Search

Aims: To analyze temporal trends (2001 -2017) of Pacemakers (PM) and Implantable Cardioverter-Defibrillators (ICD) procedures in Italy, according to the national Hospital Discharge Database (HDD). Methods: Frequency and implant rate (IR) in the Italian population were analyzed by age groups (

IntroductionMajor haemorrhage after injury is the leading cause of preventable death for trauma patients. Recent advancements in trauma care suggest damage control resuscitation (DCR) should start in the prehospital phase following major trauma. In Italy, Helicopter Emergency Medical Services (HEMS) assist the most complex injuries and deliver the most advanced interventions including DCR. The effect size of DCR delivered prehospitally on survival remains however unclear.Methods and analysisThis is an investigator-initiated, large, national, prospective, observational cohort study aiming to recruit >500 patients in haemorrhagic shock after major trauma. We aim at describing the current practice of hypotensive trauma management as well as propose the creation of a national registry of patients with haemorrhagic shock. Primary objective: the exploration of the effect size of the variation in clinical practice on the mortality of hypotensive trauma patients. The primary outcome measure will be 24 hours, 7-day and 30-day mortality. Secondary outcomes include: association of prehospital factors and survival from injury to hospital admission, hospital length of stay, prehospital and in-hospital complications, hospital outcomes; use of prehospital ultrasound; association of prehospital factors and volume of first 24-hours blood product administration and evaluation of the prevalence of use, appropriateness, haemodynamic, metabolic and effects on mortality of prehospital blood transfusions. Inclusion criteria: age >18 years, traumatic injury attended by a HEMS team including a physician, a systolic blood pressure Ethics and disseminationThe study has been approved by the Ethics committee ‘Comitato Etico di Area Vasta Emilia Centro’. Data will be disseminated to the scientific community by abstracts submitted to international conferences and by original articles submitted to peer-reviewed journals.Trial registration numberNCT04760977.

INTRODUCTION Hematology analyzers produce reliable, reproducible, precise, accurate results, as well as a premicroscopic characterization of abnormal samples. We have evaluated the clinical performance of a new blood cell counter, which has been temporarily made available to our hematology laboratory. METHODS Over four months, we analyzed with the Mindray BC-6800 Plus more than 1000 samples with a high incidence of hematological abnormalities, using recommended ICSH and CLSI protocols. We have also assessed flagging efficiency for abnormal cells and scattergram cell distribution. RESULTS From a quantitative point of view, our assessment has identified state-of-the-art level reproducibility, excellent linearity, stability over 48°C at 4°C for the conventional parameters, lack of carry-over (

Craniosynostosis, a deformity of the skull caused by premature fusion of ≥1 cranial sutures, is treated surgically via endoscopic approaches or cranial vault remodeling. Postoperative infection is rare. Management of postoperative surgical site infections often involves culture-directed intravenous antibiotics and debridement, with removal of osteomyelitic bone and hardware in refractory cases. Removal of autologous bone in a pediatric patient presents a reconstructive challenge, as alloplastic options are not optimal in a growing child, especially in the setting of infection. Moreover, infants and small children have limited autologous bone options for reconstruction. We present our case of a young child who developed an infectious complication following cranial vault remodeling. The patient's demographic information, clinical presentation and postoperative course, radiologic features, surgical interventions, and treatment outcomes were reviewed. In our case, autologous osteomyelitic bone underwent tissue processing to eradicate the infection and complete skull reconstruction using the patient's own processed autologous bone was performed in a delayed fashion. The patient is now 1 year postoperative with no recurrence of infection. We present this case as a novel technique to eradicate infection in autologous bone, allowing for delayed autologous cranial reconstruction.

Background The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. The 42-month report on 18 patients was published in 2009 in Plastic and Reconstructive Surgery with 89 percent success at level II evidence, and this article is the 10-year comprehensive review of 62 patients. Methods All grafts met standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography, cone beam volumetric computed tomography, and computed tomography at up to 10 years. Vascularization and incorporation of new bone elements within the grafts were demonstrated by fluorine-18 sodium fluoride positron emission tomography at up to 10 years. Subjective estimation of graft volume persisting up to 10 years was obtained by patient response to a query conducted by an independent surveyor. Results The authors report objective proof of persistence of volume alone or combined with proof of neovascularization in 16 of 19 allografts. The authors report the patient's subjective opinion of volume persistence in 37 of 43 grafts. The dorsal augmentation was assessed overall to be successful in 85 percent of 62 patients evaluated between 1 and 10 years, with a mean of 4.7 years. Conclusions Freeze-dried allograft bone is a safe and equal alternative for dorsal augmentation without donor-site morbidity. Further studies are needed to (1) confirm these findings for young patients needing long-term reconstruction, and (2) partially demineralize allograft bone to allow carving with a scalpel. Clinical question/level of evidence Therapeutic, IV.

Sequential use of the TPO-RAs romiplostim and eltrombopag in ITP patients failing either agent was retrospectively evaluated to assess efficacy and impact of clinical characteristics on outcome. Patients were grouped into 5 categories: efficacy issues: 1st TPO-RA failure; loss of response; non-efficacy issues: platelet fluctuations; patient's preference; adverse event development. Either one TPO-RA sequence was analyzed at 3 month and at last follow-up. 106/546 patients on TPO-RA underwent switch and 65% achieved, regained or maintained a short- term response independent of switch sequence, gender or age; lower response rates were associated with lines of previous therapy; disease duration lowers probability to respond. Clinically, patients switched for efficacy issue did not differ from those switched for non-efficacy issues. Response was achieved/regained in 57.8% of patients switched for efficacy issues, the lowest response rates were observed in non-responders to 1st TPO-RA; 80% of patients switched for non-efficacy issues maintained a response. Platelet fluctuation resolved in 44.4%. Of the 49 patients evaluable for long-term outcome, 27 were in response on therapy; 16 discontinued the TPO-RA for reasons other than efficacy, while only 6 were non responders. We confirm the efficacy of TPO-RA switch; once achieved, response to the 2nd TPO-RA seems durable.

Background and aims The relationship between platelet indices and glucose control may differ in type 1 (T1DM) and type 2 (T2DM) diabetes. We aimed to investigate differences in mean platelet volume (MPV), platelet count, and platelet mass between patients with T1DM, T2DM, and healthy controls and to explore associations between these platelet indices and glucose control. Methods and results A total of 691 T1DM and 459 T2DM patients and 943 control subjects (blood donors) were included. HbA1c was measured in all subjects with diabetes and 36 T1DM patients further underwent 24 h-continuous glucose monitoring to estimate short-term glucose control (glucose mean and standard deviation). Adjusting for age and sex, platelet count was higher and MPV lower in both T1DM and T2DM patients vs control subjects, while platelet mass (MPV × platelet count) resulted higher only in T2DM. Upon further adjustment for HbA1c, differences in platelet count and mass were respectively 19.5 × 109/L (95%CI: 9.8–29.3; p Conclusion By accounting for confounders and glucose control, our data evidenced higher platelet mass and different volume-count kinetics in subjects with T2DM vs T1DM. Long-term glucose control seemed to influence platelet mass and the volume-count relationship only in T1DM subjects. These findings suggest different mechanisms behind platelet formation in T1DM and T2DM patients with long-term glycaemic control being more relevant in T1DM than T2DM.

Delayed healing of pressure ulcers (PUs) in long-term care facilities (LTCFs) is associated with increased morbidity and expense.The authors hypothesize that guideline-based, weekly coordinated care using specialized wound care surgeon-led bedside teams (SLBTs) may improve PU time-to-heal (TTH) outcomes when compared with usual care (UC).Using a deidentified United States nationwide database, the authors retrospectively compared TTH outcomes of PUs diagnosed in LTCFs treated by either weekly SLBTs or UC. The SLBTs included an external specialized wound care surgeon (with or without a physician assistant and nurse practitioner) collaborating with facility nurses. Usual care was defined as all patient encounters not known to incorporate this team process. Variables assessed included patient age, gender, and comorbidities. The primary outcome measure was TTH; the TTH outcomes then were compared graphically and statistically between groups. Statistical significance was double-sided P ⟨ .05.In 2014, there were 39 459 consecutive PUs treated by UC and 5985 by SLBTs. The 5985 SLBT wounds originated from 3435 patients in 10 states and all geographic regions (mean age, 76.6 years; 55.9% female; 42.8% with hypertension; 23.7% with diabetes). The mean TTH for wounds managed by SLBTs was 47.5 days (median, 21 days) versus 69.0 days (median, 28 days) for wounds managed by UC, corresponding to an absolute TTH decrease of 21.5 days in wounds managed by SLBTs versus UC. Wounds managed by SLBTs also were significantly more likely to heal in less than 28 days (P ⟨ .0001).Pressure ulcers managed by coordinated nursing and weekly SLBTs appear to heal significantly faster than wounds managed by UC. Further studies are required to confirm these hypothesis-generating results.

An immunocompetent 21-year-old woman presented to student health services on her college campus with very dark urine, right upper quadrant abdominal pain, and slight scleral icterus. She was given ciprofloxacin for a suspected urinary tract infection. After taking 1 dose, she felt her abdominal pain diminish, but she began developing bouts of watery diarrhea, dizziness, and weakness. She presented to the emergency room the following day with hypotension, respiratory distress, dark urine, and right upper quadrant abdominal pain. The clinical team determined she was in shock with acute liver failure, acute renal failure, metabolic acidosis, hemolytic anemia, and disseminated intravascular coagulation (DIC)3. She required immediate treatment and resuscitation for stabilization. After a red blood cell transfusion for her severe anemia, she developed fever and chills that were determined to be caused by the hemolysis she was experiencing. Selected laboratory results upon admission can be found in Table 1. Of note, the patient's aspartate transferase, alanine transferase, and bilirubin levels were markedly increased, and prothrombin time (PT) was prolonged, most likely owing to the acute liver failure. The blood urea nitrogen, creatinine, and phosphorus concentrations were also increased, indicative of acute renal failure. The venous blood pH and bicarbonate level were decreased owing to the partially compensated metabolic acidosis. The …

Platelet activation is persistently enhanced, and its inhibition by low-dose aspirin is impaired in type 2 diabetes mellitus. We investigated in vivo thromboxane (TX) and prostacyclin (PGI2) biosynthesis and their determinants, as well as aspirin responsiveness, in young adult subjects with type 1 diabetes mellitus (T1DM) without overt cardiovascular disease and stable glycemic control. The biosynthesis of TXA2 was persistently increased in subjects with T1DM versus matched healthy subjects, with females showing higher urinary TX metabolite (TXM) excretion than male subjects with T1DM. Microalbuminuria and urinary 8-iso-PGF2α, an index of in vivo oxidative stress, independently predicted TXM excretion in T1DM. No homeostatic increase in PGI2 biosynthesis was detected. Platelet COX-1 suppression by low-dose aspirin and the kinetics of its recovery after drug withdrawal were similar in patients and control subjects and were unaffected by glucose variability. We conclude that patients with T1DM and stable glycemic control display enhanced platelet activation correlating with female sex and microvascular and oxidative damages. Moreover, aspirin responsiveness is unimpaired in T1DM, suggesting that the metabolic disturbance per se is unrelated to altered pharmacodynamics. The efficacy and safety of low-dose aspirin in T1DM warrant further clinical investigation.

SummaryThe benefit of asparaginase for treating acute lymphoid leukaemia (ALL) has been well established. Native asparaginase derives from Escherichia coli (colaspase) or Erwinia chrysanthemi (crisantaspase); in a third preparation, colaspase is pegylated. Depletion of asparagine leads to decreased synthesis of procoagulant, anticoagulant, and fibrinolytic proteins, with resultant hypercoagulability and greater risk of venous thromboembolism (VTE). Colaspase and crisantaspase are not dose-equivalent, with crisantaspase displaying haemostatic toxicity only at dosages much higher and administered more frequently than those of colaspase. Cerebral venous thrombosis and pulmonary embolism are two life-endangering manifestations that occur during treatment with asparaginase particularly in children and in adults with ALL, respectively. Approximately one-third of VTEs are located in the upper extremities and are central venous line-related. Other risk factors are longer duration of asparaginase treatment and concomitant use of prednisone, anthracyclines, and oral contraceptives. The risk associated with inherited thrombophilia is uncertain but is clearly enhanced by other risk factors or by the use of prednisone. VTE prevention with fresh frozen plasma is not recommended; the efficacy of antithrombin (AT) concentrates has occasionally been reported, but these reports should be confirmed by proper studies, and AT should not be routinely employed. Therapeutic or prophylactic heparin doses are only partially effective, and direct thrombin or factor Xa inhibitors could play significant roles in the near future.

We performed a retrospective analysis of 88 adult patients with B-ALL diagnosed in our center by a flow-cytometric assessment. Immunophenotypic expression of leukemic cells was explored by simultaneous evaluation of positivity, percentage of expressing cells and median fluorescence intensity (MFI). BCR/ABL1 fusion transcripts were assessed by RT-PCR analysis and were identified in 36 patients (40.9%). CD10 and CD34 were positive in the totality of BCR/ABL1-positive cases. Patients with gene rearrangement had a greater frequency of CD66c, CD13 and CD33 positivity compared with BCR/ABL1-negative cases. Moreover, BCR/ABL1-positive cases exhibited a greater median percentage and MFI values of CD13, CD33, CD66c, CD10, CD34 and CD25 expressions, but a lower median percentage and MFI values of CD38 and CD22 expressions than patients without gene rearrangement. Multivariate logistic regression analysis showed that CD10, CD38 and CD13 expressions were independent predictors for the presence of BCR/ABL1 rearrangement. Predictive probabilities of molecular occurrence based on these markers are proposed. © 2017 International Clinical Cytometry Society.

Breast augmentation is among the most popular plastic surgery procedures in the United States. Postoperative pain management following breast surgery has traditionally involved intravenous and oral narcotics. However, pain control is not always adequately achieved through these means and may cause unwanted side effects, including headache, nausea, vomiting, constipation, altered mental status, sleep disturbance, and respiratory depression. Alternative forms of pain control have been used successfully in other surgical fields but have been utilized only recently in breast surgery. In this article, the authors systematically review the existing database of high-quality studies involving pain control following cosmetic breast augmentation to determine the best options currently available.

Health care consumers are increasingly turning to the Internet for information regarding medical and surgical procedures. When an elective procedure is under consideration, the Internet is often the first resource used by a patient. Caregivers of craniofacial patients are typically overwhelmed during the surgical planning process. A firm understanding of craniofacial condition and the associated procedures is crucial to obtain satisfactory outcomes. Furthermore, health care providers are increasingly referring their patients to on-line sources of patient education material. Currently, the National Institutes of Health suggests the information be at the fourth- to sixth-grade reading level to maximize comprehension. Much of the information available regarding health care targeted at patients is written at a 10th-grade reading level or higher. The purpose of this study was to evaluate readily available on-line patient education information for readability; being aware of this information will aid craniofacial surgeons in appropriately educating their patients.Texts were extracted from commonly used craniofacial educational Web sites regarding reconstructive procedures. Three objective and accepted methods (SMOG, Flesch-Kincaid, and Dale-Chall) were used to assess readability of each condition and its corresponding procedure's text.The results from all 3 of the methods used were higher than the recommended seventh-grade reading level. The mean reading level for eMedicine was 13.8, 15.2, and 15 for the Flesch-Kincaid, SMOG, and Dale-Chall methods, respectively. Likewise, the mean reading levels for FACES were 7.5, 10.7, and 8.3; and for World Craniofacial Foundation, the levels were 11.9, 13.8, and 13.Patient education and understanding is a critical factor in planning for surgery; this is especially true of reconstructive craniofacial procedures. Craniofacial surgery is a diverse field, and its surgeons have correspondingly diverse practices. It is up to each individual surgeon to determine what is appropriate for his or her patients. Our results show that on-line educational material is at a level that is substantially higher than the national reading average. The ultimate impact of this fact will vary from practice to practice, but all surgeons should be aware of the possible conflicts between information distributed and the patient's ability to comprehend that information. This may assist surgeons in preoperative evaluations by discussing conditions with more level appropriate means.

SummaryThe utility of laboratory investigation of relatives of individuals with inherited thrombophilia is uncertain. To assess the risk of venous thromboembolism (VTE) among the carriers, we investigated a family cohort of 1,720 relatives of probands with thrombophilia who were evaluated because of VTE (n=1,088), premature arterial thrombosis (n=113), obstetric complication (n=257), or universal screening before pregnancy or hormonal contraception or therapy (n=262); 968 relatives were carriers of thrombophilia. A first deep venous thrombosis (DVT) occurred in 44 carriers and 10 non-carriers during 37,688 and 29,548 observationyears from birth, respectively. The risk of DVT among the carriers compared with non-carriers was estimated as a hazard ratio (HR). If the proband had VTE and factor V Leiden (FVL) and/or prothrombin (PT)20210A, the HR for DVT was 2.77 (95%CI 1.21–4.82) in the carriers overall, and 5.54 (95%CI 3.20–187.00) in those homozygous or double heterozygous for FVL and PT20210A. If the proband had VTE and a deficiency of antithrombin (AT), protein C or S, the HR for DVT was 5.14 (95%CI 0.88–10.03) in the carriers overall, and 12.86 (95%CI 2.46–59.90) in those with AT deficiency. No increase in risk was found among the carriers who were relatives of the probands who were evaluated for reasons other than VTE. In conclusion, familial investigation for inherited thrombophilia seems justified for probands with previous VTE, but appears of doubtful utility for the relatives of probands without VTE. This should be taken with caution regarding families with deficiency of natural anticoagulants, given the low number of cases analysed.

Burkitt lymphoma is a highly curable disorder when treated with modern intensive chemotherapy regimens. The majority of adult patients with Burkitt lymphoma in the United States are over age 40 years. Older patients have historically been underrepresented in published clinical trials of modern intensive therapy, and the outcome of these patients has not been systematically reported. We therefore obtained and analyzed primary data from 14 Burkitt lymphoma treatment series and confirmed that older patients (age > 40 years) are underrepresented in the literature. Historically inferior outcomes of this age subgroup have improved substantially over time. We conclude that (1) modern intensive chemotherapy regimens should remain the standard of care for patients > age 40 with Burkitt lymphoma; (2) selected patients > age 40 now have highly favorable outcomes; and (3) future studies should include formal analysis of this subgroup of patients.

The Arrhinias consist of three groups of malformations: the Total Arrhinias (T-AR), the Hemi-Arrhinias (H-AR, often called Hemi-Nasal Ageneses) and the Proboscis Lateralis (P.L.) This work deals with 51 cases of Arrhinias gathered within 35 years (8 T-AR, 25 H-AR, and 18 P.L): their anatomy, clinical signs, and some indications for treatment; but it does not extend to a discussion for their etiopathology. However, the T-AR and the H-AR represent ageneses, whereas the P.L represents a dysgenesis. The anomalies common to the three groups of Arrhinias are many: the agenesis of the nasal bones, the telecanthus which is often in contrast to the hypo-telorbitism, the obstruction of the naso-lacrimal passage, the ectasia of the lacrimal sac with an erosion of the inferomedial angle of the orbit, the hypopneumatization of the maxillary sinus and a small maxilla, the unerrupted canines, the flattened fronto-nasal process, the obliteration of the cribriform plate, the dysplasia in the root of the eyebrows, the transverse hypoplasia of the upper lip, the frequency of microphthalmia, colobomas of the iris and nystagmus. Cleft lip and palate are frequently associated with the Arrhinias (see Table I) and also other facial malformations, but in different proportions, according to groups. They are: cryptophtalmias, eyelid coloboma, fronto-orbital encephalocele, agenesis of the premaxilla or prolabium, microtia. (See Table II) The basic principles of the treatment are the following: In the T-AR, a nasal passage should initially be bored through the maxilla, or there should be a displacement of the two halves of the mid-face by a procedure known as "facial bipartition". This nasal passage should be epithelialized and maintained wide open to the pharynx until the nasal construction. In the H-AR, it is sufficient to create an epithelialized passage through the curtain of bone where one would expect the pyriform rim to be and carry this passage through the septum into the contralateral nasal airway. Then, regardless of the type of arrhinia, the nasal construction is carried out with a forehead flap and bone grafts. The first grafts are either iliac or tibial, and subsequent ones are generally outer table calvarial grafts harvested from the parietal region. Later, there are further procedures: a maxillary advancement, a lengthening of the central midface, the final stages of the nasal construction, the elevation of the medial canthus, and the restoration of the infero-medial angle of the orbit (but rarely an efficient lacrimal drainage). The earliest stage for surgery can be debated. A strategy for treatment is suggested. Finally, 20 brief comments are made, which are as much questions asked concerning the three groups of arrhinia and their relationship with other centro-facial and latero-facial malformations.

Summary. Background: Little information is available on the long-term clinical outcome of cerebral vein thrombosis (CVT). Objectives and methods: In an international, retrospective cohort study, we assessed the long-term rates of mortality, residual disability and recurrent venous thromboembolism (VTE) in a cohort of patients with a first CVT episode. Results: Seven hundred and six patients (73.7% females) with CVT were included. Patients were followed for a total of 3171 patient-years. Median follow-up was 40 months (range 6, 297 months). At the end of follow-up, 20 patients had died (2.8%). The outcome was generally good: 89.1% of patients had a complete recovery (modified Rankin Score [mRS] 0–1) and 3.8% had a partial recovery and were independent (mRS 2). Eighty-four per cent of patients were treated with oral anticoagulants and the mean treatment duration was 12 months. CVT recurred in 31 patients (4.4%), and 46 patients (6.5%) had a VTE in a different site, for an overall incidence of recurrence of 23.6 events per 1000 patient-years (95% confidence Interval [CI] 17.8, 28.7) and of 35.1 events/1000 patient-years (95% CI, 27.7, 44.4) after anticoagulant therapy withdrawal. A previous VTE was the only significant predictor of recurrence at multivariate analysis (hazard ratio [HR] 2.70; 95% CI 1.25, 5.83). Conclusions: The long-term risk of mortality and recurrent VTE appears to be low in patients who survived the acute phase of CVT. A previous VTE history independently predicts recurrent events.

Splanchnic vein thrombosis (SVT) and chronic myeloproliferative neoplasms (MPN) are closely related. The JAK2 V617F mutation is a hall-mark of MPN but is present also in a relevant percentage of patients with SVT and without an overt chronic MPN. To investigate in patients with essential thrombocythemia (ET) the impact of this mutation on the risk of thrombosis in unusual sites (splanchnic or cerebral veins), we carried out a retrospective cohort study including 224 patients. One hundred forty-two patients (63%) had the mutation, and 68 had suffered either arterial thromboses (n = 39), venous thromboses in a common site (n = 12), or in the eye (n = 1), SVT (n = 13), or cerebral vein thrombosis (CVT; n = 3). All patients with SVT or CVT were

OBJECTIVE Postoperative airway obstruction is a complication of cleft palate repair. A technique to control the airway is to place a suture through the tongue at the conclusion of the palate repair, but it is not uniformly adopted by surgeons. Although it has been frequently performed, the use and effectiveness of the tongue suture have not been studied. Our purpose was to determine the usefulness of tongue suture placement. DESIGN We surveyed health care providers as to their frequency of use and the value of the tongue suture in postoperative airway management of the cleft palate patient. The survey was sent via e-mail to 2080 members of the American Cleft Palate-Craniofacial Association, with a total of 396 responders. RESULTS Surgeons were nearly equally split on placing a tongue suture, with 41.1% responders reporting that they use a tongue suture all of the time and 41.1% of responders reporting that they never used a tongue suture. Some criterion used for placement was the complexity of the case, syndromic patients, and overseas cleft missions. CONCLUSIONS Many cleft palate repairs are done annually without using tongue sutures, but it does not seem to affect the outcomes among surgeons, thus confounding the question of effectiveness. At this time, tongue suture placement after cleft palate repair is variable and subjective. Further studies need to be performed to assess outcomes after placing a tongue suture.

Objective To describe and discuss the ongoing endeavor to establish a multiregional trauma registry in Italy. Methods Design: Prospective observational analysis by description and cohort comparison. Setting: Three Italian hospitals, referral centers for severely traumatized patients. Patients: trauma victims admitted between 1 July 2004 and 28 February 2005 with an Injury Severity Score >15 or requiring early admission to intensive care. Interventions: None. Measures: Compilation rates for some 'sentry' variables. Total number of patients and Injury Severity Score. Ten widely used descriptive variables (type of trauma, mechanism of injury, age, gender, Injury Severity Score, Revised Trauma Score, Prognostic Severity Index, 'call-to-hospital' and 'admission-to-ward' intervals, and outcome at 30 days) measured in the subgroup with Injury Severity Score >15, in general and by hospital. Results A trauma registry has been established that fit the present organization of trauma care in Italy. It seems to compare well with the references available in the literature. Five hundred and forty-nine patients have been enrolled so far. The compilation rate has been well above 70% for all variables in all hospitals, except pre-hospital times in two hospitals. A substantial homogeneity exists among the hospitals in the general characteristics of the patients with Injury Severity Score >15. Conclusions The project has achieved its goals so far. The previous estimates on the number of cases (about 300/year/hospital) are confirmed and major shortcomings in methodology seem unlikely. Therefore, positive future developments are possible: usage for quality improvement and research, linkage to other European registries and participation of other hospitals.

Objectives The h-index has utility in examining the contributions of faculty members by quantifying both the amount and the quality of research output and as such is a metric in approximating academic productivity. The objectives of this study were (1) to evaluate the relationship between h-index and academic rank in plastic surgery and (2) to describe the current gender representation in academic plastic surgery to assess whether there are any gender disparities in academic productivity. Design The h-index was used to evaluate the research contributions of plastic surgeons from academic departments in the United States. Results There were 426 (84%) men and 79 (16%) women in our sample. Those in higher academic ranks had higher h-index scores (p h-index by gender, where the mean scores were 9.0 and 6.0 for men and women, respectively (p = 0.0005). When analyzed by academic rank, there was a significant difference in academic productivity between men and women in assistant and associate professor positions (6.4 vs 5.1, respectively; p=0.04). Conclusions The h-index is able to objectively and reliably quantify academic productivity in plastic surgery. We found that h-indices increased with higher academic rank, and men had overall higher scores than their female colleagues. Adoption of this metric as an adjunct to other objective and subjective measures by promotions committees may provide a more reliable measure of research relevance and academic productivity in academic plastic surgery.

A b s t r ac t Background Current treatment recommendations for patients with polycythemia vera call for maintaining a hematocrit of less than 45%, but this therapeutic strategy has not been tested in a randomized clinical trial. Methods We randomly assigned 365 adults with JAK2-positive polycythemia vera who were being treated with phlebotomy, hydroxyurea, or both to receive either more intensive treatment (target hematocrit

Monoclonal gammopathy of undetermined significance (MGUS) has been associated with an increased risk of thrombosis. We carried out a retrospective multicentre cohort study on 1491 patients with MGUS. In 49 patients (3.3%) MGUS was diagnosed after a thrombotic event. Follow-up details for a period of at least 12 months after diagnosis of MGUS were obtained in 1238 patients who had no recent history of thrombosis (2 years) prior to diagnosis, for a total of 7334 years. During the follow-up, 33 of 1238 patients (2.7%) experienced thrombosis, with an incidence of 2.5 arterial events and 1.9 venous events per 1000 patient-years. Multivariate analysis showed increased risks of arterial thrombosis in patients with cardiovascular risk factors [hazard ratio (HR) 4.92, 95%confidence interval (CI) 1.42-17.04], and of venous thrombosis in patients with a serum monoclonal (M)-protein level16 g/l at diagnosis (HR 3.08, 95%CI 1.01-9.36). No thrombosis was recorded in patients who developed multiple myeloma (n = 50) or other neoplastic diseases (n = 21). The incidence of arterial or venous thrombosis in patients with MGUS did not increase relative to that reported in the general population for similarly aged members. Finally, the risk of venous thrombosis did increase when the M-protein concentration exceeded16 g/l.

SummaryWhether the administration of low-molecular-weight heparin (LMWH) during pregnancy is effective in preventing obstetric complications and pregnancy-related venous thromboembolism (VTE) in women who are carriers of factor V Leiden (FVL) and/or prothrombin variant G20210A (PTm) is controversial. This observational study investigated the possible efficacy of pharmacological treatment with LMWH ± aspirin (ASA) in pregnancy outcomes in 1,011 pregnancies of 416 women with thrombophilia (FVL and/or PTm). Most patients were chosen on the basis of previous obstetrical complications (36%), or because of familial or personal history of venous/arterial thromboembolism (28% and 18%, respectively); 74 patients (18%) were incidentally identified. The outcome was evaluated according to the type of treatment and of the period of pregnancy when the treatment was started. After adjustment for observation before and after diagnosis of thrombophilia, previous miscarriages and VTE, parity, age and centre, we observed that LMWH had a protective effect on miscarriages (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.29–0.94) and VTE (OR 0.05, 95% CI 0.01–0.21). ASA appeared to have no effect on the prevention of obstetric complications and VTE. A nested analysis performed in 116 women with two or more obstetric complications confirmed that the highest number of live births was recorded in the group under LMWH prophylaxis (OR 0.19, 95% CI 0.05–0.75). These results suggest that LMWH prophylaxis reduces the risk of obstetric complications in carriers of FVL and/or PTm, particularly in those with previous obstetric events. Furthermore, LMWH prophylaxis reduces the risk of pregnancy-related VTE.

The clavicular myocutaneous island flap, with circulation provided by the platysma and superficial cervical fascia, was first performed by Paul Tessier in 1970, taking his motivation from the prior experience of John Barron with subcutaneous island flaps. A manuscript written by Dr. Tessier on his experience of 120 cases using the flap (which we will refer to as the BT, or Barron-Tessier flap) has been translated and is presented, as well the experiences of Matthews and Wolfe, who learned the procedure from Dr. Tessier, and Kamerer, an ENT/Head and Neck surgeon who learned the procedure from Matthews. In aggregate, we will present our joint experience with 443 cases of the BT flap. Because of its ease and speed of harvest, reliability, and provision of thin, pliable skin, we feel that, in many instances, it is equivalent, or even superior to microsurgical free flap for reconstruction of intraoral lining defects.

Background: Properly prepared freeze-dried bone has been used with impunity by orthopedic surgeons since 1992 without a single report of disease transmission. The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. Methods: Freeze-dried human cortical bone was obtained from DCI Donor Services, Nashville, Tennessee. Standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention were followed. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning. Results: The average persistence of projection in 18 patients was 87 percent at 6 months. Thereafter, 10 patients showed 100 percent maintenance of projection at 12 to 36 months. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning in four patients. Conclusions: The initial loss of 13 percent of projection is most likely attributable to resolution of early surgical edema. The authors postulate that there are two pathways based on whether the recipient bed allows vascular access to the graft. The revascularization or inductive pathway involves stem cell conversion to eventual osteoblasts. The scar bed barrier or noninductive pathway involves the preservation of the graft as an unchanged alloimplant. This report is the first of a series that will include a 5-year and a 10-year follow-up.

The most common craniofacial malformation in the newborn is the orofacial cleft, consisting of cleft lip with or without cleft palate and isolated cleft palate. Given its prevalence it is important to understand the etiology of the deformity, medical management prior to surgical correction, surgical techniques and timing.

It is uncertain whether the JAK2 V617F mutation increases the thrombotic risk in patients with essential thrombocythemia, and it is unknown whether inherited thrombophilia is an additive risk factor in mutated subjects. We studied 132 patients with essential thrombocythemia, 38 of them (29%) with a history of thrombosis. The JAK2 mutation was present in 83 (63%), and inherited thrombophilia in 7. The mutated patients60 years had a relative risk (RR) for thrombosis at any time of 3.83 (95%CI 1.27-11.49) in comparison with wild-type patients; in those with both the mutation and thrombophilia the RR was 2.23 (95%CI 1.57-3.18) and 7.66 (95%CI 2.66-22.03) in comparison with mutated or wild-type patients without thrombophilia, respectively. During the follow-up, only the homozygotes for JAK2 V617F were more prone to thrombosis (RR 17.25, 95%CI 2.33-127.4). Among the patients60 years, no increase in RR was associated with the JAK2 mutation. In conclusion, in the younger patients with ET the thrombotic risk is higher in the JAK2 V617F-mutated and is further increased by the presence of inherited thrombophilia.

Craniofacial distraction can be planned using cephalograms, computed tomography, medical models, and other forms of anatomic data. However, it is often difficult to translate this plan to the patient. Specifically, it is difficult to obtain true parallel placement of bilateral midface and mandibular distractors. Intraoperative translation of preoperatively determined vectors is also troublesome. One method of application uses computed tomography data with radiofrequency triangulation technology in a specially equipped room. This helps with the issue of placement on the patient but does not establish parallelism. We have developed a simple-to-use craniofacial application stabilization device that allows equal placement of bilateral distractors and measurement of distraction vectors. The applicator measures 20 cm in length in its open configuration. The terminal portion of the device has a coupler that holds the distractor during placement. The device is hinged in 3 points so that it can be easily folded into a compact and autoclavable device (7 x 3 cm). The hinges allow equal placement of bilateral distractors. Each hinge can be calibrated to determine the vector of distraction and confirm equal application. Lastly, the stabilizer can be fixed to nasion with a Steinmann pin for reference, allowing intraoperative translation of distraction vectors. We demonstrated on skull models that the craniofacial distractor applicator can accurately allow parallel intraoperative placement of craniofacial distractors. We demonstrated simultaneous placement of the distractors allowing a more precise determination of end points.

SummaryIt is uncertain whether the presence of inherited thrombophilia influences the risk of developing symptomatic pulmonary embolism (PE) and whether different thrombophilic alterations are associated with different risks of symptomatic PE. To investigate such issue, we retrospectively studied 920 patients with proximal deep vein thrombosis (DVT) of the legs with or without symptomatic PE referred for thrombophilia screening; patients with overt cancer or antiphospholipid antibodies had been excluded. Three hundred fifty-four patients (38.5%) had deficiency of antithrombin (AT, n=16), protein C (PC, n=26), protein S (PS, n=22), factor V Leiden (FVL, n=168), prothrombin G20210A (PT-GA, n=87), or multiple abnormalities (n=35), and 566 had none of the studied thrombophilic abnormalities. Symptomatic PE complicated the first DVT in 242 patients (26%); the risk of PE was increased in patients with AT deficiency (relative risk [RR] 2.4, 95% confidence interval [CI] 1.6–3.6) or with PT-GA (RR 1.5, 95%CI 1.1–2.0) and decreased in those with FVL (RR 0.7, 95%CI 0.5–1.0) in comparison with those with unknown inherited defect. These data suggest that patients with proximal DVT have different risks of symptomatic PE according to the type of inherited thrombophilia.

Candida spp. are recently frequent cause of nosocomial sepsis in neonates admitted in NICU, expecially VLBW. Amphotericin B is used in the treament of infections caused by Candida, but heavy side effects, expecially due to renal toxiticy, prevent often its use in the VLBW neonates. We used a new formulation of Amphotericin (AmBisome--NEXSTAR), in the treatment of 17 VLBW neonates affected by sepsis caused by Candida albicans, admitted in our NICU during two years. Twelve neonates survived, one neonate died for NEC and bowel perforation. The treatment was prolonged for 13 days (7-33 days), the total amount of dose was 65 mg/Kg, none side effect was noted.

FOR many years, it was widely held that brain tumors not uncommonly presented acutely as a result of hemorrhage into the tumor. The 1930 edition of Osler's textbook of medicine contains the statement that gliomas of the brain, "are usually very vascular and the vessels are very liable to degenerate with resulting hemorrhage, thrombosis and edema. This often accounts for acute features appearing suddenly."1Over the years a sufficient body of information has accumulated which rather demolishes this view. Oldberg2in 1933 was among the first to correct this misapprehension. He reviewed Cushings series of 832 gliomas and found 31 instances of gross hemorrhage for a ratio of 1:27 or 3.7%. Various other series have corroborated this intelligence,3-6in studies primarily concerned with the etiology of massive intracerebral hemorrhage per se; other studies are devoted to the incidence of intracerebral hemorrhage secondary to tumor.7,8 As