A systematic review of classification systems for pilonidal sinus.

BACKGROUND: Pilonidal sinus disease (PSD) is a simple chronic inflammatory condition resulting from loose hairs forcibly inserted into vulnerable tissue in the natal cleft. It is an acquired disease with a slight familial tendency. There is no agreement on optimum treatment and the multitude of therapeutic options cannot be compared due to the lack of a universally adopted classification of the disease. The aim of our study was to perform a systematic review of the literature to determine how presentations of PSD are classified and reported. METHODS: A systematic review of the English language literature was undertaken searching studies published after 1980. RESULTS: Eight classification systems of PSD were identified. Most classification systems were based on anatomical pathology hypotheses. The location and number of sinuses were the main factors defining classification systems. No articles were retrieved that assessed the validity and/or reliability of the classification system employed. Furthermore, there was no evidence to suggest a correlation between prognosis outcome and subgroup. CONCLUSIONS: Based on the evidence available from the literature reviewed we have no recommendations regarding the use of the current classification of PSD. A well-recognised and practical classification system to guide clinical practice is required.

Population-Based Studies Should not be Used to Justify a Policy of Routine Cholangiography to Prevent Major Bile Duct Injury During Laparoscopic Cholecystectomy.

Iatrogenic bile duct injury at time of cholecystectomy is a rare but devastating event. A twofold higher frequency of bile duct injury during cholecystectomy without cholangiography is reported in population-based studies. Some interpret this as a cause-and-effect relationship and thus mandate routine cholangiography. A critical appraisal of population studies is required to determine whether these studies are suitable in determining the role of routine cholangiography. The literature search was performed using combinations of the forced search terms "duct injury", "population" and "cholangiography" to identify population-based studies assessing the relationship between cholangiography and iatrogenic bile duct injury. All seven population-based studies reported a numerically higher rate of bile duct injury when an intraoperative cholangiogram was not obtained during cholecystectomy. Five predate the critical view technique. Only one was limited to laparoscopic cholecystectomy. All studies identified cholangiography as a likely marker for disease severity or surgical technique. Six studies did not demonstrate a cause-and-effect relationship by not including effect modifiers. The only study to address confounders reported the same rate of injury irrespective of the use of cholangiography. Critical appraisal of population-based studies does not support their use in justifying a policy of routine cholangiography to prevent major bile duct injury.

Does pilonidal abscess heal quicker with off-midline incision and drainage?

BACKGROUND: No clinical trials have been done to guide the surgeon in the optimal technique of draining a pilonidal abscess. The aim of our study was to investigate whether the location of the incision influences wound healing. METHODS: Electronic records from the surgical database at our 200-bed district general hospital were reviewed for operative technique (midline vs. lateral) for patients who underwent incision and drainage for acute pilonidal abscess between January 2003 and February 2010. These patients were admitted from the Emergency Department with a pilonidal abscess, underwent operative drainage, and returned for follow-up. The main outcome measure was wound healing time. RESULTS: Two hundred and forty-three pilonidal abscesses were drained, 134 with a lateral and 74 with a midline incision. All patients underwent simple longitudinal incision. No patient underwent de-roofing, marsupialisation, or closure. Forty-eight patients with midline drainage who returned for follow-up were matched for gender, age, and microbiology culture results with patients who underwent lateral drainage. Almost all were drained under general anesthesia with a median postoperative stay of 1 day. The overall length of follow-up was the same in both groups (P = 0.13). Abscesses that did not heal were followed-up for the same period of time irrespective of incision type (P = 0.48). Abscesses that healed after midline incision took approximately 3 weeks longer than those drained via a lateral incision (P = 0.02). Our study has limitations since it was a retrospective study that did not capture patients whose abscess drained spontaneously or were drained in the emergency department. CONCLUSIONS: Pilonidal abscess should be drained away from the midline.

Kinetics of fluid demixing in complex plasmas: role of two-scale interactions.

Using experiments and combining theory and computer simulations, we show that binary complex plasmas are particularly good model systems to study the kinetics of fluid-fluid demixing at the "atomistic" (individual particle) level. The essential parameters of interparticle interactions in complex plasmas, such as the interaction range(s) and degree of nonadditivity, can be varied significantly, which allows systematic investigations of different demixing regimes. The critical role of competition between long-range and short-range interactions at the initial stage of the spinodal decomposition is discussed.

Pain resolution in non-operatively managed ultrasound-only groin hernias: 3-year follow-up.

BACKGROUND: General surgeons frequently see patients with groin lumps and pain. However, in the absence of a lump, an ultrasound scan identified groin hernia is a diagnostic and management challenge. Some surgeons recommend inguinal hernia surgery while others do not. The outcome of non-operative management is uncertain. METHODS: This study represents a minimum 3-year follow-up of all non-operatively managed patients seen in general surgical outpatient clinic over a 12-month period. To be included, patients needed to meet all four criteria: groin pain, no clinical hernia, groin hernia identified on ultrasound scan requested by the general practitioner and non-operative management. Patients were interviewed via a standardised telephone survey. Primary outcome measure was groin pain which was assessed with the Sheffield Pain score. RESULTS: From July 2014 to June 2015, 67 patients met the inclusion criteria. 42 participated (37 men and 5 women). Two-thirds were pain free (68%). Only 2 patients underwent hernia surgery. Women were more likely to describe developing a lump (60% vs 14%; p = 0.013), to see a surgeon (40% vs 8%; p = 0.039) and undergo hernia surgery (20% vs 3% p = 0.088). CONCLUSION: At least in the medium term, non-operative management of men who present with groin pain (with an ultrasound scan reporting a hernia but no lump) is reasonable.

Processes of care in surgical patients who died with hospital-acquired infections in Australian hospitals.

BACKGROUND: Infection may complicate surgical patients' hospital admission. The effect of hospital-acquired infections (HAIs) on processes of care among surgical patients who died is unknown. AIM: To investigate the effect of HAIs on processes of care in surgical patients who died in hospital. METHODS: Surgeon-recorded infection data extracted from a national Australian surgical mortality audit (2012-2016) were grouped into HAIs and no infection. The audit included all-age surgical patients, who died in hospital. Not all patients had surgery. Excluded from analysis were patients with community-acquired infection and those with missing timing of infection. Multivariate logistic regression was used to determine the adjusted effects of HAIs on the processes of care in these patients. Costs associated with HAIs were estimated. FINDINGS: One-fifth of surgical patients who died did so with an HAI (2242 out of 11,681; 19.2%). HAI patients had increased processes of care compared to those who died without infection: postoperative complications [51.0% vs 30.3%; adjusted odds ratio (aOR): 2.20; 95% confidence interval (CI): 1.98-2.45; P < 0.001]; unplanned reoperations (22.6% vs 10.9%; aOR: 2.38; 95% CI: 2.09-2.71; P < 0.001) and unplanned intensive care unit admission (29.3% vs 14.8%; aOR: 2.18; 95% CI: 1.94-2.45; P < 0.001). HAI patients had longer hospital admissions and greater hospital costs than those without infection. CONCLUSION: HAIs were associated with increased processes of care and costs in surgical patients who died; these outcomes need to be investigated in surgical patients who survive.

Analysis of deficiencies in care following cholecystectomy.

INTRODUCTION: Failure To Rescue was first defined in patients who died due to a complication following (open) cholecystectomy but research into the relevant factors has been scarce. This study was designed to determine a chronological sequence of deficiencies in care. METHODS: Adult patients who died under the care of a surgeon following cholecystectomy in Queensland were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. RESULTS: Not unexpectedly, this is a high-risk patient population: median age of the 48 patients was 74.5 years and the median number of comorbidities and American Society of Anesthesiologists class was 4. Death occurred on postoperative day 6. Most deaths occurred at the end of the week. Over 80% of deaths followed emergency cholecystectomy. In almost half the patients, there were no deficiencies in care. Most common deficiency was during postoperative management (i.e. Failure To Rescue), however, significant deficiencies also arose prior to surgical admission; choice and timing of intervention as well as intraoperative decision-making. CONCLUSION: Surgeons who perform cholecystectomy need to be aware of the levels at which deficiencies arise given that many may be preventable.

Wound fluid from chronic leg ulcers contains elevated levels of metalloproteinases MMP-2 and MMP-9.

The purpose of the present research was to determine if metalloproteinase levels were elevated in human chronic wound fluid. Samples of blood and wound fluid from acute (mastectomy) and chronic (leg ulcer) wounds were collected, and metalloproteinase profiles of the samples were determined by gelatin zymography. Compared to serum, acute wound fluid (mastectomy fluid) contained markedly increased levels (five-to tenfold) of several metalloproteinases including 72-kDa and 94-kDa gelatinases (MMP-2 and MMP-9). In chronic wound fluid, not only were these enzyme levels increased another five- to tenfold over mastectomy fluid, but also both activated enzyme and proenzyme species appeared to be present. Our results suggest that non-healing ulcers develop an environment containing high levels of activated metalloproteinases, which may result in chronic tissue turnover and failed wound closure.

Degradation of fibronectin and vitronectin in chronic wound fluid: analysis by cell blotting, immunoblotting, and cell adhesion assays.

We used a combination of cell blotting, immunoblotting, and cell adhesion assays to analyze fibronectin and vitronectin in wound fluid from acute and chronic wounds. Acute wound fluid (e.g., suction blister fluid, mastectomy fluid) contained intact fibronectin and vitronectin as major cell adhesion proteins. In marked contrast, chronic wound fluid samples from three of 11 patients with venous stasis ulcers showed complete degradation of vitronectin and degradation of fibronectin into small molecular mass polypeptides less than 125 kDa. Three of these polypeptides--54, 93, and 125 kDa--were biologically active in promoting cell attachment and were recognized by monoclonal antibodies that bind fibronectin near the arg-gly-asp (RGD) domain. In wound fluid samples from the other eight of 11 patients, only slight degradation of vitronectin and fibronectin occurred, which resulted in a mixture of mostly intact molecules along with large fragments. Intact fibronectin in chronic wound fluid samples contained the ED-A domain, which showed that fibronectin synthesis occurred locally in the wound bed. Wound fluid containing extensively degraded vitronectin and fibronectin reversibly inhibited cell adhesion, and excess fetal bovine serum, but not purified fibronectin, neutralized the inhibitory effect. We suggest that protease activity in some chronic wounds may cause degradation of adhesion proteins and prevent cell adhesion necessary for normal wound closure.

Abdominal malignancies missed during laparoscopic cholecystectomy.

BACKGROUND: We present our experience with intra-abdominal malignancies different from gallbladder cancer not diagnosed preoperatively and undiscovered during laparoscopic cholecystectomy METHODS: This study involved retrospective analysis of 10 patients hospitalized in the Second Department of General Surgery between 1993 and 2000. In all of them, laparoscopic cholecystectomy had been performed between one week and 21 months earlier. RESULTS: Primary or metastatic neoplasms were diagnosed in five men and five women patients ages 38 to 79 years. In three patients with colorectal cancer, a radical resection was possible. Nonresectable pancreatic cancer was found in three patients. In one of two patients with gastric cancer, palliative, distal gastrectomy was performed. In a patient who had small bowel cancer with metastasis to the ovary, a radical operation was possible. In one patient, liver metastasis from lung cancer was found. CONCLUSIONS: In patients with atypical symptoms of gallbladder lithiasis, a thorough workup before laparoscopic cholecystectomy should be performed. During the laparoscopic procedure, a detailed examination of the whole peritoneal cavity is essential. In cases of prolonged convalescence after laparoscopic cholecystectomy, a source of symptoms different from cholelithiasis should be suspected.

Association of ocular pressure and optic disc cup volume with red blood cell sodium-potassium ATPase inhibition.

PURPOSE: To determine if there were significant differences between the number of red blood cell ouabain binding sites in normals and untreated ocular hypertensives plus one open-angle glaucoma patient. METHODS: We measured the binding of (3)H ouabain to erythrocyte membranes of 23 normals, 25 ocular hypertensives and one open-angle glaucoma. We also measured the levels of plasma cortisol and digoxin in these subjects. Characteristics of cupping of the optic disc and thickness of the retinal nerve fiber layer, as well as area of optic disc pallor of these subjects were measured by stereophotogrammetry and by computerized image analysis from single and stereo photographs. RESULTS: The number of (3)H ouabain binding sites was observed to be significantly less in the ocular hypertensives and one glaucoma compared to the normals (p = 0.0009). In multi-variate analyses, to determine what other factors affected this difference, there was a significant negative association with mean intraocular pressure (p = 0.003) (average of both eyes) and total cup volume (average of both eyes) (p = 0.005), diagnosis of ocular hypertension and glaucoma (p = 0.0005) and male gender (p = 0.019). There was a significant positive association with plasma cortisol levels (p = 0.048), and diastolic blood pressure (p = 0.037). CONCLUSIONS: The number of (3)H ouabain binding sites in red blood cells decreases significantly with increasing ocular pressure and increasing cup volume indicating the possible presence of an increased systemic endogenous digoxin-like inhibitor and/or difference in the isozymes of Na(+), K(+)-ATPase which may be associated with increased levels of plasma cortisol in ocular hypertensives and glaucomas.

Use of polypropylene prostheses for strangulated inguinal and incisional hernias.

We used monofilament polypropylene prostheses in 20 emergency operations for strangulated hernias. Sixteen of the operated patients had groin hernias (five of them recurrent), two had incisional and one had a Spigel's type hernia. Intestinal resection was performed because of bowel wall necrosis in one of the patients. During the postoperative period, we observed only one minor complication (a seroma formation). During the follow-up, no recurrence was observed. In our opinion, the use of monofilament polypropylene mesh in emergency hernia operations is safe, simple and effective.

Haemodynamic assessment following inferior vena cava resection without replacement.

BACKGROUND: Treatment of bulky retroperitoneal malignancy may require en bloc resection of the infrarenal inferior vena cava. A number of reconstructive options are available to the surgeon but objective haemodynamic assessment of the peripheral venous system following resection without replacement is lacking. The aim of the present paper was thus to determine the symptomatic and haemodynamic effects of not reconstructing the resected infrarenal inferior vena cava. METHODS: A retrospective descriptive study was carried out at Princess Alexandra Hospital in Queensland. Five patients underwent resection of the thrombosed infrarenal inferior vena cava as part of retroperitoneal lymph node dissection for testicular cancer (n = 3), radical nephrectomy for renal cell carcinoma (n = 1) and thrombosed inferior vena cava aneurysm (n = 1). Clinical effects were determined via the modified venous clinical severity score and venous disability score. Haemodynamic data were obtained postoperatively using venous duplex ultrasound and air plethysmography. RESULTS: None of the present patients scored >2 (out of 30) on the modified venous clinical severity score or >1 (out of 3) on the venous disability score. Haemodynamic studies showed only minor abnormalities. CONCLUSIONS: Not reconstructing the resected thrombosed infrarenal inferior vena cava results in minor signs and symptoms of peripheral venous hypertension and only minor abnormalities on haemodynamic assessment.

A microcomputer-based vision system for area measurement.

A vision system for measuring the area of an arbitrarily shaped object is described. The algorithm consists of a gray-level thresholding technique combined with a region correction procedure based on mathematical morphology. All processing steps are carried out on a microcomputer system equipped with a video digitizer. The algorithm has been successfully applied to a number of images of medical interest including skin wounds and various microscopic-scale objects such as cell cross-sections and multicellular tissues. Excellent agreement between results obtained by the automatic method and by using standard mechanical means has been established experimentally. The approach is demonstrated by a number of experimental examples.

International co-operation in information transfer.

PIP: Scientific and technical knowledge is cumulative and international in nature. The collection, storage, processing, and dissemination of information is of strategic national and international importance these days. Such information facilitates socioeconomic development within countries. Governments are establishing national information policies to better manage their data accumulation. There is now an ongoing process of international information cooperation, as well. International programs for cooperation in the data collection and dissemination field are described. International professional groups are also fostering international information cooperation.^ieng

Skin anatomy, physiology, and pathophysiology.

Human skin is the largest multifunctional organ of the body, and knowledge of its structure and function is essential to clinicians and researchers. The skin has two layers, the epidermis and dermis, separated by a basement membrane zone. It provides protection, sensation, thermoregulation, biochemical/metabolic, and immune functions. Key and emerging concepts important to understanding pathophysiological mechanisms for practicing clinicians are: knowledge of differences between acute and chronic wounds; ability to evaluate depth and extent of injury; understanding stages of healing versus zones of activity; and knowledge of ischemic-reperfusion injury, the skin immune system, cytokines, growth factors and other biomolecules, and matrix synthesis and degradation. These concepts are addressed in this article.

Evaluation of the contamination degree of roe-deer with cadmium and polychlorinated biphenyls in Warmia and Mazury district.

The results of investigations concerning degree the contamination degree with cadmium and polychlorinated biphenyls (PCB's) of roe-deer organs hunt in seven selected areas of Warmia and Mazury voivodship are presented. The highest mean cadmium content in the organs investigated was found in the samples from Glebock area (liver - 0.0576 mg/kg, kidney - 3.351 mg/kg) and the lowest one was observed in the samples from Pisz area (liver - 0.181 mg/kg, kidneys - 1.653 mg/kg). Mean level of polychlorinated biphenyls residues in the roe-deer fat from Warmia and Mazury district was 0.004 mg/kg. The highest PCB's mean concentration was found in the roe-deer fat samples from Milomlyn area (0.008 mg/kg), and the lowest one in those from Glebock area (0.002 mg/kg). Presented levels of investigated xenobiotics do not make at present (except cadmium in kidney) any toxicological threats for venison consumers in Warmia and Mazury district.

[Gallbladder cancer in the age of laparoscopic surgery]. / Rak pecherzyka zólciowego w dobie operacji laparoskopowych.

In routine post operative microscopic test of unsuspected of cancer gallbladder--before or during laparoscopic cholecystectomy--cancer is recognized in 0.5% to 1%. Bad prognosis is mainly connected with how far advanced the cancer is. It seems that laparoscopic technic it is a disadvantage itself as it conduces to dissemination of cancer in peritoneal cavity and also in cicatrix. Our experience so far proofs that repeatedly during the second traditional operation--even up to several days after laparoscopy--dissemination of cancer is found in peritoneum. Today's views regarding treatment of not advanced cancer considerable are based on experience when the traditional operations were used to remove gallbladder. Further more--it permitted to accept that just cholecystectomy is sufficient in cases when cancer infiltration has not gone beyond mucous membrane. In cases of more advanced cancer extensive operations may prolong life. Due to that observation in cases of gallbladder with cancer infiltration beyond mucous membrane and removed in laparoscopic way an extensive operation is carried out later and it is taking in adherent liver parenchyma and lymphatic tissue in hepato-duodenal ligament or if necessary main biliary tract. Extensive operations are being carried out till microscopic routine test has been performed and few days after laparoscopic cholecystectomy. Some other solution rely during laparoscopic operation--on treating respective with thicken wall gallbladder as a suspected of cancer and microscopic test is carried out intraoperatively. It conditions accomplishment of extensive operation. It must be emphasise that laparoscopic technique encourages dissemination of cancer. From different point of view switching from laparoscopic to traditional cholecystectomy with 1% risk of cancer in thicken wall gallbladder against remaining will be deprived of benefits of laparoscopic operation. Still this quite complicated problem remains open to discussions, research and it needs some time yet before solution will be found.