Total intravenous anesthesia (TIVA) with propofool and remifentanil during operative endoscopy tracheobronchial laser therapy

Background

The aim of our study was to assess how total intra-venous anaesthesia (TIVA) achieved by propofol and remifentanil continuous infusion could ensure proper success of the endobronchial laser therapy, in optimal conditions for the endoscopist, determining at the same time an adequate hypnosis and a good analgesia.

Methods

We studied 50 patients (28M - 22F), ASA class I-IV, mean age 42 ± 32.5 years , subjected to laser endoscopy to repair tracheal stenosis. TIVA was performed in all patients, and spontaneous breathing was maintained.

Results

10.2% of patients experienced episodes of coughing during induction. The depth of the anaesthesia plan, monitored by BIS, was 55 ± 5. The awakening was fast in all patients, with an Aldrete score of 7.71 ± 1.14 at 1 minute and 9.31 ± 1.12 at 10 minutes.

Conclusion

The results of this study allow us to state that the continuous infusion of propofol and remifentanil proved to be the gold standard in patients ASA I-II-III undergoing endobronchial laser therapy. The use of TIVA has also allowed to perform endoscopic intervention on patients who suffered from a significant decrease of both cardiac and respiratory functions.

Achieving the learning curve in total thyroidectomy: a prospective evaluation on resident's training by CUSUM and KPSS analysis

INTRODUCTION

Total thyroidectomy (TT) is one of the most common procedures among general and endocrine surgeons worldwide. The conventional approach by neck incision is still the most frequently used, despite the growth of mini-invasive approaches. Controversies exist about the optimal learning curve for resident surgeons approaching this procedure. The aim of this study was to compare TT performed by experienced surgeons and residents in two academic hospitals, to define the correct shape of the specific learning curve.

METHODS

Between January 2016 and December 2018 patients undergoing TT in two academic departments were prospectively enrolled. In each department patients were divided into four groups: a reference group (A), consisting of 50 consecutive patients operated on by a senior surgeon, and three other groups (B, C, D) of 50 patients each where thyroidectomy was carried out by three different general surgery residents in their last 3 years of residency, respectively. Data were analysed by CUSUM and KPSS tests in order to compare operative time (OT) and its stabilisation during the learning curve.

RESULTS

Data from CUSUM test reported that residents could perform TT with OT similar to the senior surgeon after approximately 25-30 procedures, while the KPSS test showed that residents became more stable after 30 procedures, with no increase in perioperative complications.

CONCLUSIONS

This prospective study shows how a specific training in thyroid surgery can be reliable thanks to experienced tutors, and confirmed that the effect of dedicated and programmed training may result in positive outcomes for patients requiring thyroidectomy.

Venous thromboembolism prophylaxis in plastic surgery: state of the art and our approach

OBJECTIVE

The issue of prevention of thromboembolism in plastic surgery is a rather controversial subject. The actual frequency of VTE among plastic surgery patients is probably higher than we know. Although several studies have shown that chemoprophylaxis likely increases rates of re-operative hematoma by less than one percent, surgeons are strongly resistant to adopting chemoprophylaxis due to the fear of increased bleeding and its complications.

MATERIALS AND METHODS

A literature review was conducted. The 2012 ACCP guidelines suggest the use of the 2005 Caprini score as the most widely used and well-validated individualized risk-stratification tool. We propose a modified 2005 Caprini score, with specific changes pertaining to plastic surgery, in which we combine a patient risk stratification model and a procedure-driven approach explicitly indicating what procedures have to be considered at high or low risk.

RESULTS

The risk of venous thromboembolism in plastic surgery cannot be disregarded. However, the plastic surgery literature still lacks high-level evidence for appropriate means of VTE prophylaxis, although an increasing amount of attention has been paid to the topic. We suggest the development of an international guideline, based on plastic surgical data, using a validated risk assessment model, which combines the surgical risk with the patient-related risk.

CONCLUSIONS

Determining the proper venous thromboembolism prophylaxis is a clinical decision that should be made on a patient-to-patient basis. The algorithm presented in this article is meant to simplify this complex problem and to help expedite and clarify the decision-making process.

Criticism of learning curve in laparoscopic adrenalectomy: a systematic review

BACKGROUND

Laparoscopic adrenalectomy (LA) has become the treatment of choice for benign adrenal lesions. Lateral Transperitoneal Laparoscopic Adrenalectomy (LTLA) is considered the gold standard. The number of LTLAs a surgeon must perform, in order to complete his learning curve, is not well defined in Literature. Moreover, the few papers dealing with the learning curve for LTLAs show controversial results and consider different evaluation parameters.

METHODS

The systematic review has been carried out according to PRISMA statement. The literature search included PubMed and Scopus database. Hand searching of reference lists of previous review articles and relevant studies was also performed. The search string was "learning curve AND laparoscopic adrenalectomy".

RESULTS

A total of 9 papers met the inclusion criteria out of 94 non duplicate citations. The aim of this systematic review is to provide a multidimensional evaluation by bringing into focus evaluation parameters of surgical performance, (operative time, intraoperative complications, conversion rate and blood loss), factors related to patient's pathology (side, size, adrenal pathology) and surgeon-specific properties.

CONCLUSIONS

Operative time, intraoperative bleeding, intraoperative complications and conversion rate are the main parameters that have been considered for the achievement of learning curve, and for each there are discrepancies, mainly due to the relative rarity of adrenal tumors, and so for difficulties in obtaining approper analysis that could establish an effective learning curve. So, further evaluations in larger experience are needed.

Oncoplastic conservative surgery for breast cancer: long-term outcomes of our first ten years experience

OBJECTIVE

The main goal of oncoplastic breast surgery (OBS) is to optimize cosmetic outcomes and reduce patient morbidity, while still providing an oncologically-safe surgical outcome and extending the target population of conservative surgery. Although the growing number of reported experiences with oncoplastic surgery, few studies account for the long-term outcomes.

PATIENTS AND METHODS

Between January 2000 and December 2010, 1024 consecutive oncoplastic surgeries were performed and prospectively included in a database. Demographic data, histological and oncological evaluation and surgical complications were recorded. The role of tumor and patients' characteristics on the development of local recurrence and metastases were assessed by multivariate analysis.

RESULTS

Median follow up was 74.2 months. The average age of patients was 56.24. In 869 patients (84.9%) an invasive tumor and in 155 (15.1%) an in situ tumor (11% DCIS and 4% LIN) was found. The average size of the tumor was 24.5 mm. A positive margin presented in 67 (6.5%) patients. Forty patients (50%) underwent re-excision and 39 (49.4%) underwent mastectomy. The overall breast conservation rate was 96.2%. Reported complications were: 17 wound infections (1.7%); 106 hematomas (10.4%); 94 lymphorrheas (9.2%), 48 partial wound dehiscence (4.7%). Local recurrences (LR) were observed in 49 patients (4.7%). The risk of local recurrence was significantly higher in the group of patients with lymphovascular invasion and with high grade (G) (p < 0.05). 52 (5.07%) distant metastases were reported and the related risk was significantly higher in the group of patients with lymphovascular invasion and with negative receptors (p < 0.05).

CONCLUSIONS

Oncoplastic surgery provides an acceptable oncological long-term outcome and can be used to treat with conservative surgery also a selected population of patients who would had otherwise undergone mastectomy in the past.

Oncological safety of stromal vascular fraction enriched fat grafting in two-stage breast reconstruction after nipple sparing mastectomy: long-term results of a prospective study

OBJECTIVE

Autologous fat transfer (AFT) is commonly used to treat implant palpability and prevent fibrosis and thinning in mastectomy skin flaps. A major limit to this procedure is volume retention over time, leading to the introduction of fat enrichment with stromal vascular fraction (SVF+AFT). Oncological concerns have been raised over the injection of an increased concentration of progenitors cells (ASCs) in the SVF. The aim of the study is to evaluate the long-term cancer recurrence risk of SVF+AFT cases compared to AFT, in patients undergoing Nipple Sparing Mastectomy (NSM).

PATIENTS AND METHODS

A prospective study was designed to compare three groups of patients undergoing NSM followed by SVF+AFT, AFT or none (control group), after a two-stage breast reconstruction. Patients were strictly followed-up for at least 5-years from the second stage reconstructive procedure. Loco-regional and systemic recurrence rate were evaluated over time as the primary outcome. Logistic regression was used to investigate which factors were associated with recurrence events and independent variables of interest were: surgical technique, age above 50 years old, lympho-vascular invasion, oncological stage, adjuvant or neoadjuvant chemotherapy, adjuvant radiotherapy and adjuvant hormone therapy.

RESULTS

41 women were included in G1 (SVF+AFT), 64 in G2 (AFT), and 64 in G3 (control group). Loco-regional recurrence rate was 2.4% for G1, 4.7% for G2, and 1.6% for G3. Systemic recurrence was 7.3%, 3.1%, and 3.1%, respectively. Among the variables included, there were no significant risk factors influencing a recurrence event, either loco-regional or systemic. In particular, SVF+AFT (G1) did not increase the oncological recurrence.

CONCLUSIONS

Our data suggest that both centrifuged and SVF-enhanced fat transfer have a similar safety level in comparison to patients who did not undergo fat grafting in breast reconstruction after NSM.

Depression risk among patients with chronic wounds

OBJECTIVE

A wound is defined as chronic when it requires more than 6 weeks to heal. The link between chronic wounds and depression was first pointed out by House and Hughes in 1996 and later evaluated by other numerous studies. Several studies demonstrate that among chronic skin wounds causing chronical physical disease, the leg ulcers are the most frequently associated with depression. The aim of our study is to evaluate the prevalence of depression in patients with different types of chronic wounds.

PATIENTS AND METHODS

We enrolled a total of 33 patients with chronic wounds and 33 healthy controls matched by sex and age. Both patients and controls underwent a BDI II survey. We evaluated 33 patients, with a mean age of 71 years (range 25-87), and 33 controls, with a mean age of 73 years (range 31-88).

RESULTS

The average score at the BDI II questionnaire was 14.5 and 8, respectively.

CONCLUSIONS

The depression among patients with chronic wounds has a multifactorial origin that should be treated with a multidisciplinary approach. Since the improvement of the psycho-emotional state means better compliance of the patient, we can also expect a better result in terms of efficacy in chronic wound treatment.

Second jejunal loop adenocarcinoma associated with celiac disease: the first case report

INTRODUCTION

Jejunal adenocarcinoma is a very rare disease but the frequency of this rare carcinoma is higher in celiac patients. We report the first case report of a second jejunal loop adenocarcinoma associated with celiac disease.

PRESENTATION OF CASE

A 47-year-old woman, with a history of celiac disease. Computerized tomographic scans of the abdomen and pelvis demonstrated a severe retroperitoneal lymphoadenopathy, para-aortic, inter-aorto-caval, porto-caval, posterior pancreaticoduodenal space, celiac trunk, lesser gastric curvature, lymph node grouping. The patient underwent digiunal resection and regional lymphadenectomy. Diagnosis was poorly differentiated jejunal adenocarcinoma, infiltrating subserosal adipose tissue, metastasing in five out of eight regional lymph nodes. U.I.C.C. 2017 grading = pT3 pN2 G3 R0; Stage IIIB.

DISCUSSION

The jejunum accounts for 11-25% of small bowel adenocarcinoma, that accounts for less than 5% of gastrointestinal cancer, notwithstanding that 90% of the mucosa surface area of the digestive tract is made by small intestine. To the best of our knowledge, this is the first report on a second loop jejunal adenocarcinoma complicating celiac disease. In our study, the diagnosis of cancer was made by computed tomography (CT) of abdomen and the patient was operated. For the diagnosis of small bowel tumour, CT enteroclysis has a sensitivity of 85-95% and a specificity of 90-96%. Complete resection (RO) of the jejunal adenocarcinoma, with regional lymph nodes resection and jejuno-jejunal anastomosis should be performed.

CONCLUSION

After curative surgical resections of small bowel adenocarcinoma, adjuvant chemo-therapy has not shown a clear benefit in retrospective studies. Preoperative Chemo-Radio-therapy and careful Imaging Staging are the first steps to planning surgery.

New lift: the art of facial rejuvenation with minimal incisions rhytidectomy

OBJECTIVE

The new lift is a procedure for facial rejuvenation with minimal incision, giving the patient a significant improvement of mid face and neck, with limited dissection and minimal scars. A further "One-stitch" of anchorage to the deep temporal fascia is required to hold tissues. By a minimal surgical access, we get a suitable cheek lift with the improvement of nose-labial folds, mandibular edge and neck contour.

PATIENTS AND METHODS

Between February 2009 and June 2012, 32 patients underwent facial rejuvenation surgery called new lift at a mean age of 46 years (range 35-55 years). Seven of the patients had a previous facelift. 12 out of 32 patients (37.5%) had concomitant eyelid surgery and 4 (12.5%) neck contouring procedure.

RESULTS

The technique we used is a safe and effective procedure with a high satisfaction rate; 28 patients (89%) were very satisfied with their result at 24-months follow-up.

CONCLUSIONS

The surgical outcome was evaluated according to the analysis of photographs obtained before and after surgery and the analysis of pre- and postoperative measurements. Aesthetic results were evaluated also by patients themselves who indicated a high satisfaction rate at three months post-surgery questionary and by a surgeon not involved in the study using VAS (1-10) before and three months after surgery. Acquired data on the aesthetic result were statistically evaluated using Student t-test. This is a study aimed at assessing the effectiveness of the new-lift technique for facial rejuvenation. Based on the results of our study, the new-lift is a very effective surgery for rejuvenation of the face with mild to moderate aging. All patients healed uneventfully without any major postoperative problems. This technique responds to an increasing demand from a wide range of patients for less invasive, less expensive operations with faster healing time and fewer potential complications.

Coverage of exposed hardware after lower leg fractures with free flaps or pedicled flaps

OBJECTIVE

The placement of osteosynthetic materials in the leg may be complicated by hardware exposure. Successful soft tissue reconstruction often provides a critical means for limb salvage in patients with hardware exposure in the leg. Free flaps are currently considered the standard surgical procedure for soft tissue coverage of the wounds with internal hardware exposure. However, to date, no conclusive literature shows the superiority of a specific type of flap.

MATERIALS AND METHODS

The current review compares data from the literature concerning outcomes and complications of free and pedicled flaps for exposed osteosynthetic material preservation in the leg.

RESULTS

A total of 81 cases from twelve different articles presenting internal hardware exposure of the leg were analyzed in our study. Thirty-two patients underwent immediate reconstructive surgery with pedicled flaps, while forty-nine patients underwent free flap reconstruction. The overall survival rate for pedicled flaps was 96.77%, while for free flaps it was 97.77%. The overall implant preservation rate was 78.12% for pedicled flaps and 53.33% for free flaps. With reference to postoperative complications, the overall complication rate was 46.87% for pedicled flaps and 10.20% for free flaps.

CONCLUSIONS

No significant difference was found in terms of overall flap survival. However, a significant difference was found regarding successful implant preservation (78.12% in the pedicled flap group vs. 53.33% in the free flap group). In particular, the first observation appears to be in contrast with the current trend of considering the free flaps the first choice procedure for soft tissue coverage of the wounds with internal hardware exposure. Nevertheless, a higher occurrence of postoperative complications was observed in the pedicled flap group (46.87% vs. 10.20%). The choice of the most appropriate reconstructive procedure should take into account several issues including the size of the wounds with internal hardware exposure, the possibility of soft tissue coverage with pedicled flaps, the availability of recipient vessels, general conditions of the patients (such as age, diabetes, smoking history), patients' preference and presence of a microsurgical team. However, according to the results of this review, we believe that pedicled flap reconstruction should be reconsidered as a valid alternative procedure for skin tissue loss with hardware exposure whenever it is possible.

The use of botulinum toxin in the treatment of plunging nose: cosmetic results and a functional serendipity

INTRODUCTION

Muscles of the nose are active in facial movements both with the other facial muscles. An active depressor septi muscle (DSN) can accentuate a drooping nasal tip and shorten the upper lip on animation, especially during smiling. Paralysis of the DSN allows the tip of the nose to be lifted up.

MATERIALS AND METHODS

Between January and June 2011 a double blinded, randomized study was performed on 40 patients for nasal defects as "plunging" tip. 20 patients underwent to Botulinum toxin injection (B), 20 patients were treated with placebo such as saline solution (S). Both aesthetic and functional results were evaluated using objective and subjective parameters at time 0, after 7, 15 and 30 days and values were compared using t Student test.

RESULTS

S group results were not significant from an objective point of view. In botulinum group, patients showed an increase in columellar-lip distance. Satisfaction of the Group B patients was an average of 6.3 on VAS (range from 4 to 9). VAS mean values were studied with t-Student test and were found significant.

DISCUSSION

Several authors recommend the incision of DSN muscle during rhinoplasty to correct the plunging tip. In patients with no needs for rhinoplasty this procedure is unnecessary and a quick and targeted injection of Botulinum toxin is the most convenient choice to improve aesthetic of the plunging tip.

Otoplasty for prominent ears deformity

OBJECTIVE

Prominent ears are a common congenital deformity of the external ear, derived from a combination of defects in the antihelix and concha. The majority of cases are treated surgically, but one of major difficulties associated with otoplasty regards the achievement of lasting aesthetic results. With the present study we propose an effective combination of four surgical techniques of cartilage reshaping with the ultimate goal of creating a new stable antihelical fold.

PATIENTS AND METHODS

Forty-one patients with prominent ears were involved prospectively. The subjects (16 male and 25 female) ranged in age from 6 to 43 years, with a mean age of 12 years. All patients underwent to the same surgical procedure and we performed softening and reshaping of the antihelix adopting the consecutive use of four surgical techniques: hemitransfixing microincisions, scoring, squeezing and posterior mattress suture fixation.

RESULTS

Total number of ears that underwent surgery was 71. The mean postoperative follow-up period was 2 years. The mean postoperative change of protrusion was 7.96 mm referring to the superior cephaloauricular distance, while it was 12.18 mm considering the middle cephaloauricular distance. No patient developed complications or recurrence.

CONCLUSIONS

The proposed surgical procedure for otoplasty resulted in endurance of auricular appearance and symmetry with high success rate and low morbidity.

Association between drug tolerability and medical resource use in prophylaxis of invasive fungal infections after allogeneic hematopoietic stem cell transplant

OBJECTIVES

To conduct a retrospective analysis of the association between drug tolerability and potential economic impact measured by medical resource utilization (MRU) for prophylaxis of invasive antifungal infections (IFI) after allogeneic hematopoietic stem cell transplantation (alloHCT).

METHODS

An open-label, multi-center study (IMPROVIT) included patients (≥12-years old) who were randomized to receive oral voriconazole (VOR) or oral itraconazole (ITR) from the alloHCT day for at least 100 days and up to 180 days. Trial data on discontinuation and MRU for the first 100 days were analyzed.

RESULTS

Two hundred and twenty-four patients were in VOR and 241 in ITR, with similar demographic distributions (average age of 43 years, 58% male, 92% Caucasian). All-cause and study drug intolerance discontinuations were less frequent with VOR than ITR (50% vs 63%, p = 0.0137; 7% vs 22%, p < 0.0001). VOR patients had longer study drug exposure (median = 96 vs 68 days, p < 0.0001; mean = 68 vs 60 days, p = 0.0044). ITR patients were 2-times more likely (p = 0.0110) to use other antifungals vs VOR patients. Controlling for treatment and key baseline variables, longer IFI prophylaxis was associated with fewer hospital days (p < 0.0001) and less other antifungal use (p < 0.0001). Patients who discontinued prophylaxis during the first 100 days incurred 10 more hospital days (p < 0.0001) and 17 more other antifungal days (p < 0.0001) compared to their counterparts. Eight more prophylaxis days were associated with ∼1 less hospital day and 3.6 less other antifungal days (p < 0.0001). Key limitation: MRU data collection was limited to the first 100 days post-transplant, which may not fully capture the real-world utilization and outcomes.

CONCLUSIONS

Patients' ability to tolerate and continue their antifungal prophylaxis after alloHCT is associated with less use of MRU such as other antifungals and hospital days. In the current resource-constrained healthcare environment, it is important to consider the potential economic impact of the tolerability of antifungal prophylaxis.

[Inveterate squamous cell carcinoma of the upper eyelid: a case report]

Squamous cell carcinoma (SCC) is a malignant tumor of epithelium that shows squamous cell differentiation. It is the second most common cancer of the skin and usually occurs in areas exposed to the sun but it can rarely arise within the conjunctival epithelium with a deep component. We describe a woman with a history of chronic blepharoconjunctivitis unresponsive to topical medications. Examination disclosed a hyperaemic translucent patch with blurred margins of the upper palpebral conjunctiva. Tarsoconjunctival biopsy revealed intraepithelial squamous cell carcinoma. Management consisted of complete tumor excision with removal of the entire posterior lamella of the left upper eyelid and reconstruction. Histopathologic analysis confirmed primary squamous cell carcinoma arising from conjunctival epithelium, involving the underlying tarsus. Patients with unexplained chronic unilateral blepharoconjunctivitis or papillary hypertrophy of the palpebral conjunctiva should be considered for biopsy to rule out neoplasia, even when there is no sign of an evident mass.

Botulinum toxin treatment in glaucomatous patients: a pilot study

PURPOSE

The purpose was to evaluate the efficacy of the treatment of iatrogenic entropion (IE), in patients affected by primary open angle glaucoma (POAG), by botulinum toxin injections (BTI).

PATIENTS AND METHODS

20 patients of the "Glaucoma Center" of the Hospital "Umberto I" (Rome) were examined. These patients had POAG and used prostaglandin analogues (PA). Mean age was 75.5 years old (range 68-83); they had been suffering from PAOG since 10 years and were not affected by other relevant systemic diseases. One to three BTI were made into the lower orbicularis muscle using a 0.3 G needle (0.025 to 0.05 units for each injection site).

RESULTS

The results were particularly significant in 18 out of 20 patients. Two patients showed slight improvements. A rating scale ranging from 0 to 6 points (0 corresponded to 'no effect' and 6 to the 'complete' resolution of the entropion) was used to evaluate the goals of the treatment. The average rating was 5.37 points.

CONCLUSIONS

The entropion due to glaucoma therapy with PA can be successfully treated with BTI in the orbicularis muscle, despite offering temporary therapeutic effects.

Metatypical carcinoma of the head: a review of 312 cases

BACKGROUND

Metatypical cell carcinoma (MTC) is a quite rare malignancy accounting for 5% of all non melanoma skin cancers, with features of basal cell carcinoma and squamous cell carcinoma. It can be described as coexistence of basal cell carcinoma and squamous cell carcinoma with no transition zone between them.

AIM

Our review identified a correlation between gender and MTC affected region.

MATERIALS AND METHODS

We performed a retrospective study of 312 consecutive patients, diagnosed for MTC localized on face and scalp. Statistical analysis was made to determinate most affected areas, gender prevalence, average age, presence of ulceration and infiltration and peripheral clearance rate.

RESULTS

A relevant difference came out between two genders. χ2 test emphasized a relation between males and the presence of carcinoma on the scalp. In addition a strong correlation between mixed subtype and ulceration was evident. A strong relation between intermediate subtype and positive surgical margin was found; this data could identify a more aggressive behavior of intermediate type.

CONCLUSIONS

In our findings an important correlation between sun exposition and this tumor was found. Moreover, due to the difficulties that can occur in preserving the aesthetic subunits in the surgical treatment of these regions, the prevention of this pathology has an important role.

Masson's tumor: a soft tissue tumor simulating a tendon cyst: case report

INTRODUCTION

Intravascular papillary endothelial hyperplasia (Masson's hemangioma or Masson's tumor) is a benign vascular disease with an exuberant endothelial proliferation in normal blood vessels. Although relatively uncommon, its correct diagnosis is important because it can clinically be like both benign lesions and malignant neoplasms. We present a case of intravascular proliferative endothelial hyperplasia simulating a tendon cyst both clinically and on ultrasound.

CASE REPORT

A 74-year old Caucasian female presented with a 4-month history of soreness and swelling in the fourth finger of the right hand. Ultrasound showed an oval mass with fluid content, referred to a tendon cyst. A wide surgical excision was subsequently performed. The final histological diagnosis was Masson's tumor.

DISCUSSION

The pathogenesis of intravascular papillary endothelial hyperplasia is still unclear but the exuberant endothelial cell proliferation might be stimulated by an autocrine loop of endothelial basic fibroblast growth factor (bFGF) secretion. There are three types of papillary endothelial hyperplasia: primary, or intravascular; secondary, or mixed; and extravascular. The main differential diagnosis is against pyogenic granuloma, Kaposi sarcoma, hemangioma, and angiosarcoma.

CONCLUSIONS

Masson's tumor can be like both benign lesions and malignant neoplasms clinically and on ultrasound. For this reason, the right diagnosis can be made only by histology, which reveals a papillary growth composed of hyperplastic endothelial cells supported by delicate fibrous stalks entirely confined within the vascular lumen.

Fibroepithelioma of Pinkus: variant of basal cell carcinoma or trichoblastoma? Case report

INTRODUCTION

Fibroepithelioma of Pinkus (FeP) is a rare tumor that most often affects women aged between 40 and 60 years. Clinically FeP presents as a soft, usually solitary, polypoid or papillomatous well circumscribed tumor of skin color. It is typically located to the trunk and extremities.

CASE REPORT

A 75 year old male presented to our Department complaining for the presence of a lesion of the dorsal region. His medical history was free except for several basal cell carcinoma (BCC) surgically excised. Clinical examination revealed a pigmented lesion in the back. The lesion was surgically excised and histopathology showed of a fibroepithelioma of Pinkus.

DISCUSSION

Currently, FeP is considered a rare variant of basal cell carcinoma, with characteristic histopathological features, although this view is somewhat controversial as some authors considered FeP to be a variant of trichoblastoma. The pathogenesis of FeP is still under investigation. It is thought that a mutation in the tumor suppressor gene TP53 might predispose to the development of FeP.

CONCLUSIONS

Our case is interesting for two reasons. First, in our case FeP is pigmented. Moreover we present a case of Fep in a patient with a history of BCC, a finding that supports the classification of fibroepithelioma of Pinkus as a variant of basal cell carcinoma.

In-vacuum optical isolation changes by heating in a Faraday isolator

We describe a model evaluating changes in the optical isolation of a Faraday isolator when passing from air to vacuum in terms of different thermal effects in the crystal. The changes are particularly significant in the crystal thermal lensing (refraction index and thermal expansion) and in its Verdet constant and can be ascribed to the less efficient convection cooling of the magneto-optic crystal of the Faraday isolator. An isolation decrease by a factor of 10 is experimentally observed in a Faraday isolator that is used in a gravitational wave experiment (Virgo) with a 10 W input laser when going from air to vacuum. A finite element model simulation reproduces with a great accuracy the experimental data measured on Virgo and on a test bench. A first set of measurements of the thermal lensing has been used to characterize the losses of the crystal, which depend on the sample. The isolation factor measured on Virgo confirms the simulation model and the absorption losses of 0.0016 +/- 0.0002/cm for the TGG magneto-optic crystal used in the Faraday isolator.

Measurement of the optical parameters of the Virgo interferometer

The Virgo interferometer, aimed at detecting gravitational waves, is now in a commissioning phase. Measurements of its optical properties are needed for the understanding of the instrument. We present the techniques developed for the measurement of the optical parameters of Virgo. These parameters are compared with the Virgo specifications.

Relationship of obesity and body fat distribution with ceruloplasmin serum levels

OBJECTIVE

To investigate the influence of obesity and body fat distribution on serum levels of ceruloplasmin, a risk factor for myocardial infarction.

DESIGN

Fasting concentrations of ceruloplasmin, insulin, glucose, lipid pattern (cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides), blood pressure levels, and body fat distribution were determined in a population of non-diabetic subjects.

SETTING

University Hospital Outpatient Clinic.

SUBJECTS

87 consecutive individuals (35 men and 52 women), represented by 27 normal weight (BMI: < 25.0), 20 overweight (BMI: > 25.0-30.0) and 40 obese (BMI: > 30.0) subjects.

MEASUREMENTS

Serum insulin levels were quantified by radioimmunoassay, plasma glucose and lipid concentrations by enzymatic assays, and serum ceruloplasmin by nephelometry. Intra-abdominal thickness was measured by ultrasound technique.

RESULTS

Ceruloplasmin levels were significantly (P < 0.001) higher in obese (36.5 +/- 8.60 mg/dl) than in overweight (30.4 +/- 6.17 mg/dl) and normal weight (29.3 +/- 8.06 mg/dl) subjects. Of several variables associated with ceruloplasmin (BMI, waist circumference, WHR, intra-abdominal thickness, triglycerides, cholesterol, LDL-cholesterol, insulin), only triglycerides (in both men and women) and ultrasound intra-abdominal thickness (in women) maintained a significantly independent relationship with this protein in multiple stepwise analysis. Moreover, both triglycerides and total cholesterol maintained an independent correlation with ceruloplasmin when the data from both men and women were pooled together.

CONCLUSION

This study indicates that patients with central obesity have characteristically higher ceruloplasmin serum levels, and that ceruloplasmin concentrations are strongly correlated with serum triglyceride and cholesterol levels (in both sexes) and visceral fat accumulation (in women), independently of the other associated cardiovascular risk factors (insulin and blood pressure levels). Since ceruloplasmin has been shown to increase in response to the atherosclerotic inflammatory process, and to promote coronarosclerosis, the determination of serum ceruloplasmin in subjects with central obesity might be a useful tool to identify patients with the highest risk for myocardial infarction.

Divided nevus of the eyelid: a case report

Divided nevus of the eyelid as a rare pathologic entity and develops during fetal growth, when the two eyelids are still fused together. Its surgical treatment is mostly based on full thickness skin grafts. We report a case of a 22-year-old woman with a congenital divided nevus affecting the left upper and lower eyelid. The patient was treated in our Department because of the onset of a purple red nodule in the lower part of the nevus. We examined the case from embryological, histopathological, clinical, and diagnostic standpoints, and discuss surgical options in order to reach an optimal functional and aestetic result.