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The knee region represents a challenging area of soft tissue reconstruction. Specifically, in the context of total knee arthroplasty (TKA) or following high-energy trauma with fractures and hardware fixation, soft tissue defects can expose critical structures such as joint, bone or tendon, besides the implant/plates themselves, with dramatic consequences in terms of postoperative infection and hardware contamination.A retrospective study was conducted on a prospectively maintained database from January 2016 to February 2021. Inclusion criteria involved all patients who underwent an implant-associated infection of the knee and upper third of the leg coupled with a soft tissue reconstruction (STR) using the traditional gastrocnemius muscle (GM) pedicled flap or the chimeric GM-MSAP (medial sural artery perforator) flap.Thirty-eight patients were included (group A, GM flap, 22 patients; group B, chimeric GM-MSAP flap, 16 patients). No statistically significant differences were detected in terms of age, comorbidities, defect size, follow-up, and flap complications. A statistically significant difference was seen among the groups in terms of successful flap re-raise (required because of a persistent infection of the implant or in a two-stage procedure setting, including the use of a cemented spacer) in favour of the GM-MSAP group.The chimeric GM-MSAP, being safer to reraise if required, can be a significantly more powerful tool in those cases in which a two-stage procedure is planned or when there is a high probability for secondary intervention need, reducing the need to convert to either free flap coverage or amputation.

BACKGROUND: This is a retrospective study of the casuistry occurred at the Hand Surgery and Microsurgery HUB Center of Emilia-Romagna during the months of March and April 2020 in the peak of Phase 1 of COVID-19 pandemic in Italy, comparing the data with the same period in 2019. METHODS: A more relevant reduction of 92.3% in elective surgery and a significantly less relevant reduction of 37.2% in emergencies was recorded. Replantation did not present reduction while cutting lesions of tendons and saw injuries increased such as the injuries during domestic activities. RESULTS: The incidence of hand trauma looks not only at the traditional field of artisanal and industrial injuries, but also to the most recorded accidents in daily life activities. The data evidenced the significantly increase of the injuries occurring in the domestic environment. The 72.8% of emergencies was treated in day-service with significantly reduction in hospitalization, costs and infective risks. Telemedicine implementation has experienced to upgrade the relationship in the emergency network. CONCLUSIONS: Hand injuries remained a major issue also during the lockdown. A functional and skill emergency service and day-service during the phase 1 COVID-19 pandemic played a relevant role in efficacy and efficiency. The utility of telemedicine was greatly limited by liability and risk management issues.

BackgroundSystemic Sclerosis (SSc) is a connective tissue disease, characterized by endothelial dysfunction, autoimmunity abnormalities and fibrosis of the skin and internal organs. The exact pathogenetic mechanisms that propagate SSc vasculopathy are still not completely understood. A complex network of interactions between endothelial cells, pericytes, myofibroblasts, and the extracellular matrix (ECM) has been implicated but it is currently unclear what drives the activation of fibroblasts and the increased ECM deposition responsible for the fibrotic changes well known in SSc.ObjectivesUsing RNA sequencing (RNA-seq), our goal was to identify potential functional pathways possibly involved in SSc pathogenesis and markers that could potentially be used to better understand endothelial dysfunction and fibrosis mechanisms in SSc patients.MethodsRNA-seq analysis was performed on RNA obtained from biopsies from 3 SSc patients and 3 age- and sex-matched healthy controls (HC) enrolled in our University Hospital between January 2019 and December 2020. The samples were transferred to a labelled cryovial and immediately stored in liquid nitrogen. RNA extraction followed standard methodologies. RNA from each sample was used to generate sequencing libraries that were sequenced according to proper transcriptomic analyses. To identify potential functional pathways that could be involved in SSc pathogenesis, we performed gene set enrichment analysis (GSEA) of differentially expressed genes (DEGs). GSEA was applied on the entire list of genes that compose the RNA-seq expression matrix. Genes were ranked based on their fold change calculated between groups of each pairwise comparison and analyzed by GSEA in pre-ranked mode. We adopted the “classic” enrichment statistic, the recommended approach for RNA-sequencing data.ResultsAccording to GSEA analysis of DEGs applied to SSc and HC, we identified 305 DEGs that were upregulated or downregulated at least 2-fold. In particular, 175 genes were upregulated and 130 genes were downregulated. A marked upregulation of genes involved in Wnt signaling, including Wnt family members, was present in HC if compared with SSc. The upregulation of collagen type VI, extracellular matrix protein 2, vascular endothelial growth factor D, among others, was also observed. Conversely, a marked downregulation of late cornified envelope and of genes encoding for keratins, was present in HC versus SSc samples. GSEA revealed that HC were characterized, among others, by gene signatures related to stromal stem cells proliferation, cytokine-cytokine receptor interaction, macrophage-enriched metabolic network, whereas SSc tissues were enriched in signatures related to keratinization, cornification, retinoblastoma (RB) 1 and tumour suppressor (TP) 53 signaling. Figure 1 displays GSEA in HC vs SSc tissues.Figure 1.GSEA in HC vs SSc tissues.Enrichment of gene signature was analyzed in transcriptomic data from HC and SSc samples.ES=enrichment score. NES=normalized enrichment score. FDR=false discovery rate.ConclusionAccording to our preliminary data, RNA-seq, differential gene expression and pathway analysis revealed that SSc patients show a discrete pattern of gene expression associated with keratinization, extracellular matrix generation, and negative regulation of angiogenesis and stromal stem cells proliferation. Further analysis on larger numbers of patients are needed; however, our results provide an interesting framework for the development of biomarkers representing vascular injury and fibrotic changes in SSc in order to explore potential future therapeutic targets.Disclosure of InterestsNone declared

BackgroundSystemic Sclerosis (SSc) is a connective tissue disease characterized by microvascular dysfunction, abnormal fibroblast activation and antibodies production, with cutaneous and visceral involvement. Hand-related manifestations include sclerosis, loss of elasticity, sclerodactyly, painful digital ulcers, atrophy, and gangrene. Autologous fat grafting is based on the implantation of adipose-derived stem cell (ADSCs) which have demonstrated to have pro-angiogenic, anti-inflammatory, regenerative, and immunosuppressive properties. This technique, combined with bone shaving, is believed to be effective in avoiding finger amputation in SSc-patients affected by digital gangrene.ObjectivesEvaluate our experience with the use of autologous fat grafting and bone shaving for the treatment of digital necrosis in patients affected by SSc.MethodsAccording to our schedule, we treated 7 female SSc patients with digital gangrene and exposed bone at the fingertips, enrolled in our University Hospital from March 2018 to January 2020. Digital gangrene was treated by a combination of bone shaving and autologous fat grafting in order to avoid amputation. During the bone shaving, necrotic tissue was removed until bone bleeding was obtained. This procedure could be repeated by trained rheumatologists every 2 weeks in our Clinic. The aim of this repeated debridement was to promote the progression of the granulation tissue inside the dead tissue of the finger. Autologous fat grafting consists of a surgical procedure of ADSCs implantation at the base of the finger. It is performed in order to empower the neurovascular bundle and improve tissue healing. This treatment could be performed every 3 months by trained plastic surgeons. The combination of these two techniques allows the maximum finger length preservation.ResultsComplete healing of all fingers was achieved in 6-12 months by performing bone shaving every 2 weeks and 2 treatments of autologous fat grafting. Results have proved to be long-lasting. At 1-year follow-up, patients did not present any recurrence. Every procedure was performed under local anaesthesia and appropriate analgesic therapy. A high degree of compliance and satisfaction of all patients was noted.ConclusionFinger amputation in Systemic Sclerosis should be avoided. This traumatic surgical procedure is responsible for microvascular damages worsening SSc-related vasculopathy. Stump ulcers often occurs and wound healing usually takes place by secondary intention. In our experience, the combination of bone shaving and autologous fat grafting has proven to be effective and safe in preserving the maximum amount of viable tissue and obtaining a long-lasting result in treated SSc patients.Disclosure of InterestsNone declared

BackgroundSystemic Sclerosis (SSc) is a life-threatening connective tissue disease characterized by endothelial dysfunction, autoimmune abnormalities and aberrant fibrosis. Several reports showed an increased risk of cancer in SSc compared to general population, including breast cancer (BC). The relationship between BC and SSc has long been discussed with contradictory results. In our recent Sclero-Breast study we analyzed clinical-pathological features of BC in SSc; we finally observed the development of BC with early stages and good prognosis among these patients.ObjectivesThe aim of this project was to explore the immunohistochemical (IHC) expression of potential biomarkers involved in the molecular pathways at the basis of SSc and BC etiophatogenesis as update analysis from the Sclero-Breast study.MethodsOur observational multicenter retrospective study, performed at Modena University Hospital and Reggio Emilia Hospital in northern Italy, enrolled 33 SSc women with a personal history of BC between January 2017 and December 2019. Clinical and pathological characteristics of BC and SSc were collected. For 22 patients, BC tissues were available and IHC analysis was performed using specific antibodies to evaluate biomarkers and pathways potentially involved. The antibodies used included: PI3K/mTOR/TGFβ/PDGFRα/PDGFRβ/VEGF/EGFR/IL-6/CTLA-4/PDL1. We also reported TILs percentage (stromal tumor-infiltrating lymphocytes) of each sample. The following scores were assigned for general IHC analysis: (-) negative, (1+) positive tumor cells 50%. For PDL1 we considered a positivity in case of PD-L1 expression ≥1% in infiltrating inflammatory cells. For TILs quantification we applied the score: 0 (negative), ≤ 50% (low-median expression), >50% (high expression).ResultsThe first IHC analysis was performed on the samples of invasive BC patients (20 pts) and showed a prevalence of high PI3K expression (score of 3+ in 55% of cases) with mTOR overexpression in 45%. A PDL1 positivity was detected in 30%, with high TILs expression in 30%. Biopsies from the 2 pts with ductal carcinoma in situ were characterized by a negativity of almost all parameters, except for a medium-high TILs expression reported (40%/90% respectively). See Figure 1. IHC analysis was also performed according to BC subtypes. The group of HR+/HER2 negative showed high PI3K expression (score 3+) in most of cases (59%) with mTOR overexpression in 50%. CTLA-4 and PDL1 were positive in 25%, with high TILs expression in 25%. HER2 positive patients showed a high PI3K positivity in 50% of cases with mTOR positivity (score 3+) in 25% and high TGFβ expression (score 3+) in 25%. PDL1 was positive in 50% with high TILs expression in 25%. In Triple Negative group, PI3K overexpression was found in 75% of pts with half of cases represented by mTOR score 3+. PDL1 was positive in 50% with high TILs representation (80% of total cell count) in 50% of pts.Figure 1.IHC analysis and TILs% expression in histological samples of SSc patients with invasive BC.ConclusionAccording to our results, SSc patients with BC showed high positivity for PDL1 and high TILs representations in all subtypes. Furthermore, the high expression of PI3K, did not always correlate with mTOR overexpression. Further investigations on larger numbers are needed; however, these aspects seem to confirm that SSc subjects might develop BC at good prognosis, suggesting again a de-escalation strategy of cancer therapies. Finally, the possibility to personalize oncological targeted treatments in this subset of fragile patients could be promising.Disclosure of InterestsNone declared

Even if the deep inferior epigastric perforator (DIEP) free flap has become popular among plastic surgeons mostly for breast reconstruction, its use to restore head and neck defects has been widely documented in the literature, particularly when additional tissue bulk is required. The aim of this chapter is to present the anatomical feature, the harvesting technique and the specific indication related to the use of DIEP flap in head and neck reconstruction.

The development of a tracheocutaneous fistula (TCF) is a well-documented complication after tracheostomy, especially in chronic morbid patients, in whom tubes or cannulas are left in place over time, or in irradiated patients.Surgical treatments are therefore needed which range from simple curettage and dressings to local skin flaps, muscle flaps and, in the more complex cases, microsurgical free tissue transfers.We present a novel combined technique used to successfully treat recurrent TCFs in irradiated patients, involving a superiorly based turnover fistula flap and a sternocleidomastoid transposition flap.

BACKGROUND Microsurgical training on rats before starting with clinical practice is a well-established routine. Animal model training is less widespread for perforator flaps, although these flaps represent a technical challenge. Unlike other flaps, they require specific technical skills that need to be adequately trained on a living model 1 : a cadaver is not enough because no bleeding, vessel damage, or vasospasm can be simulated. 2 The purpose of this study was to assess the suitability of the porcine abdomen as a training model for the deep inferior epigastric artery perforator (DIEAP) flap, commonly used in human breast reconstruction. METHODS A female swine (Sus scrofa domesticus, ssp; weight 25kg) was used. The procedure was performed with the pig under general anesthesia and in the supine position. A deep superior epigastric artery perforator (DSEAP) flap was harvested on the left side of the abdomen, including the 3 cranial nipples and stopping in the midline to spare the contralateral flap for another dissection (as in bilateral breast reconstructions in humans; Fig. 1). All steps of a DIEAP harvest were simulated: superficial vein harvest, suprafascial perforator dissection, intramuscular perforator harvest with preservation of the nerves, and flap isolation. Observation of capillary refill was used to confirm flap viability at the end of the dissection. The procedure was recorded by means of a GoPro camera and simultaneously with a head mounted (4× magnification) Loupecam system. Photographs were taken using 2 cameras during surgery at relevant time points. RESULTS At the end of the dissection, the flap was viable. The subcutaneous adipose tissue of the pig is less represented than in human and pigs have an additional muscular layer, the panniculus carnosus, which is the analogue of the human Scarpa's fascia. The rectus fascia is thinner. The perforators are lined in 2 rows: 1 lateral and 1 medial, as in the DIEAP, and the intercostal nerves cross the vessels, as happens in humans. The porcine rectus abdominis muscle is thinner than the human one, but vessels' branching faithfully reproduces the human model. 1 We identified 5 perforating vessels of more than 1mm in diameter (2 lateral and 3 medial). We isolated a lateral perforator first and a medial one last: the latter was eventually used to nourish the flap (Fig. 2). CONCLUSIONS The DSEAP flap allows one to closely reproduce all the steps of DIEAP flap harvesting and also to carry out the intramuscular dissection of 2 perforators for each side (up to 4 for each animal), confirming the adequacy of this pig model for microsurgical training. The deep superior epigastric artery is dominant in pigs. 3 Despite this anatomical difference, the DSEAP allows one to reproduce the main steps of DIEAP flap harvesting, providing an excellent training model. Moreover, the presence of double perforating rows allows simulating the dissection twice on each side.

Although flap anatomy is well studied on cadavers and microsurgical techniques are well practiced on rats, still there are few training models for learning the techniques of perforator flap harvesting. The cadaver has no bloodstream, so accuracy of dissection cannot be evaluated and flap viability cannot be verified. Training on humans carries a high risk of flap damage. A living model for perforator flap harvest is needed to learn the technique before starting with its clinical application.

The trend towards realistic numerical models of (pathologic) patient-specific vascular structures brings along larger computational domains and more complex geometries, increasing both the computation time and the operator time. Hexahedral grids effectively lower the computational run time and the required computational infrastructure, but at high cost in terms of operator time and minimal cell quality, especially when the computational analyses are targeting complex geometries such as aneurysm necks, severe stenoses and bifurcations. Moreover, such grids generally do not allow local refinements. As an attempt to overcome these limitations, a novel approach to hexahedral meshing is proposed in this paper, which combines the automated generation of multi-block structures with a grid-based method. The robustness of the novel approach is tested on common complex geometries, such as tree-like structures (including trifurcations), stenoses, and aneurysms. Additionally, the performance of the generated grid is assessed using two numerical examples. In the first example, a grid sensitivity analysis is performed for blood flow simulated in an abdominal mouse aorta and compared to tetrahedral grids with a prismatic boundary layer. In the second example, the fluid-structure interaction in a model of an aorta with aortic coarctation is simulated and the effect of local grid refinement is analyzed.

Carotid artery stenting (CAS) has emerged as a minimally invasive alternative to endarterectomy but its use in clinical treatment is limited due to the post-stenting complications. Haemodynamic actors, related to blood flow in the stented vessel, have been suggested to play a role in the endothelium response to stenting, including adverse reactions such as in-stent restenosis and late thrombosis. Accessing the flow-related shear forces acting on the endothelium in vivo requires space and time resolutions which are currently not achievable with non-invasive clinical imaging techniques but can be obtained from image-based computational analysis. In this study, we present a framework for accurate determination of the wall shear stress (WSS) in a mildly stenosed carotid artery after the implantation of a stent, resembling the commercially available Acculink (Abbott Laboratories, Abbott Park, Illinois, USA). Starting from angiographic CT images of the vessel lumen and a micro-CT scan of the stent, a finite element analysis is carried out in order to deploy the stent in the vessel, reproducing CAS in silico. Then, based on the post-stenting anatomy, the vessel is perfused using a set of boundary conditions: total pressure is applied at the inlet, and impedances that are assumed to be insensitive to the presence of the stent are imposed at the outlets. Evaluation of the CAS outcome from a geometrical and haemodynamic perspective shows the presence of atheroprone regions (low time-average WSS, high relative residence time) colocalised with stent malapposition and stent strut interconnections. Stent struts remain unapposed in the ostium of the external carotid artery disturbing the flow and generating abnormal shear forces, which could trigger thromboembolic events.

Although arterio-venous grafts (AVGs) are the second best option as long-term vascular access for hemodialysis, they suffer from complications caused by intimal hyperplasia, mainly located in vessel regions of low and oscillating wall shear stress. However, certain flow patterns in the bulk may reduce these unfavorable hemodynamic conditions. We therefore studied, with computational fluid dynamics (CFD), the impact of a helical AVG design on the occurrence of (un)favorable hemodynamic conditions at the venous anastomosis. Six CFD-models of an AVG in closed-loop configuration were constructed: one conventional straight graft, and five helical designed grafts with a pitch of 105 mm down to 35 mm. At the venous anastomosis, disturbed shear was assessed by quantifying the area with unfavorable conditions, and by analyzing averaged values in a case-specific patch. The bulk hemodynamics were assessed by analyzing the kinetic helicity in and the pressure drop over the graft. The most helical design scores best, being instrumental to suppress disturbed shear in the venous segment. There is, however, no trivial relationship between the number of helix turns of the graft and disturbed shear in the venous segment, when a realistic closed-loop AVG model is investigated. Bulk flow investigation showed a marked increase of helicity intensity in, and a moderate pressure drop over the AVG by introducing a lower pitch. At the venous anastomosis, unfavorable hemodynamic conditions can be reduced by introducing a helical design. However, due to the complex flow conditions, the optimal helical design for an AVG cannot be derived without studying case by case.

Summary Objectives A novel stent method to simplify treatment of proximal ascending aorta and aortic arch aneurysms was developed and investigated by finite element analysis. Therapy of ascending aortic and aortic arch aneurysms is difficult and challenging and is associated with various complications. Methods A 55 mm wide × 120 mm long stent was designed without the stent graft and the stent was deployed by an endovascular method in a virtual patient-specific aneurysm model. The stress-strain analysis and deployment characteristics were performed in a finite element analysis using the Abaqus software. Results The stent, when embedded in the aortic wall, significantly reduced aortic wall stresses, while preserving the side coronary ostia and side branches in the aortic arch. When tissue growth was modeled computationally over the stent struts the wall stresses in aorta was reduced. This effect became more pronounced when increasing the thickness of the tissue growth. There were no abnormal stresses in the aorta, coronary ostium and at the origin of aortic branches. The stent reduced aneurysm expansion cause by hypertensive condition from 2 mm without stenting to 1.3 mm after stenting and embedding. Conclusion In summary, we uncovered a simple treatment method using a bare nitinol stent without stent graft in the treatment of the proximal aorta and aortic arch aneurysms, which could eventually replace the complex treatment methods for this disease.

There is a growing interest in virtual tools to assist clinicians in evaluating different procedures and devices for endovascular treatment. In the present study we use finite element analysis to investigate the influence of stent design and vessel geometry for stent assisted coiling of intracranial aneurysms. Nine virtual stenting procedures were performed: three nitinol stent designs ((i) an open cell stent resembling the Neuroform, (ii) a generic stiff and (iii) a more flexible closed cell design), were deployed in three patient-specific cerebral aneurysmatic vessels. We investigated the percentage of strut area covering the aneurysm neck, the straightening induced on the cerebrovasculature by the stent placement (quantified by the reduction in tortuosity), and stent apposition to the wall (quantified as the percentage of struts within 0.2mm of the vessel). The results suggest that the open cell design better covers the aneurysm neck (11.0±1.1%) compared to both the stiff (7.8±1.6%) and flexible (8.7±1.6%) closed cell stents, and induces less straightening of the vessel (-5.1±1.6% vs. -42.9±9.8% and -26.9±11.9% ). The open cell design has, however, less struts apposing well to the vessel wall (56.0±6.4%) compared to the flexible (73.4±4.6%) and stiff (70.4±5.1%) closed cell design. With the presented study, we hope to contribute to and improve aneurysm treatment, using a novel patient specific environment as a possible pre-operative tool to evaluate mechanical stent behavior in different vascular geometries.

Background:? polymorphisms of the interleukin-1 (IL-1) gene family have been proposed as potential variants for different diseases including multiple sclerosis (MS). With respect to MS, IL-1 beta (?511 C/T; rs16944), IL-1 beta (+3954 C/T; rs1143634), IL-1 alpha (?889 C/T; rs1800587), IL-1 alpha (+4845 G/T; rs17561), and the variable number of tandem repeats in intron 2 of the IL-1 receptor antagonist (IL-1RN) gene polymorphisms have been studied in different ethnic groups, leading to conflicting results. Methods:? this study investigates the association between IL-1 genes and MS by means of 70 markers spanning the 1.1 Mb region where the IL-1 genes map and exploring both the linkage disequilibrium (LD) and the haplotype structure in a case–control design including 410 subjects (160 patients and 250 controls). Results:? from allelic/genotypic tests, significant association was found for several polymorphisms including the IL-1 beta (?511 C/T) variant (P-adjusted = 4.5 × 10?4) and some polymorphisms around the IL-1RN gene. The ‘block-step’ pattern obtained from both the LD map and pairwise analysis identifies four LD regions. Region 1 showed a significant association with MS for the global test (P Conclusions:? our findings support the existence of a causative variant for MS within this candidate region in a representative Italian Caucasian population and, in particular, the role of the IL-1 beta (?511 C/T) variant warrants further investigation

The aim of this observational, prospective, nonrandomized study was to assess long-term psychometric outcomes of surgical treatment of HIV-related facial lipoatrophy. Two hundred ninety-nine participants (70.8% male) consecutively attending the Metabolic Clinic of Modena and Reggio Emilia University from November 2005 to July 2006, undergoing surgical interventions for HIV-related facial lipoatrophy were enrolled. Fifty-four (18.1%) underwent facial lipofilling, which consists of the harvesting of a small, intact parcel of fatty tissue with processing that removes the nonviable components and of the transport of fatty parcels through a small cannula to implant the graft in a manner that provides nutrition and anchors the fat to the host tissue. After an initial lipofilling, 24 (8%) needed polylactic acid injections to correct cheek asymmetry, 91 (30.4%) received only polylactic acid infiltrations, and 130 (43.5%) polyacrylamide infiltrations only. Subjective outcome measures were face aesthetic satisfaction, body image perception, depression evaluated by a visual analogue scale (VAS), the Assessment of Body Change and Distress questionnaire (ABCD), and by the Beck Depression Inventory questionnaire, respectively. Objective measure was cheek thickness evaluated by a 7.5-MHz frequency ultrasound probe perpendicular to the skin surface at the nasolabial fold, the corner of the mouth, the zygomatic arch, and centrally between these points in the buccal fat pad area. Both subjective and objective variables were evaluated at baseline and 48 weeks after end of surgical treatment. All 299 participants had significant improvement of the aesthetic satisfaction for the face (VAS from 2.9 +/- 2.1 to 6.2 +/- 2.1, p0.0001), of body image satisfaction (ABCD question 7 from 3.8 +/- 1 to 3.1 +/- 1 p0.0001 and ABCD question 8 from 70.7 +/- 16.7 to 77.2 +/- 17.2 p0.0001), of depression score (Beck score from 11.4 +/- 8.3 to 9.4 +/- 7.8 p = 0.001). Participants experienced a significant augmentation of both cheeks' thickness (right cheek from 4.3 +/- 1.9 mm to 9.5 +/- 3 mm p0.0001, left cheek from 4.4 +/- 2 mm to 9.6 +/- 3.1 mm, p0.0001). Our data suggest that facial surgery is an important option in the treatment of HIV-related lipoatrophy as an integral part of the management of HIV infection, because of the important and lasting psychological benefits.

Osseointegration is a direct union between bone and an allograft with no soft tissue interposition. It represents the morphological basis of secondary stability. Introduction of Resonance Frequency Analysis (RFA) as a commercially available technique has made it possible to measure implant stability as an Implant Stability Quotient (ISQ) unit at any time during the course of implant treatment and loading. The study aims to clinically and objectively analyze the stability of implants loaded upon revascularized free fibula flaps on patients who underwent maxilla or mandible reconstruction following trauma, oncological resection or class V–VI Cawood's atrophy treatment. Of the 105 patients that underwent jaw bone reconstruction with free fibula flaps in our division between 1993 and 2003, 37 were eligible for implant-supported dental rehabilitation. Of these, the last 12 were selected and included in the study. Primary and secondary implant stability assessments involved a clinical evaluation, radiograms and RFA measurements using the Osstell (Integration Diagnostics, Savedalen, Sweden) at the time of implant insertion, at 6 months and at 1 year of functional loading. 76 implants were loaded in 12 patients. All of them were clinically stable at each evaluation. Radiograms showed modest bone resorption after 1 year of functional load in 16 implants (21%). Implant stability levels ranged from 48 to 74 ISQ (mean 59.9±7.8 ISQ) at 6 months. At 1 year, the mean ISQ level was higher (62.6±7.2) but still coherent according to the radiographic evidence. Implant-supported dental rehabilitation of the reconstructed jawbone is not always possible. Free fibula flap represents a good substrate for implant osseointegration being a bicortical bone capable of structural remodelling after masticatory load enhancement. When possible, instrumental evaluation of implant stability with RFA and supported by radiograms represent the best objective way to assess osseointegration as a clinical evidence alone is unable to offer a definitive assessment.

The nutritive value of berseem clover (Trifolium alexandrinum L.) may be influenced by changes in the nutrient concentrations of morphological fractions as a consequence of cutting treatment. The aim of this study was to evaluate the effects of different cutting treatments on the nutritive value of herbage and leaf and stem components in two Mediterranean berseem genotypes during growth in order to develop management approaches for harvesting forage with a high nutritive value. Spring growth of genotypes of Egyptian (cv. Giza 10) and Italian (cv. Sacromonte) origins was harvested in each of 2 years beginning 196 days after sowing and thereafter every 6 days (twelve harvests in total) to measure dry matter (DM) yield and nutritive value. Cutting treatments were initiated at sixth internode elongation (A) and early flowering (B) and there was an uncut control treatment (C). In vitro digestibility of organic matter (IVOMD) and crude protein (CP) concentration were determined for leaf, stem and total forage of each cultivar at each harvest. For both cultivars, in the uncut treatment (C), DM yield increased linearly to a maximum of 14 800 kg ha−1, on average, by 250 days after planting, the same time at which stem DM accumulation peaked, whereas the nutritive value, in terms of IVOMD and CP concentration, declined with age, coinciding with a reduction in leaf:stem ratio (LSR) from 1·00 to 0·30. Plant parts differed (P

In the present work, we have studied the strain rate sensitivity of tensile properties of TZM and Mo–5%Re alloys. Tests were performed at room temperature and around the transition temperature of each alloy, at strain rates varying over five decades. Ductility appeared insensitive to strain rate, whereas the strength is found to be strain rate dependent. Both proof stress and ultimate tensile strength are affected by strain rate and the Mo–5%Re alloy is more sensitive than TZM. As expected, the hardening decreases with temperature; in TZM alloy the strain rate sensitivity was apparent only at room temperature.

Stapled hemorrhoidopexy is a widely used surgical technique for treating hemorrhoids, although severe complications have been reported. The authors report a rare case of extensive ascending intramural hematoma of the sigmoid colon complicating stapled hemorrhoidopexy, with perforation and hemoperitoneum. Diagnosis was established at CT scan and treatment consisted of drainage, suturing, and diverting colostomy. This reported case is the ninth described in the literature, but, so far, it is not known what preventive measures to use in order to avoid such a rare complication. Adoption of a correct surgical technique remains the step of utmost importance in order to prevent such a severe postoperative complication.

BACKGROUND: Risk-reducing mastectomy (RRM) decreases breast cancer (BC) risk in BRCA1/2 mutation carriers by up to 95%, but the Italian attitude towards this procedure is reluctant. PATIENTS AND METHODS: This is an observational study with retrospective design, using quantitative and qualitative research methods, aimed at evaluating the attitude towards RRM by rapid genetic counselling and testing (RGCT), at the time of BC diagnosis, compared with traditional genetic counselling and testing (TGCT), after previous BC surgery. Secondary aims were to investigate patient satisfaction after RRM and the rate of occult tumour in healthy breasts. A total of 1168 patients were evaluated: 1058 received TGCT, whereas 110 underwent RGCT. RESULTS: In TGCT, among 1058 patients, 209 (19.7%) mutation carriers were identified, with the rate of RRM being 4.7% (10 of 209). Conversely in RGCT, among 110 patients, 36 resulted positive, of which, 15 (41.7%) underwent bilateral mastectomy at the BC surgery time, showing an overall good satisfaction, measured by interpretative phenomenological analysis 12 months after the intervention. CONCLUSIONS: Our study shows that RGCT in patients with a hereditary profile is associated with a high rate of RRM at the BC surgery time, this being the pathway offered within a multidisciplinary organization. KEYWORDS: BRCA1/2 mutation carriers; acceptability; genetic counselling; risk-reducing mastectomy

Nine polycross (PX) and nine different self (S 1 ) progenies were randomly chosen from 43 selected tall fescue genotypes and evaluated for in vitro digestible organic matter (IVDOM), crude protein, neutral detergent fibre, acid detergent fibre and acid detergent lignin of whole plants, leaf blades and stems (stem plus leaf sheath) at each of four harvest dates in 1991 and 1992. Significant variation for all whole-plant and leaf quality traits occurred among the PX progenies at the May harvest. Variation among S 1 progenies was significant for almost all of the stem traits. Genetic variance components for both progeny groups were significant for almost all of the traits, confirming the presence of additive genetic variation. Heritability estimates on a progeny-mean basis ranged from medium to high for almost all the traits of the whole-plant and the leaf and stem fractions. The results suggest that spring would be the time at which direct selection for high IVDOM or low fibre content would be successful and that selection for leaf or stem quality traits improves whole-plant quality. Selection for quality traits in the summer or in the autumn would be difficult since no significant genetic variability was found.

Seven laboratory experimental casts of 7–9% Cr Ti-bearing martensitic steels were obtained via VIM process. Plates of 25 mm thickness were produced by hot rolling. On each cast CCT diagrams and critical temperatures were determined. Several austenitizing treatments were performed to study the grain size evolution. The effect of microstructure on impact properties were finally investigated. This paper discusses the role of chemical composition on microstructural and physical properties and shows the beneficial effect either of low-temperature austenitizing or double-austenitizing steps on impact properties.

Carotid artery stenting (CAS) is relatively new procedure introduced to treat severe carotid atherosclerotic disease for high risk patient categories. The advantages of this technique are its minimal invasiveness, easiness of the procedure and the short hospitalization compared to surgical option. However, perioperative complications, such as stroke, can lead to failure of the procedure and long terms effects of the procedure are not completely understood. It is not unrealistic to assume that the mechanical changes of the pathophysiological environment at the stented vessel can induce tissue damage and promote remodeling and restenosis but how these factor (inter)act is still a matter of debate.

Riassunto Obiettivi Scopo del presente lavoro e valutare criticamente i risultati ottenuti dai diversi autori negli studi pubblicati a proposito della coronectomia dei terzi molari mandibolari (3M). Materiali e metodi Si analizzano gli studi che mettono a confronto la procedura di coronectomia con l’estrazione del 3M a rischio di danno neurologico. Risultati Gli autori elaborano modifiche alla tecnica di Pogrel allo scopo di ridurre i fallimenti della procedura chirurgica di coronectomia dei 3M e migliorare i risultati a lungo termine delle coronectomie stesse. Conclusioni La coronectomia si presenta come una procedura chirurgica a minor rischio di danno neurologico nei casi di estrazione dei 3M in cui l’esame TAC riveli un rapporto di stretta contiguita con il nervo mandibolare. Appare una scelta obbligata in caso di radici anchilosate

The authors report a case of hormonally silent duodenal somatostatinoma. The main clinical features, the natural history and the currently available therapies of these rare neoplasms are described on the basis of this case and of the scientific literature. Although the antiblastic therapies are still debated, the patient showed a surprising outcome following chemotherapy.

Stent grafts are endovascular devices, used for minimally invasive treatment of abdominal aortic aneurysms. Although the outcome of the procedure is often successful, it is still associated with some longer term problems — especially for complex cases with geometrically challenging aneurysm geometries. An increasing number of devices, with widely varying design features, have entered the market, creating a need to investigate and compare the available treatment options.Copyright © 2012 by ASME

Cerebral aneurysms are weakened, balloon like dilations of the intracranial vessels. Rupture of these swelled vessels, with a prevalence of 1 to 5% not uncommon [1], is associated with a high mortality and morbidity [2]. Clipping (by craniotomy) or coiling (passing platinum wires into the aneurysm) is often performed to reduce the risk of rupture. Coiling of wide necked or fusiform aneurysms, which is not easily achieved without risk of coil displacement, is often assisted by placement of intracranial stents, serving as a scaffold for the platinum coils. Cerebral stents can be of either closed or open cell design. Both designs have shown to be successful at assisting coiling, yet each design has its own strengths and weaknesses [3].Copyright © 2012 by ASME

The presented study details the virtual deployment of a bifurcated stent graft (Medtronic Talent) in an Abdominal Aortic Aneurysm model, using the finite element method. The entire deployment procedure is modeled, with the stent graft being crimped and bent according to the vessel geometry, and subsequently released. The finite element results are validated in vitro with placement of the device in a silicone mock aneurysm, using high resolution CT scans to evaluate the result. The presented work confirms the capability of finite element computer simulations to predict the deformed configuration after endovascular aneurysm repair (EVAR). These simulations can be used to quantify mechanical parameters, such as neck dilations, radial forces and stresses in the device, that are difficult or impossible to obtain from medical imaging.

We used a multiphysics model to assess the accuracy of carotid strain estimates derived from a 1-D ultrasonic wall tracking algorithm. The presented tool integrates fluid-structure interaction (FSI) simulations with an ultrasound simulator (Field II), which allows comparison of the ultrasound (US) images with a ground truth. Field II represents tissue as random points on which US waves reflect and whose position can be updated based on the flow field and vessel wall deformation from FSI. We simulated the RF-signal of a patient-specific carotid bifurcation, including the blood pool as well as the vessel wall and surrounding tissue. Distension estimates were obtained from a wall tracking algorithm using tracking points at various depths within the wall, and further processed to assess radial and circumferential strain. The simulated data demonstrated that circumferential strain can be estimated with reasonable accuracy (especially for the common carotid artery and at the lumen-intima and media-adventitia interface), but the technique does not allow to reliably assess intra-arterial radial strain. These findings were supported by in vivo data of 10 healthy adults, showing similar circumferential and radial strain profiles throughout the arterial wall. We concluded that these deviations are present due to the complex 3-D vessel wall deformation, the presence of specular reflections and, to a lesser extent, the spatially varying beam profile, with the error depending on the phase in the cardiac cycle and the scanning location.

Some aspects of the mechanical behaviour of two molybdenum alloys, one belonging to the precipitation hardened sub-family (TZM) and the other is a solid solution Mo 5% rhenium-bearing alloy, have been investigated. Experimental data (tensile mechanical strength, ductility and impact properties of unirradiated materials) show that a difference in behaviour exists between the precipitation hardened and the solid solution strengthened alloy, but at the same time a serious discrepancy has been found between the present results and previously reported ductile to brittle transition temperature values for Mo alloys.

OBJECTIVE To assess the quality of antibiotic prescribing by Victorian general practitioners, and the effectiveness of educational intervention techniques in improving prescribing. DESIGN A randomised, controlled, parallel group trial. SETTING AND PARTICIPANTS In rural and metropolitan Victoria, 182 general practitioners (78 control, 104 intervention) began and 103 (41 control, 62 intervention) completed the study. INTERVENTION Participants recorded their antibiotic prescribing for tonsillitis. The intervention group received an educational mailing campaign. A project pharmacist visited each doctor to discuss campaign messages. MAIN OUTCOME MEASURE The percentages of prescriptions of antibiotics for tonsillitis complying with those recommended in Antibiotic guidelines. RESULTS In the intervention group, prescriptions consistent with recommendations in the guidelines increased from 60.5% before the campaign to 87.7% afterwards. Improvement also occurred in the control group, from 52.9% to 71.7% of prescriptions. The improvement within the intervention group was significantly greater than that within the control group. CONCLUSIONS The educational campaign significantly improved the prescribing of appropriate antibiotics for tonsillitis by general practitioners.

An Abdominal Aortic Aneurysm (AAA) is a pathological dilatation of the aorta, commonly involving the region between the renal arteries and the aortic bifurcation, with a high degree of mortality. Endovascular repair of AAA has proven to be a valid alternative for the conventional open repair, with clear benefits in terms of length of hospital stay, reduced operational mortality and less trauma [1]. However, stent grafts are still associated with various problems and failings, which may lead to AAA rupture or rise the need for an additional open surgery.Copyright © 2011 by ASME

The purpose of this study is to investigate how the imposition of personalized, non-invasively measured blood flow rates as boundary conditions (BCs) influences image-based computational hemodynamic studies in the human aorta. We extracted from 4D phase-contrast MRI acquisitions of a healthy human (1) the geometry of the thoracic aorta with supra-aortic arteries and (2) flow rate waveforms at all boundaries. Flow simulations were carried out, and the implications that the imposition of different BC schemes based on the measured flow rates have on wall shear stress (WSS)-based indicators of abnormal flow were analyzed. Our results show that both the flow rate repartition among the multiple outlets of the aorta and the distribution and magnitude of the WSS-based indicators are strongly influenced by the adopted BC strategy. Keeping as reference hemodynamic model the one where the applied BC scheme allowed to obtain a satisfactory agreement between the computed and the measured flow rate waveforms, differences in WSS-based indicators up to 49% were observed when the other BC strategies were applied. In conclusion, we demonstrate that in subject-specific computational hemodynamics models of the human aorta the imposition of BC settings based on non-invasively measured flow rate waveforms influences indicators of abnormal flow to a large extent. Hence, a BCs set-up assuring realistic, subject-specific instantaneous flow rate distribution must be applied when BCs such as flow rates are prescribed.

Measuring the blood flow is still limited by current imaging technologies and is generally overcome using computational fluid dynamics (CFD) which, because of the complex geometry of blood vessels, has widely relied on tetrahedral meshes. Hexahedral meshes offer more accurate results with lower-density meshes and faster computation as compared to tetrahedral meshes, but their use is limited by the far more complex mesh generation. We present a robust methodology for conformal and structured hexahedral mesh generation - applicable to complex arterial geometries as bifurcating vessels - starting from triangulated surfaces. Cutting planes are used to slice the lumen surface and to construct longitudinal Bezier splines. Afterwards, an isoparametric transformation is used to map a parametrically defined quadrilateral surface mesh into the vessel volume, resulting in stacks of sections which can then be used for sweeping. Being robust and open source based, this methodology may improve the current standard in patient-specific mesh generation and enhance the reliability of CFD to patient-specific haemodynamics.