The evaluation of flap growth and long‐term results of pediatric mandible reconstructions using free fibular flaps

Currently, the free fibular flap is well accepted as the first choice for mandibular reconstruction. Achieving functional results in pediatric patients requires a different approach than that employed for mature patients. Because the pediatric craniofacial skeleton continues to grow, reconstruction is more challenging, and the long‐term results can be different from those of adult patients. In this study, we sought to measure flap growth objectively in our series. Ten pediatric patients who underwent reconstruction with free fibular flaps were retrospectively reviewed. Flap growth was evaluated by comparing the intraoperative photographs with photographs of the control panoramic mandibular radiographs taken using photo‐anthropometric techniques. The measurements were converted to proportionality indices (PI), and these indices were compared. Subsequent complications and functional results were also evaluated. The mean patient age was 11.8 years, and the mean follow up was 57.7 months. The mean preoperative PI value was 10.74 ± 2.47. The mean postoperative PI value was 12.52 ± 2.34. The mean difference between the preoperative and postoperative PI values was ?1.78±0.53. These photo‐anthropometric data clearly illustrated the growth of the fibular flaps (P = 0.001). None of these patients exhibited nonunion of the fractures; however, one patient experienced a delayed union, one had chronic temporomandibular joint pain, and one had chronic temporomandibular joint luxation. In two patients, the inter‐incisive measurements were below the third percentile, and two additional patients had grade 2 eating abilities, which can be regarded as poor. All of the patients had symmetric mandibular contours. Free fibular flaps continue to grow in pediatric patients. This flap is a “workhorse” flap in children because it adapts to the craniofacial skeleton via its ability to grow, and this ability results in subsequent good cosmetic and functional results. © 2014 Wiley Periodicals, Inc. Microsurgery 35:253–261, 2015.     

Splenic lymphoma with villous lymphocytes, associated with type II cryoglobulinemia and HCV infection: a new entity?

Hepatitis C virus (HCV) has been associated with the development of B-cell non-Hodgkin lymphomas. We recently reported the regression of splenic lymphoma with villous lymphocytes (SLVL) in patients with HCV after antiviral treatment, demonstrating a direct role of HCV in lymphomagenesis. This study expands our previous results in 18 patients with chronic HCV and SLVL. Mixed cryoglobulinemia (MC) was present in all cases and was symptomatic in 13 (72%). All patients were treated with interferon alone or in association with ribavirin. Hematologic and virologic responses were correlated. Fourteen (78%) patients achieved a sustained complete hematologic response after clearance of HCV RNA. Two patients had a virologic partial response and achieved a complete hematologic response. Two virologic nonresponders achieved partial hematologic response. Regardless of the response, monoclonal immunoglobulin gene rearrangement persisted after treatment. This study underscores the role of HCV in the lymphomagenesis and the benefit of antiviral treatment for patients presenting with HCV-driven lymphoproliferations.     

The effect of defective early phase insulin secretion on postload glucose intolerance in impaired fasting glucose

Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) are two risk groups for type 2 diabetes. Type 2 diabetes is characterized by both impaired insulin secretion and insulin resistance but their relative contribution to the development of hyperglycemia may differ due to heterogeneity of the disease. Combined glucose intolerance (CGI), on the other hand, seems to represent a more advanced stage of prediabetes that bears a distinctly higher risk of progression to diabetes and its comorbidities. This study has the aim to compare isolated IFG and CGI categories with respect to the degree of early phase insulin secretion abnormalities and insulin resistance. Subjects who had IFG (fasting glucose: 110-126 mg/dl) were included in the study. A 75-g oral glucose tolerance test (OGTT) with insulin response was done and subjects were classified according to the WHO criteria. Six subjects were excluded because they had diabetic glucose tolerance. A total of 66 patients (53.4 +/- 11.1 years, female/male: 48/18) were divided into two groups according to their glucose tolerance in OGGT (Group 1: isolated IFG and group 2: CGI). Early phase insulin secretion was measured by intravenous glucose tolerance test (IVGTT) and OGTT. Insulin resistance was assessed by the R value of the homeostasis model assessment (HOMA). We did not find any statistically significant difference between groups according to age, gender, body mass index (BMI), fasting glucose, fasting insulin, insulin-AUC (0-180 min) and HOMA-R values. In OGGT there was no statistically significant difference between 0', 30', 60' and 90' insulin levels of the groups; only 120' and 180' insulin levels were higher in CGI than in IFG group (p<0.05). In IVGTT, there was no statistically significant difference between glucose levels of the groups. Furthermore, insulin response to intravenous glucose was higher in IFG than in CGI (p<0.05). Our data demonstrate that isolated IFG and CGI are similar with respect to the degree of insulin resistance, and that subjects with CGI had a more prominent deficit in early phases of insulin secretion.     

Cardiac valves in patients with Whipple endocarditis: microbiological, molecular, quantitative histologic, and immunohistochemical studies of 5 patients

The pathological features of Whipple endocarditis, which is caused by Tropheryma whipplei, were histologically evaluated in cardiac valves from 5 patients. We used quantitative image analysis to compare the valvular fibrosis, calcifications, vegetations, inflammation, and vascularization due to Whipple endocarditis with those due to non-Whipple endocarditis and degenerative valves. We also studied the presence of T. whipplei in valves by immunohistochemical analysis, culture, and polymerase chain reaction (PCR). In histologic analysis, Whipple endocarditis was characterized by significant fibrosis, a lack of calcifications, slight inflammation and vascularization, and vegetations of intermediate size. Inflammatory infiltrates consisted mainly of foamy macrophages and lymphocytes. We found that the detection of T. whipplei in cardiac valves, by immunohistochemical analysis, was correlated with the detection of the bacterium by culture and PCR. We report, for the first time, the immunodetection of T. whipplei in a surgically removed arterial embolus. Pathological and immunohistologic analyses may contribute to the diagnosis of Whipple endocarditis.