Aesthetic considerations in facial reconstructive surgery: The V-Y flap revisited

The subcutaneous pedicled V-Y advancement flap (also known as the kite flap of Dufourmentel) has been described by many authors. Its versatility in reconstructive surgery is well known, both in facial reconstructive surgery as well as surgery of the trunk and extremities. Its advantages in achieving aesthetic reconstruction in specific facial regions have been less well emphasized in the literature. The flap can be designed within natural facial creases and heals inconspicuously because of its widely based subcutaneous or muscle pedicle which incorporates venous and lymphatic drainage over most of its length. The undesirable biscuiting or flap edema frequently observed with other conventional transposition flaps is avoided. We have found the V-Y flap particularly useful in reconstructing the lower eyelid/medial canthus, supra-alar, and nasolabial regions. Our experience with over 40 such flaps is described, and technical considerations in designing and elevating the flap are discussed.     

Haemodynamic consequences and uterine contractions following 0.5 or 1.0 litre crystalloid infusion before obstetric epidural analgesia

Purpose

The efficacy of infusion of 0.5 L and 1.0 L Ringer’s lactate (LR) to prevent hypotension during induction of obstetric analgesia was studied. The effect of the different fluid boluses on fetal heart rate (FHR) and frequency of uterine contractions were also determined.

Methods

Ninety-two ASA 1–2 parturients were randomized to receive 0.5 L (Group 1) and 1.0 L (Group 2) LR immediately before incremental epidural injections with lidocaine to achieve T₁₀ sensory block. Systolic blood pressure (SBP) was measured with an automated BP cuff every two minutes for 30 min after infusion of fluid bolus. Fetal heart rate monitoring and tocometry were used continuously. The number of uterine contractions were recorded 30 min before and 60 min after iv bolus.

Results

The SBP decreased in both groups, but there was no difference between groups in mean SBP or maternal heart rate. The incidence of hypotension (SBP < 90 mmHg or decrease of 20%) was 4% in both groups. The FHR record of a patient in Group 1 showed a single late deceleration, and a decrease in beat-to-beat variability occured in one patient in Group 2. A decrease in the frequency of uterine contractions of two or more contractions per 30 min was noted more frequently in Group 2 (P < 0.05). The duration of iv bolus was longer in Group 2 than Group 1 (18.8 ± 4.3 min vs 12.3 ± 4.5 min, P < 0.01).

Conclusion

Administration of 1.0 L LR iv does not provide added protection against maternal hypotension, and is associated with delay in providing pain relief and a risk of decreasing uterine contraction frequency.     

Intramedullary spinal cord metastasis. A case report

This 54-year-old patient with a breast carcinoma of one year's evolution presented a progressive paraparesis and sphincter disregulation of a week evolution; MRI image showed a tumor in the medullary conus. She improved after removal of the conus mass. The histologic diagnosis was metastasis of adenocarcinoma. Metastasis at this level is infrequent and represents less than 1% of all spinal metastases. When the patients' general condition is good, surgery can relieve the neurologic deficit produced by the medullary mass.     

Ultrasound-based screening and characterization of an atypical clear-cell sarcoma of the hand: A case report

IntroductionClear cell soft-tissue sarcoma is a rare tumor typically presenting in the lower extremities.Case presentationWe present a middle-aged woman with a 2-month history of a growing mass in the right hand dorsum. Initial biopsy reported findings consistent with benign fibroma, however, high-resolution ultrasound screening revealed a multilobulated, heterogeneous, and hypervascular mass highly suspicious for malignancy. Excisional biopsy, histology, and immunohistochemistry confirmed the diagnosis of clear-cell soft tissue sarcoma. The patient presented no evidence of recurrence at 6-month follow-up.ConclusionUltrasound is an accessible and cost-effective modality for screening and management guidance for soft-tissue sarcomas.     

Lupus education for physicians and patients in a resource-limited setting

Clinical Rheumatology - Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a wide range of manifestations and potential to affect several organ systems. Complications arise...     

Gallstones are associated with carotid atherosclerosis

Background/Aims: Gallstone disease (GD) and cardiovascular disease (CD) are common diseases worldwide with considerable economical impact and they are strongly associated. Carotid atherosclerosis is an excellent marker of risk for CD like stroke and myocardial infarction. The aim of this study was to assess the association between gallstones and carotid atherosclerosis. Methods: A cross‐sectional study was conducted. We evaluated subjects with ultrasonographical evidence of GD and asymptomatic subjects without such evidence. Anthropometric, clinical and biochemical variables were collected. The Metabolic syndrome was evaluated using adult treatment panel III criteria. Carotid artery intima–media thickness (CIMT) was determined by a standard ultrasound protocol. Insulin‐like growth factor‐1 (IGF‐1) serum levels were measured in all subjects. Results: We studied 191 subjects: 62 subjects with GD (53.2% males) and 129 asymptomatic subjects without GD (65.9% males). Subjects with GD exhibited a higher body mass index, body fat percent, insulin serum levels and CIMT (P<0.05 for all). The prevalence of GD was higher in subjects with a CIMT>0.75 independently of other factors [odds ratio (OR) 2.12, 95% confidence interval (CI) 1.04–4.34; P=0.039], and for every 0.1 mm increase in CIMT the independent probability to be a case of GD increased by a factor of 1.25 (95% CI 1.02–1.53; P=0.027). IGF‐1 levels did not differ among groups. Conclusions: Subjects with GD exhibit greater carotid atherosclerosis, and therefore have a higher risk for stroke and myocardial infarction.     

Epidemiology, clinical characteristics, outcome, morbidity and mortality in acromegaly based on the Spanish Acromegaly Registry (Registro Espanol de Acromegalia, REA)

OBJECTIVE: To undertake a multicentre epidemiological study reflecting acromegaly in Spain. DESIGN: Voluntary reporting of data on patients with acromegaly to an online database, by the managing physician. METHODS: Data on demographics, diagnosis, estimated date of initial symptoms and diagnosis, pituitary imaging, visual fields, GH and IGF-I concentrations (requested locally), medical, radiotherapy and neurosurgical treatments, morbidity and mortality were collected. RESULTS: Data were included for 1219 patients (60.8% women) with a mean age at diagnosis of 45 years (s.d. 14 years). Reporting was maximal in 1997 (2.1 cases per million inhabitants (c.p.m.) per year); prevalence was globally 36 c.p.m., but varied between 15.7 and 75.8 c.p.m. in different regions. Of 1196 pituitary tumours, most were macroadenomas (73%); 81% of these patients underwent surgery, 45% received radiotherapy and 65% were given medical treatment (somatostatin analogues in 68.3% and dopamine agonists in 31.4%). Cures (GH values (basal or after an oral glucose tolerance test) <2 ng/ml, normal IGF-I, or both) were observed in 40.3% after surgery and 28.2% after radiotherapy. Hypertension (39.1%), diabetes mellitus (37.6%), hypopituitarism (25.7%), goitre (22.4%), carpal tunnel syndrome (18.7%) and sleep apnoea (13.2%) were reported as most frequent morbidities; 6.8% of the patients had cancer (breast in 3.1% of the women and colon in 1.2% of the cohort). Fifty-six patients died at a mean age of 60 years (s.d. 14 years), most commonly of a cardiovascular cause (39.4%); mortality was greater in patients given radiotherapy (hazard ratio 2.29; 95% confidence interval 1.03 to 5.08; P=0.026), and in those in whom GH and IGF-I concentrations were never normal (P<0.001). CONCLUSIONS: This acromegaly registry offers a realistic overview of the epidemiological characteristics, treatment outcome and morbidity of acromegaly in Spain. As active disease and treatment with radiotherapy are associated with an increase in mortality, efforts to control the disease early are desirable.