the scar is hidden in the submammary sulcus

Clinical neurophysiology and imaging of nerve injuries: preoperative diagnostic work-up and postoperative monitoring

Peripheral nerve injuries are a heterogeneous group of lesions that may occurs secondary to various causes. Several different classifications have been used to describe the pathophysiological mechanisms leading to the clinical deficit, from simple and reversible compression‑induced demyelination, to complete transection of nerve axons. Neurophysiological data localize, quantify, and qualify (demyelination vs. axonal loss) the clinical and subclinical deficits. High‑resolution ultrasound can demonstrate the morphological extent of nerve damage, fascicular echotexture (epineurium vs. perineurium, focal alteration of the cross‑section of the nerve, any neuromas, etc.), and the surrounding tissues. High field magnetic resonance imaging provides high contrast neurography by fat suppression sequences and shows structural connectivity through the use of diffusion‑weighted sequences. The aim of this review is to provide clinical guidelines for the diagnosis of nerve injuries, and the rationale for instrumental evaluation in the preoperative and postoperative periods. While history and clinical approach guide neurophysiological examination, nerve conduction and electromyography studies provide functional information on conduction slowing and denervation to assist in monitoring the onset of re‑innervation. High‑resolution nerve imaging complements neurophysiological data and allows direct visualization of the nerve injury while providing insight into its cause and facilitating surgical treatment planning. Indications and limits of each instrumental examination are discussed

The chimeric ALT-vastus lateralis free flap in reconstruction of advanced BRONJ of the maxilla.

Introduction Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a dangerous complication of bisphosphonates, a class of pharmaceutical agents used in numerous bone disor- ders. No gold standard therapy exists, but recent literature suggests that, in advanced stages, the best results are achieved with aggressive debridement. In this paper, we report our experience of treatment of stage 3 BRONJ of the maxilla with extensive surgical debridement and reconstruction with a chimeric ALT-Vastus lateralis flap. Methods Five selected patients with stage 3 BRONJ underwent partial maxillectomy with dis- ease-free margins followed by immediate reconstruction with a chimeric ALT-Vastus lateralis free flap. Results Only two patients experienced minor complications. All other patients healed unevent- fully within two weeks and donor site morbidity was minimal. Conclusions Our data suggest that aggressive debridement and reconstruction with a chimeric ALT -Vastus lateralis flap is an effective option for the treatment of stage III BRONJ of the maxilla

Incidence and Risk Factors for Tractional Macular Detachment after Anti-Vascular Endothelial Growth Factor Agent Pretreatment before Vitrectomy for Complicated Proliferative Diabetic Retinopathy

The study's purpose was to determine the incidence, risk factors, and outcomes of tractional macular detachment after anti-vascular endothelial growth factor (VEGF) pretreatment before vitrectomy for complicated proliferative diabetic retinopathy. Patients who underwent primary vitrectomy for complicated proliferative diabetic retinopathy, from January 2012 to 31 December 2018, were enrolled. Ophthalmic and pre-operative data were extracted from electronic record systems. All eyes with a valuable Optical Coherence Tomography (OCT)performed within 5 days before injection of anti-VEGF and on the day of vitrectomy were included. Multivariable logistic regression showed that significant risk factors for developing tractional macular detachment included days between anti-VEGF and vitrectomy (OR, 0.71 [95% CI 0.65-0.76]; p < 0.001), vitreous hemorrhage (OR, 0.23 [95% CI 0.11-0.49]; p < 0.001), and age (OR, 1.05 [95% CI 1.02-1.08]; p < 0.001). Decision-tree analysis showed that the stronger predictors of tractional macular detachment were the time between anti-VEGF injection and vitrectomy (p < 0.001). Secondary predictors were the presence of vitreous hemorrhage (p = 0.012) in eyes that underwent vitrectomy between 6 and 10 days after anti-VEGF injection and younger age (p = 0.031) in eyes that underwent vitrectomy 10 days after anti-VEGF injection. Tractional macular detachment occurs in 10% of eyes after anti-VEGF injection, the main risk factors being days between anti-VEGF injection and vitrectomy, vitreous hemorrhage, and age

Association of neovascular age-related macular degeneration with month and season of birth in Italy

In order to investigate the influence of season and month of birth on the risk of neovascular age-related macular degeneration (n-AMD) in Italy, we evaluated the month birth and sex of all patients, recorded in the anti-vascular endothelial growth factor (VEGF) monitoring registry of the Italian Medicines Agency, born between 1925-1944, who received intravitreal anti-VEGF injections for n-AMD between January 1, 2013 and July 29, 2015. The numbers of all births in Italy in the same years, extracted from the Italian National Institute of Statistics, were used to calculate the expected number of n-AMD cases. Overall, 45,845 patients (19,207 men, 26,638 women) received intravitreal anti-VEGF for n-AMD; in the same years, 20,140,426 people (10,334,262 male, 9,806,164 female) were born in Italy. Comparing the observed number of n-AMD cases with the expected number of n- AMD cases in each season, we found that the season-specific risk for n-AMD was 2.5% higher for those born in summer (OR=1.03, Bonferroni-corrected P=0.008) and 3% lower for those born in winter (OR=0.96, Bonferroni-corrected P=0.0004). When considering the month of birth, the risk of n-AMD was 5.9% lower for people born in January (OR=0.93, Bonferroni-corrected P=0.0012). The factors causing such differences should be determined

The Effectiveness of 0.6% Povidone Iodine Eye Drops in Reducing the Conjunctival Bacterial Load and Needle Contamination in Patients Undergoing Anti-VEGF Intravitreal Injection: A Prospective, Randomized Study

The study purpose was to assess the efficacy of a preservative-free 0.6% povidone iodine eye drops as perioperative prophylactic treatment for reducing conjunctival bacterial load and the rate of needle contamination in patients undergoing intravitreal anti-vascular endothelial growth factor injection. Enrolled patients were randomized to either the study group (0.6% povidone iodine, three day-prophylactic treatment before the injection) or to the control group (placebo, three day-prophylactic treatment). Conjunctival swabs were obtained before and after the prophylactic treatment in both groups. Intravitreal injections were performed in a sterile fashion. The injection needle and a control needle were collected for microbiological culture. Data from 254 and 253 eyes in the study group and control group, respectively, were analyzed. Bacterial growth from conjunctival swab cultures was significantly lower after 0.6% povidone iodine prophylaxis compared to baseline and to placebo prophylaxis (p < 0.001), showing an 82% eradication rate in the study group. No injection needle showed bacterial contamination in the study group, whereas six needles were culture-positive in the control group (p = 0.015). No serious ocular and non-ocular adverse events were recorded. The 0.6% povidone iodine solution proved an effective treatment in reducing conjunctival bacterial load and risk of needle contamination

Ultrasonography and Nerve Conduction Study in patients with carpal tunnel syndrome, comparison between the two techniques before and after median nerve decompression surgery: observational study

Abstract Purpose: Traditional evaluation of suspected carpal tunnel syndrome (CTS) involves a thorough history, physical examination, and nerve conduction velocity studies (NCS). The aim of the study is to evaluate whether ultrasound (US) is a valid alternative to the emg as a routine pre-operative examination, to evaluate patients with STC, comparing some us values with NCS findings pre and postopertively Methods: Only patients with symptoms, clinical examination, and NCS findings consistent with CTS were included in the study, according to the inclusion criteria. Four ultrasonographic variables were considered in treated patients: 1) CSPA (cross sectional pisiform area); 2) S-P dt: the largest diameter of the nerve in the same point; 3) Prox Area: the section area approximately 4 cm proximal to the pisiform; 4) Prox DT: the largest diameter in the same point. Each of these values was measured pre and postoperatively (three months after surgery) As for the emgraphic variables, the VCS and the SAP were taken into consideration, that is sensitive variables. The NCS and the ultrasound values are compared In this preliminary phase of the study, 25 patients were recruited. Results: A significant correlation was found between “CSPA” and “SAP” before and after surgery, As if the CSPA could be a reliable parameter for the diagnostic evaluations of these patients, as well as for any postoperative or post-therapeutic evaluation. Conclusions: Our results indicate that high-resolution ultrasound is informative in the evaluation of CTS and shows enlargement of the median nerve at the distal wrist crease in symptomatic patients. Therefore it is a reliable modality for imaging the wrist in patients with CTS. In addition ultrasound is well tolerated and safe. The extended role of US in STC diagnosis awaits further definition, these are preliminary findings to be confirmed by further studies with larger sample siz

Clinical neurophysiology and imaging of nerve injuries: preoperative diagnostic work-up and postoperative monitoring

Peripheral nerve injuries are a heterogeneous group of lesions that may occurs secondary to various causes. Several different classifications have been used to describe the pathophysiological mechanisms leading to the clinical deficit, from simple and reversible compression-induced demyelination, to complete transection of nerve axons. Neurophysiological data localize, quantify, and qualify (demyelination vs. axonal loss) the clinical and subclinical deficits. High-resolution ultrasound can demonstrate the morphological extent of nerve damage, fascicular echotexture (epineurium vs. perineurium, focal alteration of the cross-section of the nerve, any neuromas, etc.), and the surrounding tissues. High field magnetic resonance imaging provides high contrast neurography by fat suppression sequences and shows structural connectivity through the use of diffusion-weighted sequences. The aim of this review is to provide clinical guidelines for the diagnosis of nerve injuries, and the rationale for instrumental evaluation in the preoperative and postoperative periods. While history and clinical approach guide neurophysiological examination, nerve conduction and electromyography studies provide functional information on conduction slowing and denervation to assist in monitoring the onset of re-innervation. High-resolution nerve imaging complements neurophysiological data and allows direct visualization of the nerve injury while providing insight into its cause and facilitating surgical treatment planning. Indications and limits of each instrumental examination are discussed

Geo-Epidemiology of Age-Related Macular Degeneration: New Clues into the Pathogenesis

Abstract PURPOSE: To evaluate the demographic, geographic, and race-related variables that account for geographic variability in prevalence rates of age-related macular degeneration (AMD). DESIGN: Systematic review, meta-regression, and decision-tree analysis. METHODS: A systematic literature review of PubMed, Medline, Web of Science, and Embase databases identified population-based studies on the prevalence of AMD published before May 2014. Only population-based studies that took place in a spatially explicit geographic area that could be geolocalized, and used retinal photographs and standardized grading classifications, were included. Latitude and longitude data (geolocalization) and the mean annual insolation for the area where survey took place were obtained. Age-standardized prevalence rates across studies were estimated using the direct standardization method. Correlations between the prevalence of AMD and longitude and latitude were obtained by regression analysis. A hierarchical Bayesian meta-regression approach was used to assess the association between the prevalence of AMD and other relevant factors. We further investigated the interplay between location and these factors on the prevalence of AMD using regression based on conditional-inference decision trees. RESULTS: We observed significant inverse correlations between latitude or longitude, and crude or age-standardized prevalence rates, of early and late AMD (P < .001). Metaregression analysis showed that insolation, latitude, longitude, age, and race have a significant effect on the prevalence rates of early and late AMD (P < .001). Decision-tree analysis identified that the most important predictive variable was race for early AMD (P = .002) and insolation for late AMD (P = .001). CONCLUSIONS: Geographic position and insolation are key factors in the prevalence of AMD