Flap reconstruction of the hypopharynx: a defect orientated approach

The present retrospective analysis evaluated the outcomes of different flap reconstructions for several hypopharyngeal defects in 136 patients who underwent hypopharyngeal reconstruction with a free or pedicled flap after excision of pharyngeal or laryngeal carcinoma.Functional and oncological outcome were the main measures. Nine patients had a type I-a hypopharyngeal defect (partial with larynx preserved), 33 type I-b (partial without larynx preserved), 85 type II (circumferential), 5 type III (extensive superior) and 4 vertical hemipharyngolaryngectomy. The flaps used to reconstruct these defects were pectoralis major (n = 34), free radial forearm (n = 25), jejunum (n = 72), pedicled latissimus dorsi (n = 2), sternocleidomastoid (n = 1), lateral thigh (n = 1) and deltopectoral (n = 1). Twelve defects (9%) needed a secondary flap reconstruction. Surgical and medical complications were seen in 29% and 8% of patients, respectively; 18% of patients developed a fistula. No difference in complication rate or admission days was found for pre-operative versus no previous radiotherapy, type of defect or free versus pedicled flap. After 12 months follow-up, 38% of patients had a tracheo-oesophageal voice prosthesis, in 82% a fully oral diet was obtained and the average body weight gain was 0.9 kg. Five-year overall and disease-specific survival rates were 35% and 49%, respectively, while local and regional control rates were 65% and 91%, respectively. Considering these results, a defect orientated approach may be helpful for deciding which flap should be used for reconstruction of the hypopharynx. An algorithm is proposed with similar functional and oncological outcomes for the different groups. The choice of flap should be based on expected morbidity and functional outcome

Italian patients with hemoglobinopathies exhibit a 5-fold increase in age-standardized lethality due to SARS-CoV-2 infection.

Since the beginning of the COVID-19 pandemic, concerns have been expressed worldwide for patients with hemoglobinopathies and their vulnerability to SARS-CoV-2 infection. Data from Lebanon confirmed a role of underlying comorbidities on COVID-19 severity, but no deaths among a cohort of thalassemia patients.1 Patients with sickle cell disease (SCD) displayed a broad range of severity after SARS-CoV-2 infection, spanning from a favorable outcome unless pre-existing comorbidities (UK cohort)2 to high case mortality in US.3 History of pain, heart, lung, and renal comorbidities was identified as risk factors of worse COVID-19 outcomes by the US SECURE-SCD Registry.4 While Italy experienced a death rate in the general population among the highest in the world, preliminary data from the first wave of the pandemic showed a lower than expected number of infected thalassemia patients (updated up to April 10, 2020), likely due to earlier and more vigilant self-isolation compared to the general population.

Riflessioni in tema di centralizzazione della committenza negli appalti pubblici

Il contributo analizza come la c.d. “cultura del sospetto” ostacoli l’attività contrattuale della pubblica amministrazione. La “cultura del sospetto” consiste nella percezione che ogni procedura negoziale sia foriera di reati e/o di “cattiva amministrazione”. Gli effetti di questa c.d. “cultura del sospetto” consistono in immobilismo e inerzia, dal momento che inibiscono il pieno ricorso ad azioni discrezionali ed efficienti, facendo sì che i funzionari evitino scelte rischiose, in termini di responsabilità penale, civile ed erariale. In tale contesto il tema della centralizzazione della committenza può acquisire un rilievo decisivo. Questo perché l’attribuzione ad un unico soggetto della competenza ad acquistare beni e servizi sul mercato, oltre a conseguire positive “economie di scala”, è in grado di accrescere le professionalità dei funzionari, che operano all’interno della centrale di committenza, e favorire la trasparenza delle procedure di gara. Il contributo si sofferma altresì su un’analisi critica dell’odierna disciplina normativa, nazionale ed europea, in tema di centrali di committenza e a vagliarne e proporre necessarie riforme e miglioramenti