Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps.

Reconstructive surgery of the head and neck region has undergone tremendous advancement over the past three decades, and the success rate of free tissue transfers has risen to greater than 95%. It must always be considered that not all patients are ideal candidates for free flap reconstruction, and also that not every defect strictly requires a free flap transfer to achieve good functional results. At our institution, free flap reconstruction is first choice, although we use pedicled alternative flaps for most weak patients suffering from severe comorbidities, and for pretreated patients presenting a second primary or a recurrent cancer. From July 2006 to May 2010, 54 consecutive patients underwent soft tissue reconstruction of oral cavity and oropharyngeal defects. We divided the cohort in three groups: Group 1 (G1): 16 patients in good general conditions that received free radial forearm flap reconstruction; Group 2 (G2): 18 high-risk patients that received a reconstruction with infrahyoid flap; Group 3 (G3): 20 patients that received temporal flap (10 cases) or pectoral flap (10 cases) reconstruction. We must highlight that pedicled alternative flaps were used in elderly, unfavourable and weak patients, where usually the medical costs tend to rise rather than decrease. We compared the healthcare costs of the three groups, calculating real costs in each group from review of medical records and operating room registers, and calculating the corresponding DRG system reimbursement. For real costs, we found a statistically significant difference among groups: in G1 the average total cost per patient was € 22,924, in G2 it was € 18,037 and in G3 was € 19,872 (p = 0.043). The amount of the refund, based on the DRG system, was € 7,650 per patient, independently of the type of surgery. Our analysis shows that the use of alternative non-microvascular techniques, in high-risk patients, is functionally and oncologically sound, and can even produce a cost savings. In particular, the infrahyoid flap (G2) ensures excellent functional results, accompanied by the best economic savings in the worst group of patients. Our data reflect a large disconnection between the DRG system and actual treatment costs.

Bone metastasis in hepatocellular carcinoma. A report of five cases and a review of the literature.

Hepatocarcinoma occurs frequently throughout the world. Bone metastases are rare although incidence has increased because of progress in diagnosis and treatment. The authors report 5 cases of bone metastases and review the literature. The spine is the most frequent localization of bone metastases. Radiotherapy is the treatment of choice for this lesion. Surgery should be used to prevent and treat complications such as nerve compression and pathologic fracture, only if the coagulative pattern and the conditions of the patient allow it. The authors recommend the use of long intramedullary nailing when localization of the disease is in the femur, with prophylactic stabilization of the neck in diaphyseal metastasis.

Essential amino acids increase the growth and alkaline phosphatase activity in osteoblasts cultured in vitro.

An inadequate protein intake seems to be involved in the pathogenesis of osteoporosis. Moreover, protein from animal sources appears to protect against hip fracture, while protein from vegetable sources, which present low levels of essential amino acids, has no effect. In this preliminary work, the growth, the alkaline phosphatase activity and the collagen synthesis were evaluated in osteoblast cultures obtained from calvaria of newborn Sprague-Dawley rats and incubated with lysine, threonine, methionine, triptophan and arginine. Our results have shown that the essential amino acids can modulate the growth and the differentiation of osteoblasts cultured in vitro, confirming the relationship between osteoporotic hip fracture and inadequate protein intake. The compounds have mainly enhanced cell growth and alkaline phosphatase activity, and, to a lower degree, collagen synthesis. In summary, the essential amino acids can stimulate bone formation and could represents useful agents for the prevention and therapy of osteoporosis.