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The field of transplantation, including the specialized area of vascularized composite allotransplantation (VCA), has been transformed since the first hand transplant in 1998. The major challenge in VCA comes from the need for life-long immunosuppressive therapy due to its non-vital nature and a high rate of systemic complications. Ongoing research is focused on immunosuppressive therapeutic strategies to avoid toxicity and promote donor-specific tolerance. This includes studying the balance between tolerance and effector mechanisms in immune modulation, particularly the role of costimulatory signals in T lymphocyte activation. Costimulatory signals during T cell activation can have either stimulatory or inhibitory effects. Interfering with T cell activation through costimulation blockade strategies shows potential in avoiding rejection and prolonging the survival of transplanted organs. This review paper aims to summarize current data on the immunologic role of costimulatory blockade in the field of transplantation. It focuses on strategies that can be applied in vascularized composite allotransplantation, offering insights into novel methods for enhancing the success and safety of these procedures. [ABSTRACT FROM AUTHOR]

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Introduction. The field of composite tissue allotransplatation became a clinical reality since first hand transplant performed in 1998 at Lyon, France and has been progressing over the past two decades. Vascularized composite allotransplantation (VCA) is now performed for life enhancing indications in a selected group of patients under institutional protocols. Aim. This paper is an attempt to review the outcomes of VCA to date. Method. Analysis of relevant publications of composite tissue allotransplantation was performed, including the International Registry on Hand and Composite Tissue Transplantation (IRHCTT). Results and discussion. To date, there are more than 200 composite tissue allograft transplants performed worldwide, including upper limb, face, larynx, trachea, abdominal wall, lower limb, penis, and uterus. The technical aspects of VCA are no longer the factors limiting the widespread application of this treatment modality in the clinical setting. The feasibility of the procedure has been established, and the functional outcomes have been very good so far. The major challenge is at the immunologic level, long-term goal being to promote donor-specific tolerance and to avoid the toxicity of immunosuppression. Conclusions. Vascularized composite allografts transplatation is a viable treatment option well on the way of becoming a standard of care for those who have lost extremities and suffered large tissue defects. The initial ethical dilemmas and concerns of safety and feasibility have been overcome recently and with further standardized surgical and immunological protocols the field is likely to grow significantly in the future. [ABSTRACT FROM AUTHOR]

Skin cancer represents the most frequent type of human malignancy. Skin poses an important immunologic role, therefore also the correlation between skin cancer development and immunologic mechanisms are intensely studied. These aspects are of the utmost importance in patients requiring immunosuppressive therapy as transplant recipients or immunologic disorders. Cancer development after organ transplantation is the result of intense intercommunication between immunological and nonimmunological factors. Non-immunologic risk factors like individual predisposition, sun and environmental exposure are a contributing part to the skin neoplasia incidence. In addition, continuous exposure to immunosuppressive medication is closely linked to the development of the new malignancy. A similar situation is encountered in autoimmune diseases, those patients having an increased risk of skin cancer, especially squamous cell carcinoma. Immunotherapy shows promising results and encourages further studies in this direction. Also, an important aspect is to support preventive strategies in patients with high risk of skin cancer development. [ABSTRACT FROM AUTHOR]

Non-syndromic toe syndactyly is a regular cause of foot malformation in children, bilateral form being less common. Syndactyly release procedures had few contraindications, as uncomplicated malformation or important patient comorbidities. Reported data show that corrective surgery using skin grafts is associated with an increased risk of infection, contractures, and web creep. Reconstruction surgical techniques, using flaps reduce morbidity, revision surgery, complication, may be associated with skin grafts and have superior aesthetic and functional results. We present a case of simple bilateral incomplete asymmetric toe syndactyly, released using a modified personalized local flaps reconstruction technique. The normal function and aesthetic of the feet was obtained, with no complications at one-year follow-up. [ABSTRACT FROM AUTHOR]

The nerve transfer represents a current technique for the treatment of the adult posttraumatic brachial plexus lesions, the objective of our study being to mention the neurotization variants used in our clinic for the therapy of this paretic pathology and to present the results from the restoration of the important motor functions of the superior limb. The surgical methods of nerve transfer used as donor nerve intra and extraplexal sources which were neurotised to supra and infraclavicular branches of the brachial plexus. The functional evaluation at 1 year postoperatively revealed a favourable evolution both for shoulder abduction and for elbow flexion. We can conclude that the nerve transfer method has several advantages over the other classical techniques of reconstruction of the brachial plexus but it requires following some technical rules in order to obtain a positive surgical result. It has to be mentioned that the final functional result is primary dependent from the surgical success but also from a series of other factors that together can regain the reintegration of the patient in the working place and into the society. [ABSTRACT FROM AUTHOR]

Electrocutions are a particular type of trauma, usually affecting young active people, leading to high morbidity and mortality rates in extensive injured patients. Those patients require complex, multidisciplinary treatment in specialized burn centers. We conducted a three-year retrospective study in the Burn Unit of the Clinical Emergency Hospital Bucharest, Romania, aiming to identify different factors that characterize electrical injuries, with the goal to improve our clinical practice, in order to decrease overall complications, the morbidity and mortality rates and obtain an optimal functional prognosis for those severely injured patients. Patient-related and injury-related parameters were analyzed, and particularities observed in our burn unit were noted. A clear understanding of the physiopathology of those injuries and their complications is essential for providing an optimal therapeutic strategy. Rapid initiation of systemic supportive measures, accurate diagnostic and an adequate surgical treatment, correctly conducted, are essential for improving the vital and functional prognostic of patients who suffer electric injuries. [ABSTRACT FROM AUTHOR]

The reconstruction of bone defects still represents a great challenge for surgeons mainly because it is aimed to properly restore the site of the defect, to maintain the motor and sensate function, and, not lastly, to recreate or maintain the aesthetics of the region. The fibular flap is a great choice for bone defect reconstruction, with a large array of clinical utilization, but insufficiently used because of its demanding technique of harvesting. The ability to transfer simultaneously bone, muscle and skin in a one-stage vascular anastomosis makes this flap even more appealing when addressing composite defects. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing postmastectomy breast reconstruction, with a history of prior radiation therapy, present a particular clinical scenario. This is because of their well-documented higher complication rates, secondary to deleterious effects of irradiation on the soft tissue envelope of the remaining breast. Case presentation: This article presents the case of a breast reconstruction in a 53-year old woman with two subsequent breast reconstruction procedures after being treated with chemotherapy and radiotherapy. The first procedure was placing an expander under the mastectomy skin flaps, but it was followed by complications requiring the removal of the expander. One year later the second procedure was performed with latissimus dorsi flap and implant with satisfactory results. But after two years from the latest procedure, the patient turned to our clinic for improvement of the cosmetic outcome. Taking into account the medical and surgical history of the patient and after a complete clinical evaluation, the decision was to perform the right breast reconstruction with contralateral unipedicle musculocutaneous TRAM flap. Conclusions: The aesthetic results of standard delayed breast reconstruction after radiation therapy in patients with locally advanced breast cancer are satisfactory at best, even in the hands of experienced surgeons. The result quality that can be obtained in a patient with previous radiotherapy is therefore less optimal than the one achieved in a nonirradiated patient. [ABSTRACT FROM AUTHOR]

Background: Over the past two decades, the distally based neurocutaneous sural flap has become the best known neurocutaneous flap of the leg. When microsurgical expertise is not available or feasible, the sural flap has become the mainstay of reconstruction for lower leg, ankle and foot defects. Matherial and method: The large series of cases published in the medical literature, innovations, technique modifications along with risk factors identification has been followed by this flap rise in popularity. 64 publications on the sural flap subject, in the international literature, were summarized in this study. The relevant anatomy reviewed in anatomical studies is presented in order to understand the circulation and tissue composition of the sural flap. The surgical technique and its various modifications are highlighted, in order to make proper indications and minimize complications. Risk factor identification is presented in order to preclude unfitted patients from this flap. Several clinical cases from the senior author are ilustrated. Conclusion: The distally based neurocutaneous sural flap offers a reliable and versatile technique, alternative to free flap transfer, for the treatment of complex lower limb defects in healthy or vascularly compromised patients. [ABSTRACT FROM AUTHOR]

Botulinum toxin, originally used in the treatment of spastic neuromuscular diseases, received increased attention in recent decades and a deeper research, further mechanisms of action being carefully studied in order to determine other possible therapeutic properties. Method and material: This is an experimental study conducted on 60 CD1 mice, divided into 4 groups of 15 each, injected with saline solution and 3 different doses of type A botulinum toxin. Objectives: Our study aims to establish an anti-nociceptive properties of botulinum toxin, dose-dependent, remote from the injection site. Results: We could observe possible anti-nociceptive effects of botulinum toxin at doses of 20 U / kg after the statistical data analysis. Conclusions: We can draw a conclusion on the existence of an anti-nociceptive effect of type A botulinum toxin, remote from the injection site, through retrograde axonal mechanisms or interaction with central μ-opioid receptors. The study represents a starting point for subsequent experiments for possible interactions with other substances with analgesic or anti-inflammatory effects. [ABSTRACT FROM AUTHOR]

Science is based on experimental studies. Medical science has known progress to the current state, only with lab animals. Human anatomy and physiology research was performed since ancient times along with animal studies. The benefits of animal biomedical research, although widely accepted by scientists, raised a big problem among animal rights activists. It is based on well-conceived philosophical arguments such as that people have no right to use animals for experiments (Singer, 1975; Regan, 1983), although these studies could help to develop new directions for treatment or diagnosis in certain diseases. In order to achieve optimal conditions for these experiments, to reduce pain and unnecessary damage caused to the animals, international rules have been established for conducting such studies, since the late 20th century. Romanian legal frame experiregarding the ethics of animal research for scientific purpose, adopted in 2006, is a takeover from the provisions and laws of the European Union, first adopted in 1986 in Strasbourg and modified until now, to protect vertebrates and invertebrates laboratory animals. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing postmastectomy breast reconstruction, with a history of prior radiation therapy, present a particular clinical scenario. This is because of their well-documented higher complication rates, secondary to deleterious effects of irradiation on the soft tissue envelope of the remaining breast. Case presentation: This article presents the case of a breast reconstruction in a 53-year old woman with two subsequent breast reconstruction procedures after being treated with chemotherapy and radiotherapy. The fi rst procedure was placing an expander under the mastectomy skin flaps, but it was followed by complications requiring the removal of the expander. One year later the second procedure was performed with latissimus dorsi flap and implant with satisfactory results. But after two years from the latest procedure, the patient turned to our clinic for improvement of the cosmetic outcome. Taking into account the medical and surgical history of the patient and after a complete clinical evaluation, the decision was to perform the right breast reconstruction with contralateral unipedicle musculocutaneous TRAM flap. Conclusions: The aesthetic results of standard delayed breast reconstruction after radiation therapy in patients with locally advanced breast cancer are satisfactory at best, even in the hands of experienced surgeons. The result quality that can be obtained in a patient with previous radiotherapy is therefore less optimal than the one achieved in a nonirradiated patient [ABSTRACT FROM AUTHOR]

Since 1998, when the first successful hand transplant was performed in France, at Lyon, an unpredicted development of reconstructive transplant surgery (transplant of VCA: vascularized composite allografts) occurred. Those procedures represents the only option for patients having extensive, complex tissue defects, involving multiple anatomical layers, impossible to approach using conventional reconstructive techniques. More than two hundred VCA procedures were reported worldwide, including: upper and lower limbs, face, larynx, trachea, abdominal wall, penis, uterus, knee allotransplant. Important aspects arise in the study of immunological mechanisms of acceptance and rejection of the allograft, the mode of action of immunosuppressive agents and protocols currently used in transplant programs for vascularized composite allografts. Immunosuppressive regimens that are used for solid organ transplantation (kidney, heart) are also effective for VCA transplants with good results regarding survival and functionality of the allografts. Current goal is the minimization of immunosuppression, composite tissue allotransplantation procedures being addressed for functional recovery (are not life-saving interventions like solid organ transplants). The ideal situation, which would allow a large scale utilization of VCA procedures, is the possibility of induction the donor-specific tolerance, allowing allograft acceptance without the need of immunosuppressive therapy. Currently this circumstance is difficult to achieve in clinical practice, resulting in large transplant centers ongoing research focusing on immunological difficult aspects. [ABSTRACT FROM AUTHOR]

Purpose: The treatment of segmental bone defects of the tibia after high-energy calf trauma is demanding for both, orthopaedic and plastic surgeons. Multiple treatment options are available, including non-vascularised bone grafts, allografts, bone substitutes, callus distraction, and free vascularised bone transfers. We shall present, herein, two small series of patients with major segmental defects of the tibia treated by reconstruction of the tibia with non-vascularised iliac crest bone grafts (NVIBG) and micro-surgically transferred double-barrel fibular osteomusculocutaneous flap. Materials and Methods: Patients with segmental bone defects of the tibia, 5 cm or more in length, have been included in the two series. The bone reconstruction of the tibia was performed by means of non-vascularised bone grafts harvested from the iliac crest and double-barrel fibular osteomusculocutaneous flap. Bone fixation has been ensured through external fixation in two cases and screws and initial external fixation followed by early conversion to locking plate internal fixation in the other cases. Results: In all cases included in the two series, bone union has been achieved. No case of irreversible graft loss or infection occurred in the process. Stress fractures developed in the cases treated by non-vascularised iliac crest bone grafts reconstruction. Time to bone union was of 25 months in the cases treated with non-vascularised iliac crest bone graft and, 5 to 8 months in the cases treated with double-barrel free vascularised fibular graft. Conclusions: The use of double-barrel free vascularised fibular flap was successful and it is the best option in the management of segmental tibial defects. Treatment with non-vascularised iliac crest graft can be successful in segmental bone defects of the tibia not exceeding 10 cm, but this requires a longer recovery time. [ABSTRACT FROM AUTHOR]

Toxina botulinică, folosită iniţial în tratarea afecţiunilor neuromusculare spastice, a primit în ultimele decenii o atenţie crescută şi o cercetare din ce în ce mai aprofundată, mecanismele de acţiune fiind în continuare atent studiate, în vederea stabilirii altor posibile proprietaţi terapeutice. Material si metodă: Este un studiu experimental realizat pe 60 de şoareci CD1, împărţiţi în 4 loturi de câte 15, injectaţi cu ser fiziologic şi respectiv 3 doze diferite de toxină botulinică tip A. Obiective: Studiul nostru îşi propune să stabilească existenţa unei proprietăţi antinociceptive a toxinei botulinice, dependentă de doză, la distanţă de locul injectării. Rezultate: După analiza statistică a datelor, am putut observa posibile efecte antinociceptive ale toxinei botulinice la doze de 20 U/kg. Concluzii: Putem formula o concluzie privind existenţa unui efect antinociceptiv al toxinei botulinice tip A, la distanţă de locul injectării, fie prin mecanisme retrograde axonal, fie prin interacţiunea cu receptori opioizi centrali. Studiul reprezintă un punct de plecare pentru experimente ulterioare, privind posibilele interacţiuni ale toxinei cu alte substanţe cu efecte antialgice sau antiinflamatorii. Botulinum toxin, originally used in the treatment of spastic neuromuscular diseases, received increased attention in recent decades and a deeper research, further mechanisms of action being carefully studied in order to determine other possible therapeutic properties. Method and material: This is an experimental study conducted on 60 CD1 mice, divided into 4 groups of 15 each, injected with saline solution and 3 different doses of type A botulinum toxin. Objectives: Our study aims to establish an anti-nociceptive properties of botulinum toxin, dose-dependent, remote from the injection site. Results: We could observe possible anti-nociceptive effects of botulinum toxin at doses of 20 U / kg after the statistical data analysis. Conclusions: We can draw a conclusion on the existence of an anti-nociceptive effect of type A botulinum toxin, remote from the injection site, through retrograde axonal mechanisms or interaction with central opioid receptors. The study represents a starting point for subsequent experiments for possible interactions with other substances with analgesic or anti-inflammatory effects. [ABSTRACT FROM AUTHOR]

Introduction: Digital flexible ureteroscopy (FURS) increasingly became a routine diagnostic procedure in upper urinary tract transitional cell carcinoma (UUT-TCC). Identifying elements that may suggest the malignant nature of a lesion and obtaining biopsy specimens sufficient for a reliable pathological analysis remain difficult challenges. Narrow-band imaging (NBI) technology appears to provide a more accurate observation of the upper tract urothelium., Patients, Materials and Methods: During this prospective analysis, white light (WL) and NBI-assisted digital FURS were performed in 87 consecutive patients admitted for primary suspicion of UUT-TCC. The endoscopic technique comprised digital WL FURS, followed by the NBI assessment of the renal collecting system' mucosa. All suspicious areas of the pyelocaliceal urothelium were biopsied using the grasping forceps, separately for WL and NBI findings., Results: A total of 113 UUT-TCC tumors (104 pTa and nine carcinoma in situ - CIS) were confirmed by pathology in 62 patients. The patients' detection rate was significantly improved in NBI mode when compared to standard FURS (98.4% versus 91.9%, respectively), due to cases either exclusively diagnosed with UUT-TCC (8.1%) or presenting additional urothelial tumors (12.9%). Overall, 13 pTa and two CIS lesions were solely observed in NBI, which was on the other hand characterized by a significantly increased proportion of unnecessary biopsies (NBI versus WL rate of false-positive results - 17.5% versus 10.1%, respectively)., Conclusions: As additional tool for the standard WL evaluation of the pyelocaliceal system' urothelium, NBI-guided biopsies were emphasized as providing a significant diagnostic improvement during digital FURS.