Free flap head and neck reconstruction in the elderly: What is the impact on quality of life?

Morphofunctional reconstruction is a pivotal aspect in the surgery of head and neck neoplasms: Nowadays, microvascular free flap surgery represents the gold standard. In choosing the surgical technique, the effects on residual quality of life, especially in elderly people, usually considered more fragile and so often excluded from microsurgical procedures, must be taken into account. This multicentre study evaluated the quality of life index in patients more than 75 years of age and who underwent to head and neck microsurgical reconstruction. Data from patients aged > 75 years at the time of major head and neck reconstruction conducted with free flaps between 1 January 2005 and 30 June 2015 were analysed retrospectively. We administered the Italian version of Quality of Life questionnaire SF-36, at least 24 months after surgery. Results were compared to those for the general Italian population of the same age. We enrolled 39 patients with an average age of 80.6 years. The results did not differ significantly from the reference population. The international literature has already shown that chronologic age is not a valid parameter to determine the surgical treatment modality. Even considering the quality of residual life, our study supports the indication for free-flap reconstruction of head and neck defects in the elderly, confirming its effectiveness in this population

Advancing Our Understanding of the Inheritance and Transmission of Pectus Excavatum

Pectus excavatum is the most common congenital chest wall abnormality expressed in children, yet its inheritance is poorly understood. Here we present the first comprehensive assessment of the inheritance of this disorder. After evaluating 48 pedigrees and 56 clinical traits of probands and family members, we find strong evidence of autosomal recessive, genetic control for this disorder. Additionally there is likely more than one pectus disease-associated allele, as well as a relatively large number of disease allele carriers in the human population. Some clinical traits appear important and may serve as reliable indicators for predicting the likelihood of pectus excavatum in children before severe symptoms present. Quantifying sex-ratio bias in probands demonstrates a highly significant male bias associated with pectus excavatum. When combined with pedigree data, sex-bias is indicative of sex-linked, sex-limited, and/or epigenetic control such as X-inactivation, reiterating a point made with pedigrees alone, which is that more than one mutation is likely responsible for this disorder

Free flap loss caused by heparin-induced thrombocytopenia and thrombosis (HITT) : a case report and literature review = Trombocitopenia eparino-indotta e trombosi (HITT): Una causa sottostimata di fallimento di lembi liberi : Case report e revisione della letteratura

Heparin-induced thrombocytopenia and thrombosis (HITT) represents a dramatic condition that is difficult to diagnose because of nuanced clinical presentation. Therefore, in every case of microvascular thrombosis during heparin-therapy prompt suspicion about HITT is necessary to avoid flap necrosis. We present a case of HITT which, as the 8 other articles reviewed, clearly shows that HITT is difficult to diagnose and complex to manage. Microvascular reconstruction is the first choice in head and neck reconstruction; unfortunately, dramatic outcomes in free flap surgery due to unpredictable thrombotic events are still reported in the English literature. More knowledge is required about HITT and reaching a consensus about thrombotic prevention in microsurgery could be helpful. Furthermore, a careful anamnesis can help minimise unexpected situations

Free flap loss caused by heparin-induced thrombocytopenia and thrombosis (HITT): a case report and literature review

La trombocitopenia eparino-indotta con trombosi rappresenta una complicanza che può portare a esiti drammatici nella chirurgia ricostruttiva microvascolare, tanto più che il suo riconoscimento non è sempre semplice. In ogni caso di trombosi microvascolare, in corso di terapia eparinica, il sospetto di HITT deve subito insorgere, così da poter intercettare e trattare la catena di eventi che porterebbe alla necrosi del lembo ricostruttivo. Presentiamo un caso che dimostra quanto possa essere difficile la diagnosi di HITT, così come appare negli altri reports reperibili in letteratura internazionale. I lembi microvascolari sono il gold standard nella chirurgia ricostruttiva cervico-facciale: purtroppo però il successo della metodica può essere inficiato da eventi trombo-embolici imprevedibili. Crediamo che una maggior divulgazione e la formulazione di domande anamnestiche specifiche possano essere utili nel limitare le conseguenze devastanti della HITT

Subclinical Thyroid Dysfunction and the Risk of Cognitive Decline: a Meta-Analysis of Prospective Cohort Studies.

Although both overt hyper- and hypothyroidism are known to lead to cognitive impairment, data on the association between subclinical thyroid dysfunction and cognitive function are conflicting. This study sought to determine the risk of dementia and cognitive decline associated with subclinical thyroid dysfunction among prospective cohorts. We searched in MEDLINE and EMBASE from inception until November 2014. Two physicians identified prospective cohorts that assessed thyroid function and cognitive outcomes (dementia; Mini-Mental State Examination [MMSE]). Data were extracted by one reviewer following standardized protocols and verified by a second reviewer. The primary outcome was dementia and decline in cognitive function was the secondary outcome. Eleven prospective cohorts followed 16,805 participants during a median followup of 44.4 months. Five studies analyzed the risk of dementia in subclinical hyperthyroidism (SHyper) (n = 6410), six in subclinical hypothyroidism (SHypo) (n = 7401). Five studies analyzed MMSE decline in SHyper (n = 7895), seven in SHypo (n = 8960). In random-effects models, the pooled adjusted risk ratio for dementia in SHyper was 1.67 (95% confidence interval, 1.04; 2.69) and 1.14 (95% confidence interval, 0.84; 1.55) in SHypo vs euthyroidism, both without evidence of significant heterogeneity (I(2) = 0.0%). The pooled mean MMSE decline from baseline to followup (mean 32 mo) did not significantly differ between SHyper or SHypo vs euthyroidism. SHyper might be associated with an elevated risk for dementia, whereas SHypo is not, and both conditions are not associated with faster decline in MMSE over time. Available data are limited, and additional large, high-quality studies are needed

Thyroid function tests in the reference range and fracture: individual participant analysis of prospective cohorts.

Context Hyperthyroidism is associated with increased fracture risk, but it is not clear if lower TSH and higher free thyroxine (FT4) in euthyroid individuals are associated with fracture risk. Objective To evaluate the association of TSH and FT4 with incident fractures in euthyroid individuals. Design Individual participant data analysis. Setting Thirteen prospective cohort studies with baseline examinations between 1981 and 2002. Participants Adults with baseline TSH 0.45-4.49 mIU/L. Main Outcome Measures Primary outcome was incident hip fracture. Secondary outcomes were any, non-vertebral, and vertebral fractures. Results were presented as hazard ratios (HR) with 95% confidence interval (CI) adjusted for age and sex. For clinical relevance, we studied TSH according to five categories: 0.45-0.99mIU/L; 1.00-1.49mIU/L; 1.50-2.49mIU/L; 2.50-3.49mIU/L; 3.50-4.49mIU/L (reference). FT4 was assessed as study-specific standard deviation increase, because assays varied between cohorts. Results During 659,059 person-years, 2,565/56,835 participants had hip fracture (4.5%; 12 studies with data on hip fracture). The pooled adjusted HR (95% CI) for hip fracture was 1.25 (1.05-1.49) for TSH 0.45-0.99mIU/L, 1.19 (1.01-1.41) for TSH 1.00-1.49mIU/L, 1.09 (0.93-1.28) for TSH 1.50-2.49mIU/L, and 1.12 (0.94-1.33) for TSH 2.50-3.49mIU/L (P for trend = 0.004). Hip fracture was also associated with FT4 (HR [95%CI] 1.22 [1.11-1.35] per one standard deviation increase in FT4). FT4 only was associated with any and non-vertebral fracture. Results remained similar in sensitivity analyses. Conclusions Among euthyroid adults, lower TSH and higher FT4 are associated with an increased risk of hip fracture. These findings may help refine the definition of optimal ranges of thyroid function tests

Mars mission performance enhancement with hybrid nuclear propulsion

Nuclear electric propulsion (NEP), compared with chemical and nuclear thermal propulsion (NTP), can effectively deliver the same mass to Mars using much less propellant, consequently requiring less mass delivered to Earth orbit. The lower thrust of NEP requires a spiral trajectory near planetary bodies, which significantly increases the travel time. Although the total travel time is long, the portion of the flight time spent during interplanetary transfer is shorter, because the vehicle is thrusting for much longer periods of time. This has led to the supposition that NEP, although very attractive for cargo missions, is not suitable for piloted missions to Mars. However, with the application of a hybrid application of a hybrid approach to propulsion, the benefits of NEP can be utilized while drastically reducing the overall travel time required. Development of a dual-mode system, which utilizes high-thrust NTP to propel the spacecraft from the planetary gravitational influence and low-thrust NEP to accelerate in interplanetary space, eliminates the spiral trajectory and results in a much faster transit time than could be obtained by either NEP or NTP alone. This results in a mission profile with a lower initial mass in low Earth orbit. In addition, the propulsion system would have the capability to provide electrical power for mission applications

Reliability comparison of various nuclear propulsion configurations for Mars mission

Currently, trade-offs are being made among the various propulsion systems being considered for the Space Exploration Initiative (SEI) missions. It is necessary to investigate the reliability aspects as well as the efficiency, mass savings, and experience characteristics of the various configurations. Reliability is a very important factor for the SEI missions because of the long duration and because problems will be fixed onboard. The propulsion options that were reviewed consist of nuclear thermal propulsion (NTP), nuclear electric propulsion (NEP) and various configurations of each system. There were four configurations developed for comparison with the NTP as baselined in the Synthesis (1991): (1) NEP, (2) hybrid NEP/NTP, (3) hybrid with power beaming, and (4) NTP upper stage on the heavy lift launch vehicle (HLLV). The comparisons were based more or less on a qualitative review of complexity, stress levels and operations for each of the four configurations. Each configuration included a pressurized NEP and an NTP ascent stage propulsion system for the Mars mission