Physiotherapy after ultrasound-guided percutaneous irrigation in rotator cuff calcific tendinopathy.

BACKGROUND: Rotator cuff calcific tendinopathy (RCCT) is a very frequent and debilitating disease often treated with Ultrasound-guided percutaneous irrigation (UGPI) followed by physiotherapy. OBJECTIVE: A multicenter observational clinical study was designed to assess the effects of physiotherapy after UGPI on the functional recovery of the shoulders of patients suffering from RCCT. METHOD: One hundred sixty-six patients (mean age 50.7± 7.6 years), 121 women, with painful RCCT were treated with UGPI and assessed at the day of UGPI (T0), and at one (T1), 3 (T2) and 6 (T3) months after treatment by the Constant- Murley Score (CMS), Oxford Shoulder Scale (OSS) and Numerical Rating Scale (NRS). Patients were divided into 2 groups, Physiotherapy (PT+) and not Physiotherapy (PT-) according to the performance of the rehabilitation program based on personal decision. RESULTS: A significant improvement at T1 in all outcomes in both groups and between T1 and T3 for NRS during movement and OSS was found, but not for NRS at rest and CMS. There was no difference between groups for all outcome measures. In 27,1% of patients symptoms recurred in an average of 13 ± 8 weeks. CONCLUSIONS: Results suggest that post-UGPI not-standardized physiotherapy might not provide additional clinical benefits in short and medium term. Further studies could assess the effectiveness of physiotherapy performed after three months in patients with recurrence of pain.

End of life care for patients with meningioma.

Palliative care (PC) supports patient with serious illnesses and can help patients with meningioma through the phases of their clinical trajectory, from initial diagnosis through the last hours of life. The PC team implements a multimodal transdisciplinary approach to address physical, psychosocial, and spiritual suffering with patients and their families, while also fostering constructive communication with the many health care providers involved. To achieve these goals the PC core team is comprised of physicians, nurse practitioners, physician assistants, nurses, social workers, and spiritual care providers who are trained to take care of patients with serious illnesses and to provide support to their families. The PC intervention can be instituted concurrently with all other treatments including those with a curative intent, and symptom management can be implemented while at the same time addressing reversible causes of distress. PC is practiced in acute care centers and long-term care facilities, usually by a consulting team, but other settings include outpatient clinics and home. When patients experience recurrence of their tumor and their life expectancy is shortened to 6 months or less, a hospice can provide the same transdisciplinary support by focusing on quality of life and symptom management for the patient while assisting the family through the clinical course and providing professional bereavement services after the patient's death.

Proactive Identification of Palliative Care Needs Among Patients With COVID-19 in the ICU.

In the setting of the coronavirus disease 2019 (COVID-19) pandemic, new strategies are needed to address the unique and significant palliative care (PC) needs of patients with COVID-19 and their families, particularly when health systems are stressed by patient surges. Many PC teams rely on referral-based consultation methods that can result in needs going unidentified and/or unmet. Here, we describe a novel system to proactively identify and meet the PC needs of all patients with COVID-19 being cared for in our hospital's intensive care units. Patients were screened through a combination of chart review and brief provider interview, and PC consultations were provided via telemedicine for those with unmet needs identified. In the first six weeks of operation, our pilot program of proactive screening and outreach resulted in PC consultation for 12 of the 29 (41%) adult patients admitted to the intensive care unit with COVID-19 at our institution. Consultations were most commonly for patient and family support as well as for goals of care and advance care planning, consistent with identified PC needs within this unique patient population.

COVID-19 Lessons: The Alignment of Palliative Medicine and Trauma-Informed Care.

As the COVID-19 pandemic wears on, its psychological, emotional, and existential toll continues to grow and indeed may now rival the physical suffering caused by the illness. Patients, caregivers, and health-care workers are particularly at risk for trauma responses and would be well served by trauma-informed care practices to minimize both immediate and long-term psychological distress. Given the significant overlap between the core tenets of trauma-informed care and accepted guidelines for the provision of quality palliative care (PC), PC teams are particularly well poised to both incorporate such practices into routine care and to argue for their integration across health systems. We outline this intersection to highlight the uniquely powerful role PC teams can play to reduce the long-term psychological impact of the COVID-19 pandemic.

Rapid Implementation of Inpatient Telepalliative Medicine Consultations During COVID-19 Pandemic.

As coronavirus disease 2019 cases increase throughout the country and health care systems grapple with the need to decrease provider exposure and minimize personal protective equipment use while maintaining high-quality patient care, our specialty is called on to consider new methods of delivering inpatient palliative care (PC). Telepalliative medicine has been used to great effect in outpatient and home-based PC but has had fewer applications in the inpatient setting. As we plan for decreased provider availability because of quarantine and redeployment and seek to reach increasingly isolated hospitalized patients in the face of coronavirus disease 2019, the need for telepalliative medicine in the inpatient setting is now clear. We describe our rapid and ongoing implementation of telepalliative medicine consultation for our inpatient PC teams and discuss lessons learned and recommendations for programs considering similar care models.

Orbital Fractures in Childhood.

Pediatric orbital floor fractures exhibit distinctive features that distinguish them from orbital injuries seen in the adult population. This is mainly due to different anatomy and mechanical properties of the orbital bones in children. The management of pediatric orbital floor fractures requires consideration of these factors, including the age of the patient and therefore child's growth potential, using, if possible, a minimally invasive surgical approach. The aim of this paper is to report a case of a 1-year-old male child with a surgically treated blowout fracture of the orbital floor. To enable early diagnosis and treatment, accurate physical examination is mandatory, but a computed tomographic examination is important, especially in younger patients because of their inability to fully express their symptoms and poor compliance. We discuss the specific presentation and diagnostics of orbital floor fractures in early childhood and the related surgical planning and treatment.

Craniomaxillofacial Fibrous Dysplasia: Conservative Treatment and Maxillary Osteotomy Using the Schuchardt-Kufner Technique.

Fibrous dysplasia (FD) is a disturbance of the mesenchymal tissue that accounts for 2.5% of all bone tumors and more than 7% of nonmalignant bone tumors. In the craniomaxillofacial region, FD affects the calvaria, skull base, zygoma, and jaws, the prevalent site being the maxilla (50% of cases). Therapy for craniomaxillofacial FD is surgical. The goals of surgery are to prevent functional disorders and restore facial symmetry, volume, and contour. In this article, we present a case of a young female patient affected by right orbital-zygomatic-maxillary FD. She had developed facial asymmetry and malocclusion that were corrected using the Schuchardt-Kufner osteotomy technique.

The iliac crest in forensic age estimation: evaluation of three methods in pelvis X-rays.

Age assessment in children and young adults is a relevant forensic issue. It is requested not only in evaluating criminal responsibility in youths without proper identification documents, often in relation to age thresholds, but also for release of a residency permit, and asylum seekers of minors. The analysis of the Risser sign and the iliac crest ossification process has been proposed as a useful tool for forensic age estimation. We evaluated the applicability of three different age estimation methods on a sample of 497 pelvic radiographs of Italian individuals between 10 and 25 years of age. Each method showed high reliability for both reproducibility and repeatability. The staging technique inspired by Kreitner and Kellinghaus methods (KK-MS) is easier than the Risser method in applicability, as it is not affected by the variations of ossification. We observed that all subjects who attained stage 3c of KK-MS and 5 of Risser Fr were >14 years, suggesting the benefits of these methods for that age threshold. The applicability of the area measurement method, inspired by Cameriere's approach, ranged between 12 and 20 years, but the statistical analysis showed only a moderate correlation with age. In order to evaluate the possible use of this approach it is therefore necessary to clarify and exclude external factors influencing the parameter. In conclusion, the iliac crest ossification is of interest in age estimation for forensic purposes. The evaluation of the pelvis X-ray, in addition to the other common dental and skeletal methods, could become a useful supplementary tool in age estimation for the 14 year threshold in order to fulfill forensic-level requirements.

Palliative Care in Heart Failure: What Triggers Specialist Consultation?

Heart failure (HF) continues to cause substantial death and suffering despite the availability of numerous medical, surgical, and technological therapeutic advancements. As a patient-centered holistic discipline focused on improving quality of life and decreasing anguish, palliative care (PC) has a crucial role in the care of HF patients that has been acknowledged by multiple international guidelines. PC can be provided by all members of the HF care team, including but not limited to practitioners with specialty PC training. Unfortunately, despite recommendations to routinely include PC techniques and providers in the care of HF patients, use of general PC strategies as well as expert PC consultation is limited by a dearth of evidence-based interventions in the HF population and knowledge as to when to initiate these interventions, uncertainty regarding patient desires, prognosis, and the respective roles of each member of the care team, and a general shortage of specialist PC providers. This review seeks to provide guidance as to when to employ the limited resource of specialist PC practitioners, in combination with services from other members of the care team, to best tend to HF patients as their disease progresses and eventually overcomes.

Temporomandibular Joint Ankylosis After Early Mandibular Distraction Osteogenesis: A New Syndrome?

Distraction osteogenesis (DO) has been one of the most innovative concepts in cranio-maxillofacial syndromology and surgery over the last 25 years.Early mandibular distraction in severe micrognathia has recently been recognized as an effective treatment option to safely relieve upper airway obstruction associated with mandibular deficiency.An increased incidence in temporomandibular joint complications during DO in neonates has recently been reported, especially in syndromic patients.The authors report 2 children affected by severe micrognathia and severe respiratory distress at birth.Early DO was performed during the first 2 months of the life in another institution with the aim of increasing mandibular length and upper airway size.Both the patients had severe restricted jaw opening after DO and mandibular abnormalities.Temporomandibular joint ankylosis after early mandibular distraction could be a considered a new pathological entity.

The Buccal Fat Pad for Closure of Oroantral Communication.

The buccal fat pad (BFP) is a well-established tool in oral and maxillofacial surgery and its use has proved of value for the closure of oroantral communications. Oroantral communication may be a common complication after sequestrectomy in "bisphosphonate-related osteonecrosis of the jaws."The authors report a clinical case of a 70-year-old female patient in bisphosphonate therapy presented with right maxillary sinusitis and oroantral communication after implants insertion.The BFP was used to close the defect. The patient had an uneventful postoperative healing without dehiscence, infection, and necrosis.The authors postulate that the primary closure of the site with BFP may ensure a sufficient blood supply and adequate protection for an effective bone-healing response to occur.

Multiple mandibular fractures. Treatment outlines.

Multiple mandibular comminuted fractures usually occur in high energy traumas. The authors describe the management and treatment of multiple mandibular fractures in a young patient after a suicide attempt.

Piezosurgery: A new and safe technique for distraction osteogenesis in Pierre Robin sequence review of the literature and case report.

INTRODUCTION: Pierre Robin sequence (PRS) is characterized by microgenia and retrognathia. Cleft palate and glossoptosis are frequently associated with airway obstruction and difficulty in swallowing. Distraction osteogenesis with micro-distractors has recently been considered as a surgical option during the neonatal age. CASE PRESENTATION: A 6-week-old female with PRS underwent mandibular lengthening in neonatal age. Mandibular osteotomies were performed with the piezoelectric scalpel. DISCUSSION: Piezosurgery represents an innovative technique as it offers the maxillofacial surgeon the opportunity to make precise bone cuts without damaging the soft tissue, minimizing the invasiveness of the surgical procedure, and the opportunity of working in a field which is almost totally blood free. CONCLUSION: The use of a piezoelectric device to perform this kind of surgery provides clinical and surgical results which would be difficult with traditional instruments, not only for the patient's benefit but also for the surgeon's. Preservation of the original bony structure, especially of the cancellous bone, will benefit the bone healing process due to its high estrogenic potential.

Selective augmentation of stem cell populations in structural fat grafts for maxillofacial surgery.

Structural fat grafting utilizes the centrifugation of liposuction aspirates to create a graded density of adipose tissue. This study was performed to qualitatively investigate the effects of centrifugation on stem cells present in adipose tissue. Liposuction aspirates were obtained from healthy donors and either not centrifuged or centrifuged at 1,800 rpm for 3 minutes. The obtained fat volumes were divided into three layers and then analyzed. The results demonstrate that centrifugation induces a different distribution of stem cells in the three layers. The high-density layer displays the highest expression of mesenchymal stem cell and endothelial markers. The low-density layer exhibits an enrichment of multipotent stem cells. We conclude that appropriate centrifugation concentrates stem cells. This finding may influence the clinical practice of liposuction aspirate centrifugation and enhance graft uptake.

Three-dimensional volumetric restoration by structural fat grafting.

The use of adipose tissue transfer for correction of maxillofacial defects was reported for the first time at the end of the 19th century. Structural fat grafting (SFG) was introduced as a way to improve facial esthetics and in recent years has evolved into applications in craniomaxillofacial reconstructive surgery. Several techniques have been proposed for harvesting and grafting the fat. However, owing to the damage of many adipocytes during these maneuvers, the results have not been satisfactory and have required several fat injection procedures for small corrections. The author's (L.C.) overview the application of SFG in the management of volumetric deficit in the craniomaxillofacial in patients treated with a long-term follow-up.

Management of temporomandibular joint reankylosis in syndromic patients corrected with joint prostheses: surgical and rehabilitation protocols.

Temporomandibular joint ankylosis (TMJA) is a severe disorder described as an intracapsular union of the disc-condyle complex to the temporal articular surface with bony fusion. The management of this disability is challenging and rarely based on surgical and rehabilitation protocols. We describe the treatment in two young adults affected by Goldenhar syndrome and Pierre Robin sequence with reankylosis after previous surgical treatments. There are three main surgical procedures for the treatment of TMJA: gap arthroplasty, interpositional arthroplasty, and joint reconstruction. Various authors have described reankylosis as a frequent event after treatment. Treatment failure could be associated with surgical errors and/or inadequate intensive postoperative physiotherapy. Surgical treatment should be individually tailored and adequate postoperative physiotherapy protocol is mandatory for success.

Cranial bone grafts in forehead reconstruction after resection for benign tumors.

Cranial bone graft was first used in forehead reconstruction by Muller and König as early as 1890. Because cranial bone graft is the ideal material for almost all facial and skull repairs, surgeons have subsequently used this technique to repair skull defects. In fact, membranous bone (calvaria) is superior to endochondral bone (ilium, rib) and maintains its volume to a significantly greater extent than endochondral bone.The authors, after reviewing the literature, report 3 cases of forehead benign tumors treated by resection and primary reconstruction using cranial bone grafts. The preoperative computed tomographic scanning should lead to appropriate diagnosis and treatment planning, which includes total excision and primary bone grafting of the defect to prevent soft-tissue contraction.

Symptom control in stem cell transplantation: a multidisciplinary palliative care team approach. Part 2: psychosocial concerns.

Stem cell transplantation (SCT) offers a potential cure for patients with otherwise incurable benign and malignant disorders. However, the treatment will cause considerable physical, social, psychological, and spiritual suffering. In part 1 of this review, the management of the physical symptoms was reviewed. In part 2, we discuss the approaches to managing the other aspects of distress that are primarily psychological, social, and spiritual in nature. In practice, these dimensions are not so easily distinguished; the division between physical and psychological symptoms is blurred, and physical symptoms are often interrelated with the patient's emotional status and social support.

Symptom control in stem cell transplantation: a multidisciplinary palliative care team approach. Part 1: Physical symptoms.

Stem cell transplantation (SCT) offers a potential cure for patients with otherwise incurable benign and malignant disorders, but the arduous SCT process may cause considerable physical, social, psychological, and spiritual suffering. Relief of suffering associated with SCT begins by understanding the patient experience and the SCT culture. Symptom burden is the combined impact of all disease- or therapy-related symptoms on the patient's ability to function. In approaching symptom management, the division between physical and psychological symptoms is blurred; physical symptoms are often interrelated with the patient's emotional status and social support. Physical symptoms that frequently occur in SCT include pain, nausea, mucositis, diarrhea, and delirium. At the same time, SCT is recognized as one of the most stressful treatments in modern cancer care, resulting in psychological distress, social isolation, and role changes. Psychological symptoms include depression/ anxiety, grief/loss, demoralization, and anger. Based on our experience on an academic SCT ward for adults, we review physical, psychological, social, and spiritual symptoms during the course of SCT in a two-part series and offer an approach to their management. This month, in part I, we focus on physical symptoms linked to SCT. In a future issue, part II will highlight psychosocial concerns in SCT.

Contrast-enhanced ultrasound: a filter role in AJCC stage I/II melanoma patients.

One of the most significant advances in melanoma staging is sentinel lymph node biopsy (SLNB). It is a surgical technique to detect occult nonpalpable micrometastases in regional lymph nodes. Recently, contrast-enhanced ultrasound (CEUS) was introduced as a noninvasive procedure, in spite of SLNB, for the detection of SLNs in patients with cutaneous melanoma. The main purpose of this study was to evaluate the diagnostic accuracy of CEUS in the diagnostic workup of patients with melanoma in comparison with the final histology of SLNs detected through preoperative lymphoscintigraphy. Fifteen patients with cutaneous melanoma underwent prompt excisional biopsy with narrow margins in order to avoid impairment of the melanoma lymphatic basin and were referred for SLNB according to routine indications between January and February 2009. In our study CEUS showed, albeit based on a small patient sample, a negative predictive value of 100%, that means that all negative results were confirmed by negative SLN histopathological examination; all ultrasonographically negative lymph nodes corresponded to nonmetastatic sentinel nodes.