The combination of hyaluronic acid and collagenase in the treatment of skin ulcers: an open, multicenter clinical study assessing safety and tolerability of Bionect Start®.

OBJECTIVE: Several clinical studies have shown that hyaluronic acid collagenase is well-tolerated and very effective in managing chronic venous ulcers. The aim of the present study is to confirm the safety and tolerability of daily application in patients suffering from cutaneous ulcers of different etiologies. The efficacy of the treatment and its impact on patients' quality of life are also assessed. PATIENTS AND METHODS: Patients with a clinical diagnosis of skin ulcer with devitalized/fibrinous/slough tissue that could delay the healing process were enrolled in the study. The hyaluronic acid/collagenase ointment was applied topically until wound closure or total debridement of non-viable tissue was achieved, however, with a limit of 30 days. Monitoring was performed weekly, either through outpatient visits or telephone surveys. Assessments included adverse events, local irritation reactions, pain at dressing changes, and wound bed status. Patients were also requested to complete a quality-of-life questionnaire. RESULTS: The study involved 96 patients with a mean age of 71 years. The patients suffered mainly from traumatic (21.9%), venous (15.6%), or pressure ulcers (12.5%); in 26% of cases, ulcers had mixed etiology. In approximately 32% of patients, the ulcer had been present for more than 6 months, and 18.1% of subjects had previously undergone surgical wound debridement. CONCLUSIONS: Daily application of hyaluronic acid-collagenase achieved the following results: i) absence of adverse events related to the use of the product; ii) significant reduction in the degree of localized irritation and pain at dressing changes; iii) significant support to wound bed preparation; iv) trend towards improvement in the quality of life and health status of the patients.

Anxiety does not always affect balance: the predominating role of cognitive engagement in a video gaming task.

Scientists have predominantly assessed anxiety's impact on postural control when anxiety is created by the need to maintain balance (e.g., standing at heights). In the present study, we investigate how postural control and its mechanisms (i.e., vestibular function) are impacted when anxiety is induced by an unrelated task (playing a video game). Additionally, we compare watching and playing a game to dissociate postural adaptations caused by increased engagement rather than anxiety. Participants [N = 25, female = 8, M (SD) age = 23.5 (3.9)] held a controller in four standing conditions of varying surface compliance (firm or foam) and with or without peripheral visual occlusion across four blocks: quiet standing (baseline), watching the game with a visual task (watching), playing the game (low anxiety), and playing under anxiety (high anxiety). We measured sway area, sway frequency, root mean square (RMS) sway, anxiety, and mental effort. Limited sway differences emerged between anxiety blocks (only sway area on firm surface). The watching block elicited more sway than baseline (greater sway area and RMS sway; lower sway frequency), and the low anxiety block elicited more sway than the watching block (greater sway area and RMS sway; higher sway frequency). Mental effort was associated with increased sway area and RMS sway. Our findings indicate that anxiety, when generated through competition, has minimal impact on postural control. Postural control primarily adapts according to mental effort and more cognitively engaging task constraints (i.e., playing versus watching). We speculate increased sway reflects the prioritization of attention to game performance over postural control.

Local dynamic stability during long-fatiguing walks in people with multiple sclerosis.

BACKGROUND: Altered balance/stability during walking is common in people with multiple sclerosis (PwMS). While dynamic gait stability has been related to falling and localized muscle fatigue, it has rarely been studied in MS. Specifically, the effects of walking-related fatigue on dynamic stability are unclear in PwMS. RESEARCH QUESTIONS: 1) Are temporal changes in dynamic stability during long-walks different among PwMS and healthy controls (HC)? 2) Is there a relationship between stability and walking performance changes in PwMS? METHODS: Twenty-five PwMS and ten HC participated in the six-minute walk test (6MWT) wearing six-wireless inertial sensors. Local dynamic stability (LDS) during gait was quantified by maximum-finite-time Lyapunov exponents (λS), where larger λS indicates less stable dynamics. Linear mixed models were fit to compare changes in LDS and walking performance over time among two groups. Additionally, the percent changes in λS and distance from minute 1 to 6 were recorded as Dynamic Stability Index (DSI6-1) and Distance-Walked Index (DWI6-1) respectively. Finally, Pearson correlation compared the association between DSI6-1 and DWI6-1. RESULTS: A significant group*time interaction was found for LDS. PwMS did not have different LDS than HC until minute-4 of walking, and differences persisted at minute-6. Further, PwMS walked significantly shorter distances and demonstrated a greater decline in walking performance (DWI6-1) during the 6MWT. Finally, DSI6-1 and DWI6-1 were significantly correlated in PwMS. Significance The dynamic stability differences among PwMS and HC were only apparent after 3-minutes of walking and ∼60% of PwMS became less stable over time, supporting the use of long walks in MS to capture stability changes during the motor task performance. A significant relationship between the decline in stability and poor walking performance over time during the 6MWT suggested a possible role of walking-related fatigue in the worsening of balance during long walks in PwMS.

The use of dermal regeneration template (Pelnac®) in a complex upper limb trauma: the first Italian case report.

Dermal regeneration template (DRT) has been well widely implicated in the reconstruction of full-thickness injury. We present our experience and our clinical application of Pelnac® to achieve wound closure with complex acute, upper limb, full-thickness defect post-trauma. A 22-year-old boy presented a soft tissues loss of the back of the hand and forearm with tendon's involvement and exposure. The wound was treated with Pelnac®; the silicone layer was removed at postoperative day 30 and dermal regeneration template was reapplied at the level of the residual tendon exposure; a split-thickness skin graft (0.2 to 0.3 mm) was inserted. Clinically, the reconstructed areas demonstrated good granulation tissue at 14 days with a good take of the skin graft. There were no major acute graft loss, rejection or associated infections cells through downregulating TLR4 expression.

Depression risk among patients with chronic wounds.

OBJECTIVE: A wound is defined as chronic when it requires more than 6 weeks to heal. The link between chronic wounds and depression was first pointed out by House and Hughes in 1996 and later evaluated by other numerous studies. Several studies demonstrate that among chronic skin wounds causing chronical physical disease, the leg ulcers are the most frequently associated with depression. The aim of our study is to evaluate the prevalence of depression in patients with different types of chronic wounds. PATIENTS AND METHODS: We enrolled a total of 33 patients with chronic wounds and 33 healthy controls matched by sex and age. Both patients and controls underwent a BDI II survey. We evaluated 33 patients, with a mean age of 71 years (range 25-87), and 33 controls, with a mean age of 73 years (range 31-88). RESULTS: The average score at the BDI II questionnaire was 14.5 and 8, respectively. CONCLUSIONS: The depression among patients with chronic wounds has a multifactorial origin that should be treated with a multidisciplinary approach. Since the improvement of the psycho-emotional state means better compliance of the patient, we can also expect a better result in terms of efficacy in chronic wound treatment.

Inflection points in longitudinal models: Tracking recovery and return to play following concussion.

The return to play (RTP) process may occur during longitudinal studies tracking recovery after concussion. This factor, which is often omitted within statistical designs, could affect the fit and overall interpretation of the statistical model. This article demonstrates the difference in results and interpretation between 2 linear mixed-model designs: (1) a between-group longitudinal (GROUP) analysis and (2) a between-group longitudinal model that used an inflection point to account for changes around the time of RTP (RTP analysis). These analyses were conducted on instrumented balance data collected on 23 concussed athletes and 25 controls over 8 weeks following concussion. Total sway area and the range of mediolateral acceleration were used as outcome measures. No significant findings were found in the GROUP design for either outcome measure. In contrast, the RTP analysis revealed significant effects of time (P = .007) and RTP change (P = .007), and group*time (P = .028) and group*RTP change (P = .022) interactions for total sway area, and effects of group (P = .011), time (P = .010), and RTP change (P = .014), and group*time (P = .013) and group*RTP change interactions (P = .013) for range of mediolateral acceleration. For both outcomes, the RTP model fit the data significantly better on comparison of likelihood ratios (P ≤ .027). These results suggest that allowing for an inflection point in the statistical design may assist understanding of what happens around clinically meaningful time points. The choice of statistical model had a considerable effect on the interpretation of findings, and provokes discussion around the best method for analyzing longitudinal datasets when important clinical time points like RTP exist.

Axillary ectopic lobular carcinoma of breast: two rare case reports.

OBJECTIVE: The presence of ectopic or supernumerary breast tissue is a rare event, related to a not complete regression of breast tissue along the milk line. Primary ectopic breast cancer of the axilla can create many difficulties in differential diagnosis with subsequent delayed specific treatments. The incidence of ectopic breast tissue is 0.2-6%, and the axilla is the most common site involved. In this tissue, the same physiologic and pathologic changes as seen in ectopic breast tissue may occur, including carcinoma formation. PATIENTS AND METHODS: Two patients (a 56 years old and 70 years old women) came to our attention for the recent development painless nodular axillary lesions, clinically characterized by an increased thickness, irregular margins and adherence to the floors below. RESULTS: Patients underwent ultrasonography (US) and mammography (MMG) revealing non-specific features of the lesions. Magnetic resonance imaging (MRI), demonstrated margins slightly irregular and a non-specific appearance of each lesion. Both patients underwent wide local excision with axillary lymph node dissection. Histological examination showed infiltrating lobular carcinomas of the breasts. CONCLUSIONS: We describe two unusual cases of ectopic axillary breast carcinoma localization. It is important a correct and fast diagnosis with a local examination, diagnostic instruments, surgical excision and histological examination.

New lift: the art of facial rejuvenation with minimal incisions rhytidectomy.

OBJECTIVE: The new lift is a procedure for facial rejuvenation with minimal incision, giving the patient a significant improvement of mid face and neck, with limited dissection and minimal scars. A further "One-stitch" of anchorage to the deep temporal fascia is required to hold tissues. By a minimal surgical access, we get a suitable cheek lift with the improvement of nose-labial folds, mandibular edge and neck contour. PATIENTS AND METHODS: Between February 2009 and June 2012, 32 patients underwent facial rejuvenation surgery called new lift at a mean age of 46 years (range 35-55 years). Seven of the patients had a previous facelift. 12 out of 32 patients (37.5%) had concomitant eyelid surgery and 4 (12.5%) neck contouring procedure. RESULTS: The technique we used is a safe and effective procedure with a high satisfaction rate; 28 patients (89%) were very satisfied with their result at 24-months follow-up. CONCLUSIONS: The surgical outcome was evaluated according to the analysis of photographs obtained before and after surgery and the analysis of pre- and postoperative measurements. Aesthetic results were evaluated also by patients themselves who indicated a high satisfaction rate at three months post-surgery questionary and by a surgeon not involved in the study using VAS (1-10) before and three months after surgery. Acquired data on the aesthetic result were statistically evaluated using Student t-test. This is a study aimed at assessing the effectiveness of the new-lift technique for facial rejuvenation. Based on the results of our study, the new-lift is a very effective surgery for rejuvenation of the face with mild to moderate aging. All patients healed uneventfully without any major postoperative problems. This technique responds to an increasing demand from a wide range of patients for less invasive, less expensive operations with faster healing time and fewer potential complications.

Surgical therapy of breast hypertrophy: a comparison of complications and satisfaction rate in large and small superior pedicle custom-made reduction mammaplasty.

OBJECTIVE: The reduction mammaplasty is indicated for patients with symptomatic breast hypertrophy. Although surgery is considered the gold standard treatment, it is still debated which is the complication rate and whether or not there is an increased complication rate with increased tissue resection per breast. The main objective of this retrospective study was to determine whether the rates of complications are higher in large reductions (≥2000 g per breast) as compared with smaller reductions (≤1999 g per breast) using the superior pedicle custom-made technique. PATIENTS AND METHODS: A retrospective study of 90 consecutive operated patients was performed. All the patients underwent a bilateral breast reduction for macromastia. 43 patients had a reduction of 1999 g or less and 47 patients had a reduction of 2000 g or more. RESULTS: There were no statistically significant differences in the rates of nipple necrosis, hematoma, seroma, wound dehiscence, wound infection, loss or reduction of nipple sensation, and a pathologic scar between the large and small resections. CONCLUSIONS: The large reduction patients pointed higher mean satisfaction rate than the small reduction patients. The superior pedicle custom-made technique is a safe method of breast reduction regardless of the degree of parenchymal resection, achieving a successful aesthetic outcome with minimal scarring and high satisfaction rate for both small and large breast reduction.

Patient satisfaction as an excellent track record in nonsurgical rejuvenation procedures.

OBJECTIVE: Patient satisfaction is the goal of most aesthetic procedures. The aim of this study is to analyse nonsurgical rejuvenation procedures in a private practice setting, over a period of 10 years, evaluating patients' compliance, satisfaction and maintenance of a good fiduciary link with the medical operator. PATIENTS AND METHODS: A retrospective study was performed on 429 patients who received nonsurgical rejuvenation procedures. Four types of treatments were considered: Botulinum toxin type A injections, Hyaluronic acid or Poly-L-lactic acid injections, and a combination therapy. The outcome analyzed included a number of patients for each treatment for each year, the treatment time interval, the number of treatments for each patient, the number of treatments according to facial sub site and the "degree of satisfaction". RESULTS: The most required treatment was combination therapy (36.8% of patients). The mean time and the median time of permanency in the study were respectively 19 and 6 months. After 18 months, which is the time that we considered to attest a good "degree of satisfaction", 55% of patients were still in the study. Patients with only one treatment were excluded. CONCLUSIONS: The study findings support evidence of a more recently described increase in popularity in minimally invasive aesthetic procedures, of which combination therapy has the best performances with a good degree of satisfaction.

Upper lip reconstruction and aesthetic aspects in the female patient: our point of view.

Brief title: A brief description of our point of view about upper lip reconstruction supporting a quite simple and effective surgical option, which surgeons could consider whenever little neoformations must be removed from the lips, an aesthetically important anatomical region.

Breast reduction: personal technique.

INTRODUCTION: Macromastia is a health problem that requires the coordination of surgical and medical specialists. Goals of reduction mammaplasty are to alleviate physical, emotional and psychosocial discomforts and to restore a conical-shaped breast, maintaining scars as short as possible. We report our approach for reduction mammaplasty with superior pedicle. MATERIALS AND METHODS: Our method combines advantages of round block with vertical scar, using a dermal flap that is fixed to the new mammary crease. We analyzed skin and glandular resection customizing the mammaplasty. RESULTS: The dermal flap works against the weight of residual tissue, maintaining the crease at the desired position with a natural result. Benefits are an excellent projection, short scar, suitable reshaping and patient satisfaction. CONCLUSIONS: This technique can be used for mild to severe hypertrophy with various degrees of ptosis. It results in a successful aesthetic outcome with minimal scarring, suitable breast remodeling and natural long-lasting projection.

Bilateral hand squamous-cells carcinoma in patient affected with non-Hodgkin lymphoma. Case report and literature review.

BACKGROUND: Squamous-cell skin cancer is the most frequent tumor in the hand. It occurs on sun-damaged skin, especially in lightskinned individuals with a long history of chronic sun exposure. CASE REPORT: We describe a case of bilateral hand squamous-cell carcinoma in a elderly patient affected with non-Hodgkin's lymphoma, who underwent several non-successful surgical treatment, radiotherapy and at the least, amputation of right hand for rapid clinical evolution after radiotreatment. Available literature on the subject has been reviewed. RESULTS: In our case, after several non-successful treatment, elective amputation at the distal third of forearm was performed. We reviewed 56 items including books, original articles, reviews, cases report. CONCLUSIONS: Current evidence on treatment of hand squamouscells carcinoma is to perform a first radical surgical treatment in order to avoid recurrence/metastasis and to achieve a safer level of amputation thus increasing the surface area of healthy tissue available for eventually subsequent reconstruction/prosthesization.

Caustic burn caused by intradermal self administration of muriatic acid for suicidal attempt: optimal wound healing and functional recovery with a non surgical treatment.

BACKGROUND: Caustic burns are burns of third and fourth degree caused by strong acids or strong bases. Muriatic acid is often used for suicidal attempt by ingestion. We describe a case of a caustic skin lesion caused by intravenous failed attempt of suicide by injection of Muriatic acid in a woman affected with bipolar-syndrome. Generally, caustic burns are treated by cleansing, escarectomy and coverage with skin grafts. CASE REPORT: We treated the patient with a non invasive technique with collagenase and hyaluronic acid sodium salt cream (Bionect start®), hyaluronic acid-based matrix (Hyalomatrix®) and Vacuum-Assisted Closure (VAC) Therapy®. RESULTS: We obtained complete healing in 6 weeks. CONCLUSIONS: Combined use of non invasive techniques seems to ensure only advantages for both the patients and the Health System. It reduces health care costs and risks for the patients such as nosocomial infections. Patient's compliance is high, as its quality of life. Complete healing of the wound is fast and recovery of function is full.

[Inveterate squamous cell carcinoma of the upper eyelid: a case report]. / Carcinoma squamocellulare inveterato della palpebra superiore: Caso clinico.

Squamous cell carcinoma (SCC) is a malignant tumor of epithelium that shows squamous cell differentiation. It is the second most common cancer of the skin and usually occurs in areas exposed to the sun but it can rarely arise within the conjunctival epithelium with a deep component. We describe a woman with a history of chronic blepharoconjunctivitis unresponsive to topical medications. Examination disclosed a hyperaemic translucent patch with blurred margins of the upper palpebral conjunctiva. Tarsoconjunctival biopsy revealed intraepithelial squamous cell carcinoma. Management consisted of complete tumor excision with removal of the entire posterior lamella of the left upper eyelid and reconstruction. Histopathologic analysis confirmed primary squamous cell carcinoma arising from conjunctival epithelium, involving the underlying tarsus. Patients with unexplained chronic unilateral blepharoconjunctivitis or papillary hypertrophy of the palpebral conjunctiva should be considered for biopsy to rule out neoplasia, even when there is no sign of an evident mass.

The use of botulinum toxin in the treatment of plunging nose: cosmetic results and a functional serendipity.

INTRODUCTION: Muscles of the nose are active in facial movements both with the other facial muscles. An active depressor septi muscle (DSN) can accentuate a drooping nasal tip and shorten the upper lip on animation, especially during smiling. Paralysis of the DSN allows the tip of the nose to be lifted up. MATERIALS AND METHODS: Between January and June 2011 a double blinded, randomized study was performed on 40 patients for nasal defects as "plunging" tip. 20 patients underwent to Botulinum toxin injection (B), 20 patients were treated with placebo such as saline solution (S). Both aesthetic and functional results were evaluated using objective and subjective parameters at time 0, after 7, 15 and 30 days and values were compared using t Student test. RESULTS: S group results were not significant from an objective point of view. In botulinum group, patients showed an increase in columellar-lip distance. Satisfaction of the Group B patients was an average of 6.3 on VAS (range from 4 to 9). VAS mean values were studied with t-Student test and were found significant. DISCUSSION: Several authors recommend the incision of DSN muscle during rhinoplasty to correct the plunging tip. In patients with no needs for rhinoplasty this procedure is unnecessary and a quick and targeted injection of Botulinum toxin is the most convenient choice to improve aesthetic of the plunging tip.

A new association between hyaluronic acid and collagenase in wound repair: an open study.

BACKGROUND: Most ulcers occur with slough and need debridement treatment. Surgical treatment is usually performed but many patients need an additional chemical therapy to promote healing process. This type of wound bed preparation is slower than surgical one, but it is essential in those patients who are not eligible for surgery because of systemic diseases. A collagenase derived from the bacterium Clostridium hisolyticum is the most used. AIM: To evaluate the safety and the effectiveness of a new collagenase produced by Vibrio algynoliticum. MATERIALS AND METHODS: Forty patients were enrolled and daily treated for five weeks with Bionect Start® ointment. Parameters took into account were fibrin degradation and pain relief. The same team carried out treatment during the study period of five weeks. RESULTS: 32 patients achieved a relevant reduction of the ulcer size, an improvement of the wound bed and a reduction of fibrin and exudates. Among of 32, 14 patients presented with a complete healing. Eight patients had mild or no improvements. The patients referred a remarkable pain reduction, 20 out of 40 patients reported a decrease in pain during treatment, 16 patients referred no pain at all and four patients had no significant changes. CONCLUSIONS: The application of this product on the lesions promotes vascularized granulation tissue and reduces formation of fibrin and exudate. Furthermore, a macroscopical margins proliferation is highlighted after a short time and an improvement of periwound skin is observed during the treatment period. Bionect Start® allowed easy removal of dressing, less pain for patient, reduction of dressing time.

Masson's tumor: a soft tissue tumor simulating a tendon cyst: case report.

INTRODUCTION: Intravascular papillary endothelial hyperplasia (Masson's hemangioma or Masson's tumor) is a benign vascular disease with an exuberant endothelial proliferation in normal blood vessels. Although relatively uncommon, its correct diagnosis is important because it can clinically be like both benign lesions and malignant neoplasms. We present a case of intravascular proliferative endothelial hyperplasia simulating a tendon cyst both clinically and on ultrasound. CASE REPORT: A 74-year old Caucasian female presented with a 4-month history of soreness and swelling in the fourth finger of the right hand. Ultrasound showed an oval mass with fluid content, referred to a tendon cyst. A wide surgical excision was subsequently performed. The final histological diagnosis was Masson's tumor. DISCUSSION: The pathogenesis of intravascular papillary endothelial hyperplasia is still unclear but the exuberant endothelial cell proliferation might be stimulated by an autocrine loop of endothelial basic fibroblast growth factor (bFGF) secretion. There are three types of papillary endothelial hyperplasia: primary, or intravascular; secondary, or mixed; and extravascular. The main differential diagnosis is against pyogenic granuloma, Kaposi sarcoma, hemangioma, and angiosarcoma. CONCLUSIONS: Masson's tumor can be like both benign lesions and malignant neoplasms clinically and on ultrasound. For this reason, the right diagnosis can be made only by histology, which reveals a papillary growth composed of hyperplastic endothelial cells supported by delicate fibrous stalks entirely confined within the vascular lumen.