Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial.

OBJECTIVE: To compare costs for 2 days versus 5 days of postoperative antibiotics within the antibiotics after an aPPendectomy In Complex appendicitis trial.Background:Recent studies suggest that restrictive antibiotic use leads to a significant reduction in hospital stays without compromising patient safety. Its potential effect on societal costs remains underexplored. METHODS: This was a pragmatic, open-label, multicenter clinical trial powered for noninferiority. Patients with complex appendicitis (age ≥ 8 years) were randomly allocated to 2 days or 5 days of intravenous antibiotics after appendectomy. Patient inclusion lasted from June 2017 to June 2021 in 15 Dutch hospitals. The final follow-up was on September 1, 2021. The primary trial endpoint was a composite endpoint of infectious complications and mortality within 90 days. In the present study, the main outcome measures were overall societal costs (comprising direct health care costs and costs related to productivity loss) and cost-effectiveness. Direct health care costs were recorded based on data in the electronic patient files, complemented by a telephone follow-up at 90 days. In addition, data on loss of productivity were acquired through the validated Productivity Cost Questionnaire at 4 weeks after surgery. Cost estimates were based on prices for the year 2019. RESULTS: In total, 1005 patients were evaluated in the "intention-to-treat" analysis: 502 patients were allocated to the 2-day group and 503 to the 5-day group. The mean difference in overall societal costs was - €625 (95% CI: -€ 958 to -€ 278) to the advantage of the 2-day group. This difference was largely explained by reduced hospital stay. Productivity losses were similar between the study groups. Restricting postoperative antibiotics to 2 days was cost-effective, with estimated cost savings of €31,117 per additional infectious complication. CONCLUSIONS: Two days of postoperative antibiotics for complex appendicitis results in a statistically significant and relevant cost reduction, as compared with 5 days. Findings apply to laparoscopic appendectomy in a well-resourced health care setting.

2 days versus 5 days of postoperative antibiotics for complex appendicitis: a pragmatic, open-label, multicentre, non-inferiority randomised trial.

BACKGROUND: The appropriate duration of postoperative antibiotics for complex appendicitis is unclear. The increasing global threat of antimicrobial resistance warrants restrictive antibiotic use, which could also reduce side-effects, length of hospital stay, and costs. METHODS: In this pragmatic, open-label, non-inferiority trial in 15 hospitals in the Netherlands, patients with complex appendicitis (aged ≥8 years) were randomly assigned (1:1) to receive 2 days or 5 days of intravenous antibiotics after appendicectomy. Randomisation was stratified by centre, and treating physicians and patients were not masked to treatment allocation. The primary endpoint was a composite endpoint of infectious complications and mortality within 90 days. The main outcome was the absolute risk difference (95% CI) in the primary endpoint, adjusted for age and severity of appendicitis, with a non-inferiority margin of 7·5%. Outcome assessment was based on electronic patient records and a telephone consultation 90 days after appendicectomy. Efficacy was analysed in the intention-to-treat and per-protocol populations. Safety outcomes were analysed in the intention-to-treat population. This trial was registered with the Netherlands Trial Register, NL5946. FINDINGS: Between April 12, 2017, and June 3, 2021, 13 267 patients were screened and 1066 were randomly assigned, 533 to each group. 31 were excluded from intention-to-treat analysis of the 2-day group and 30 from the 5-day group owing to errors in recruitment or consent. Appendicectomy was done laparoscopically in 955 (95%) of 1005 patients. The telephone follow-up was completed in 664 (66%) of 1005 patients. The primary endpoint occurred in 51 (10%) of 502 patients analysed in the 2-day group and 41 (8%) of 503 patients analysed in the 5-day group (adjusted absolute risk difference 2·0%, 95% CI -1·6 to 5·6). Rates of complications and re-interventions were similar between trial groups. Fewer patients had adverse effects of antibiotics in the 2-day group (45 [9%] of 502 patients) than in the 5-day group (112 [22%] of 503 patients; odds ratio [OR] 0·344, 95% CI 0·237 to 0·498). Re-admission to hospital was more frequent in the 2-day group (58 [12%] of 502 patients) than in the 5-day group (29 [6%] of 503 patients; OR 2·135, 1·342 to 3·396). There were no treatment-related deaths. INTERPRETATION: 2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days in terms of infectious complications and mortality within 90 days, based on a non-inferiority margin of 7·5%. These findings apply to laparoscopic appendicectomy conducted in a well resourced health-care setting. Adopting this strategy will reduce adverse effects of antibiotics and length of hospital stay. FUNDING: The Netherlands Organization for Health Research and Development.

Programmatic approach to patients with advanced ischemic cardiomyopathy: Integrating microaxial support into strategies for the modern era.

Patients with advanced ischemic cardiomyopathy manifesting as left ventricular dysfunction exist along a spectrum of severity and risk, and thus decision-making surrounding optimal management is challenging. Treatment pathways can include medical therapy as well as revascularization through percutaneous coronary intervention or coronary artery bypass grafting. Additionally, temporary and durable mechanical circulatory support, as well as heart transplantation, may be optimal for select patients. Given this spectrum of risk and the complexity of treatment pathways, patients may not receive appropriate therapy given their perceived risk, which can lead to sub-satisfactory outcomes. In this review, we discuss the identification of high-risk ischemic cardiomyopathy patients, along with our programmatic approach to patient evaluation and perioperative optimization. We also discuss our strategies for therapeutic decision-making designed to optimize both short- and long-term patient outcomes.

The Ste20-like kinase - a Jack of all trades?

Over the past 20 years, the Ste20-like kinase (SLK; also known as STK2) has emerged as a central regulator of cytoskeletal dynamics. Reorganization of the cytoskeleton is necessary for a plethora of biological processes including apoptosis, proliferation, migration, tissue repair and signaling. Several studies have also uncovered a role for SLK in disease progression and cancer. Here, we review the recent findings in the SLK field and summarize the various roles of SLK in different animal models and discuss the biochemical mechanisms regulating SLK activity. Together, these studies have revealed multiple roles for SLK in coupling cytoskeletal dynamics to cell growth, in muscle repair and in negative-feedback loops critical for cancer progression. Furthermore, the ability of SLK to regulate some systems appears to be kinase activity independent, suggesting that it may be an important scaffold for signal transduction pathways. These various findings reveal highly complex functions and regulation patterns of SLK in development and disease, making it a potential therapeutic target.

The acoustical and perceptual features of snore-related sounds in patients with obstructive sleep apnea sleeping with the dynamic mandibular advancement system MATRx plus®.

PURPOSE: The effect of snoring on the bed partner can be studied through the evaluation of in situ sound records by the bed partner or unspecialized raters as a proxy of real-life snoring perception. The aim was to characterize perceptual snore events through acoustical features in patients with obstructive sleep apnea (OSA) with an advanced mandibular position. METHODS: Thirty-minute sound samples of 29 patients with OSA were retrieved from overnight, in-home recordings of a study to validate the MATRx plus® dynamic mandibular advancement system. Three unspecialized raters identified sound events and classified them as noise, snore, or breathing. The raters provided ratings for classification certainty and annoyance. Data were analyzed with respect to respiratory phases, and annoyance. RESULTS: When subdividing perceptual events based on respiratory phase, the logarithm-transformed Mean Power, Spectral Centroid, and Snore Factor differed significantly between event types, although not substantially for the spectral centroid. The variability within event type was high and distributions suggested the presence of subpopulations. The general linear model (GLM) showed a significant patient effect. Inspiration segments occurred in 65% of snore events, expiration segments in 54%. The annoyance correlated with the logarithm of mean power (r = 0.48) and the Snore Factor (0.46). CONCLUSION: Perceptual sound events identified by non-experts contain a non-negligible mixture of expiration and inspiration phases making the characterization through acoustical features complex. The present study reveals that subpopulations may exist, and patient-specific features need to be introduced.

Perceptual snoring as a basis for a psychoacoustical modeling and clinical patient profiling.

PURPOSE: The perceptual burden and social nuisance for mainly the co-sleeper can affect the relationship between snorer and bedpartner. Mandibular advancement devices (MAD) are commonly recommended to treat sleep-related breathing such as snoring or sleep apnea. There is no consensus about the definition of snoring particularly with MAD, which is essential for assessing the effectiveness of treatment. We aimed to stablish a notion of perceptual snoring with MAD in place. METHODS: Sound samples, each 30 min long, were recorded during in-home, overnight, automatic mandibular repositioning titration studies in a population of 29 patients with obstructive sleep apnea syndrome (OSAS) from a clinical trial carried out to validate the MATRx plus. Three unspecialized and calibrated raters identified sound events and classified them as noise, snore, or breathing as well as providing scores for classification certainty and annoyance. Data were analyzed with respect to expiration-inspiration, duration, annoyance, and classification certainty. RESULTS: A Fleiss' kappa (>0.80) and correlation duration of events (>0.90) between raters were observed. Prevalence of all breath sounds: snore 55.6% (N = 6398), breathing sounds 31.7% (N = 3652), and noise 9.3% (N = 1072). Inspiration occurs in 88.3% of events, 96.8% contained at least on expiration phase. Snore and breath events had similar duration, respectively 2.58s (sd 1.43) and 2.41s (sd 1.22). Annoyance is lowest for breathing events (8.00 sd 0.98) and highest for snore events (4.90 sd 1.92) on a VAS from zero to ten. CONCLUSION: Perceptual sound events can be a basis for analysis in a psychosocial context. Perceived snoring occurs during both expiration as well as inspiration. Substantial amount of snoring remains despite repositioning of the mandible aimed at the reduction of AHI-ODI.

A multicentre, open-label, single-arm phase II trial of the efficacy and safety of sclerotherapy using 3% polidocanol foam to treat second-degree haemorrhoids (SCLEROFOAM).

BACKGROUND: The aim of the present study was to evaluate the efficacy and safety of 3% polidocanol foam for treating 2nd-degree haemorrhoids. METHODS: A multicentre, open-label, single-arm, phase 2 trial involving 10 tertiary referral centres for haemorrhodal disease (HD) was performed. Between January and June 2019, patients with 2nd-degree haemorrhoids were prospectively included in this study. The primary outcome was to establish the success rate after one sclerotherapy session in terms of complete resolution of bleeding episodes one week after the injection. The Hemorrhoidal Disease Symptom Score (HDSS), the Short Health Scale for HD (SHS-HD) score and the Vaizey incontinence score were used to assess symptoms and their impact on quality of life and continence. Pain after the procedure, subjective symptoms and the amount and type of painkillers used were recorded. Patients were followed up for 1 year. RESULTS: There were 183 patients [111 males; 60.7%, mean age 51.3 ± 13.5 (18-75) years]. Complete resolution of bleeding was reached in 125/183 patients (68.3%) at 1 week and the recurrence rate was 12% (15/125). Thirteen patients (7.4%) underwent a second sclerotherapy session, while only 1 patient (1.8%) had to undergo a third session. The overall 1-year success rate was 95.6% (175/183). The HDSS and the SHS score significantly improved from a median preoperative value of 11 and 18 to 0 and 0, respectively (p < 0.001). There were 3 episodes of external thrombosis. No serious adverse events occurred. CONCLUSIONS: Sclerotherapy with 3% polidocanol foam is a safe, effective, painless, repeatable and low-cost procedure in patients with bleeding haemorrhoids.

AKT-mediated phosphorylation of Sox9 induces Sox10 transcription in a murine model of HER2-positive breast cancer.

BACKGROUND: Approximately 5-10% of HER2-positive breast cancers can be defined by low expression of the Ste20-like kinase, SLK, and high expression of SOX10. Our lab has observed that genetic deletion of SLK results in the induction of Sox10 and significantly accelerates tumor initiation in a HER2-induced mammary tumor model. However, the mechanism responsible for the induction of SOX10 gene expression in this context remains unknown. METHODS: Using tumor-derived cell lines from MMTV-Neu mice lacking SLK and biochemical approaches, we have characterized the signaling mechanisms and relevant DNA elements driving Sox10 expression. RESULTS: Biochemical and genetic analyses of the SOX10 regulatory region in SLK-deficient mammary tumor cells show that Sox10 expression is dependent on a novel -7kb enhancer that harbors three SoxE binding sites. ChIP analyses demonstrate that Sox9 is bound to those elements in vivo. Our data show that AKT can directly phosphorylate Sox9 in vitro at serine 181 and that AKT inhibition blocks Sox9 phosphorylation and Sox10 expression in SLK(-/-) tumor cells. AKT-mediated Sox9 phosphorylation increases its transcriptional activity on the Sox10 -7kb enhancer without altering its DNA-binding activity. Interestingly, analysis of murine and human mammary tumors reveals a direct correlation between the levels of active phospho-Sox9 S181 and Sox10 expression. CONCLUSIONS: Our results have identified a novel Sox10 enhancer and validated Sox9 as a direct target for AKT. As Sox10 is a biomarker for triple-negative breast cancers (TNBC), these findings might have major implications in the targeting and treatment of those cancers.

Periostin gene expression in neu-positive breast cancer cells is regulated by a FGFR signaling cross talk with TGFß/PI3K/AKT pathways.

BACKGROUND: Breast cancer is a highly heterogeneous disease with multiple drivers and complex regulatory networks. Periostin (Postn) is a matricellular protein involved in a plethora of cancer types and other diseases. Postn has been shown to be involved in various processes of tumor development, such as angiogenesis, invasion, cell survival and metastasis. The expression of Postn in breast cancer cells has been correlated with a more aggressive phenotype. Despite extensive research, it remains unclear how epithelial cancer cells regulate Postn expression. METHODS: Using murine tumor models and human TMAs, we have assessed the proportion of tumor samples that have acquired Postn expression in tumor cells. Using biochemical approaches and tumor cell lines derived from Neu+ murine primary tumors, we have identified major regulators of Postn gene expression in breast cancer cell lines. RESULTS: Here, we show that, while the stromal compartment typically always expresses Postn, about 50% of breast tumors acquire Postn expression in the epithelial tumor cells. Furthermore, using an in vitro model, we show a cross-regulation between FGFR, TGFß and PI3K/AKT pathways to regulate Postn expression. In HER2-positive murine breast cancer cells, we found that basic FGF can repress Postn expression through a PKC-dependent pathway, while TGFß can induce Postn expression in a SMAD-independent manner. Postn induction following the removal of the FGF-suppressive signal is dependent on PI3K/AKT signaling. CONCLUSION: Overall, these results reveal a novel regulatory mechanism and shed light on how breast tumor cells acquire Postn expression. This complex regulation is likely to be cell type and cancer specific as well as have important therapeutic implications.

Evolutionary bedfellows: Reconstructing the ancestral state of autotomy and regeneration.

Some form of regeneration occurs in all lifeforms and extends from single-cell organisms to humans. The degree to which regenerative ability is distributed across different taxa, however, is harder to ascertain given the potential for phylogenetic constraint or inertia, and adaptive processes to shape this pattern. Here, we examine the phylogenetic history of regeneration in two groups where the trait has been well-studied: arthropods and reptiles. Because autotomy is often present alongside regeneration in these groups, we performed ancestral state reconstructions for both traits to more precisely assess the timing of their origins and the degree to which these traits coevolve. Using an ancestral trait reconstruction, we find that autotomy and regeneration were present at the base of the arthropod and reptile trees. We also find that when autotomy is lost it does not re-evolve easily. Lastly, we find that the distribution of regeneration is intimately connected to autotomy with the association being stronger in reptiles than in arthropods. Although these patterns suggest that decoupling autotomy and regeneration at a broad phylogenetic scale may be difficult, the available data provides useful insight into their entanglement. Ultimately, our reconstructions provide the important groundwork to explore how selection may have played a role during the loss of regeneration in specific lineages.

A step-by-step approach to endorectal proctopexy (ERPP): how we do it.

There are many surgical treatments aimed at correcting internal mucosal prolapse and rectocele associated with obstructed defecation syndrome (ODS). Perineal procedures can be considered as first options in young men in whom an abdominal approach poses risks of sexual dysfunction and in selected women with isolated posterior compartment prolapse who failed conservative treatment. About 20 years ago, we described endorectal proctopexy (ERPP) also known as internal Delorme procedure. The aim of the present study was to describe, with attention to technical details and the aid of a video, the different steps of ERPP for the treatment of ODS. A retrospective analysis of our last 100 cases confirms our initial good results. Complications included suture line dehiscence with consequent stricture in four patients (4%). Bleeding occurred in four (4%) patients and was conservatively treated. Transient anal continence impairment consisting of urgency and soiling occurred in 12 (12%) and 6 (6%) patients, respectively. At 6-month follow-up the Cleveland Clinic Constipation Score and ODS score improved from a median preoperative value of 18.9 and 18.5 to 5 and 5, respectively (p < 0.0001). The mean follow-up was 36.05 ± 13.3 (range 12-58) months and anatomical recurrence rate was 6 (%). Due to its excellent safety profile and the ability to tailor the procedure to different disease presentations, we think that ERPP should be part of the basic armamentarium of all colorectal surgeons operating on the pelvic floor.

Evaluation of opening a type III/IV medical psychiatric unit.

OBJECTIVE: The aim of this study is to examine the impact of opening a medical psychiatric unit (MPU) on a variety of outcomes. METHODS: In this non-equivalent groups design, there were two groups: 'pre-MPU' and 'actual MPU'. Staff assessed whether patients in the pre-MPU group were eligible for admission to a planned MPU, resulting in virtual admissions and discharges. The actual MPU group consisted of patients admitted after opening of the MPU. RESULTS: The length of stay (LOS) in the hospital was one day longer for patients in the MPU group (8.68 vs. 9.89, p = .004), but the LOS on the MPU was comparable in both groups (5.63 vs. 6.06, p = .231). The LOS on the intensive care unit (ICU) was longer in the MPU group (0.10 vs. 0.40, p < .001), even as the time patients were physically restraint (0.28 vs. 0.83, p < .001). In the pre-MPU group, the odds were not significantly different for involuntary commitment (OR = 0.92; p = .866) and death within six months after discharge (OR = 1.84; p = .196). CONCLUSIONS: Both physical restraint and ICU admission have a link with patient complexity, it therefore seemed that opening of the MPU resulted in the treatment of more complex patients with a comparable LOS on the MPU.KEY POINTSThe LOS on the MPU was not significantly different between the groups before and after opening of the MPU.Opening of the MPU resulted in the admission of patients that were admitted more days to the ICU and to more days of physically restraint.It can be considered that opening of the MPU resulted in an increased ability to treat complex patients.

A tailored rhomboid mucocutaneous advancement flap to treat anal stenosis.

AIM: Anal stenosis (AS) is a rare but disabling disorder that often represents a complication of anorectal surgery. The aim of our study was to assess the safety and functional outcome of a modified rhomboid flap (MRF) in the treatment of moderate and severe AS. METHODS: Between January 2002 and September 2017, 50 consecutive patients with moderate and severe AS who underwent an MRF were retrospectively included. Anal continence (Cleveland Clinic Incontinence Score) and symptoms (Obstructed Defaecation Syndrome Score) were assessed preoperatively and postoperatively at 12 months. Furthermore, anal calibre was measured both preoperatively and postoperatively at 1, 6 and 12 months. RESULTS: The mean follow-up period was 97 ± 48.3 (33-180) months. The main aetiology was a previous excisional haemorrhoidectomy (N = 23; 46%). The mean preoperative anal calibre was 9.96 ± 2.68 (5-15) mm and there was a statistically significant improvement in all three periods (P < 0.0001) of postoperative evaluation (1, 6 and 12 months) with a mean difference, obtained comparing preoperative and 12 months anal calibre, of 14.1 ± 2.72 (P < 0.0001). Statistically significant improvement in both Cleveland Clinic Incontinence Score and Obstructed Defaecation Syndrome Score was observed in all patients at 12 months. The overall success rate was 96% (48/50 patients). CONCLUSION: The use of an MRF is a safe and suitable option for the treatment of moderate and severe AS. The possibility of tailoring the flap, based on the degree as well as the level of AS, is the key.

Correction to: Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR).

An amendment to this paper has been published and can be accessed via the original article.

Mesoglycan for pain control after open excisional HAEMOrrhoidectomy (MeHAEMO): an observational multicentre study on behalf of the Italian Society of Colorectal Surgery (SICCR).

BACKGROUND: Excisional haemorrhoidectomy is the gold standard technique in patients with III and IV degree haemorrhoidal disease (HD). However, it is associated with a significant rate of post-operative pain. The aim of our study was to evaluate the efficacy of mesoglycan in the post-operative period of patients who underwent open excisional diathermy haemorrhoidectomy (OEH). METHODS: This was a retrospective multicentre observational study. Three hundred ninety-eight patients from sixteen colorectal referral centres who underwent OEH for III and IV HD were enrolled. All patients were followed-up on the first post-operative day (T1) and after 1 week (T2), 3 weeks (T3) and 6 weeks (T4). BMI, habits, SF-12 questionnaire, VAS at rest (VASs), after defecation (VASd), and after anorectal digital examination (VASe), bleeding and thrombosis, time to surgical wound healing and autonomy were evaluated. RESULTS: In the mesoglycan group, post-operative thrombosis was significantly reduced at T2 (p < 0.05) and T3 (p < 0.005), and all patients experienced less post-operative pain at each time point (p < 0.001 except for VASe T4 p = 0.003). There were no significant differences between the two groups regarding the time to surgical wound healing or post-operative bleeding. There was an early recovery of autonomy in the mesoglycan group in all three follow-up periods (T2 p = 0.016; T3 p = 0.002; T4 p = 0.007). CONCLUSIONS: The use of mesoglycan led to a significant reduction in post-operative thrombosis and pain with consequent early resumption of autonomy. Trial registration NCT04481698-Mesoglycan for Pain Control After Open Excisional HAEMOrrhoidectomy (MeHAEMO) https://clinicaltrials.gov/ct2/show/NCT04481698?term=Mesoglycan+for+Pain+Control+After+Open+Excisional+HAEMOrrhoidectomy+%28MeHAEMO%29&draw=2&rank=1.

Evaluation and management of perianal abscess and anal fistula: SICCR position statement.

Perianal sepsis is a common condition ranging from acute abscess to chronic anal fistula. In most cases, the source is considered to be a non-specific cryptoglandular infection starting from the intersphincteric space. Surgery is the main treatment and several procedures have been developed, but the risks of recurrence and of impairment of continence still seem to be an unresolved issue. This statement reviews the pertinent literature and provides evidence-based recommendations to improve individualized management of patients.

Assessment of spawning site fidelity in interior Fraser River Coho salmon Oncorhynchus kisutch using otolith microchemistry, in British Columbia, Canada.

Coho Salmon Oncorhynchus kisutch show fidelity to natal spawning watersheds. Fine-scale homing, however, within rivers is not well understood. Interior Fraser Coho (IFC) salmon eggs were incubated at known spawning locations in the Coldwater River, two main stem sites and one-off channel pond site, providing otolith reference data for comparison to otolith signatures for returning adults using laser ablation inductively coupled plasma mass spectrometry. Elemental ratios for Ba:Ca and Sr:Ca in otoliths of juvenile O. kisutch differed significantly among the spawning locations examined. Juvenile otolith data were used to conduct a linear discriminant analysis to assess fine-scale homing in adults. Juvenile data were all assigned to the location where they had been incubated, producing a robust data set used to compare adult otoliths and define natal locations based on elemental signatures in otoliths of adult spawners. Homing and straying were apparent at the reach level; 57.1% of adults returned to their natal spawning locations, while 42.9% strayed to other spawning sites within the Coldwater River. Straying to novel incubation sites at the reach scale demonstrated plasticity in homing within a watershed.

Triple pelvic osteotomy with a 12.5° and a 20° Slocum-type plate: A short-term prospective clinical pilot study in 38 dogs.

OBJECTIVE: To determine whether using 12.5° Slocum-like triple pelvic osteotomy (TPO) plates would create sufficient femoral head coverage and lower the occurrence of overrotation compared with using 20° TPO plates in dogs with hip dysplasia. STUDY DESIGN: Prospective clinical study. SAMPLE POPULATION: Thirty-five dogs with hip dysplasia (38 hips). METHODS: Nineteen hips were surgically treated with a custom-made Slocum-type 12.5° TPO plate, and these were matched to 19 hips surgically treated with a 20° commercial Slocum TPO plate. Hips were case matched according to size and breed. Ortolani sign, angles of subluxation and reduction, distraction index, and femoral head coverage (FHC) were compared between groups. Excessive coverage was defined as >80%. RESULTS: In the 12.5° group, FHC was ≥50% in all hips, with mean FHC (67%), gain (37%), and excessive coverage (11%) all significantly less than in the 20° group (79%, 54%, and 42%, respectively). CONCLUSION: The 12.5° plate produced sufficient FHC compared with the 20° plate, with fewer hips with excessive coverage. CLINICAL SIGNIFICANCE: The 12.5° TPO plate may result in sufficient FHC with a lower occurrence of excessive coverage compared with 20° plates.

Use of the Martius advancement flap for low rectovaginal fistulas.

AIM: The percentage recurrence after any surgical treatment for low rectovaginal fistula (LRVF) is unacceptably high. The aim of this study was to evaluate the short- and long-term results of the Martius procedure in a carefully selected series of patients with a LRVF of at least 1 cm diameter who had had at least two previous surgeries or in the presence of chronically inflamed local tissues. METHOD: Between January 2009 and April 2017, 24 patients with the abovementioned features were prospectively included in this study. Success was defined both as the absence of any subjective symptoms and the fistula, as confirmed by evaluation under anaesthesia. Postoperative complications were assessed using the Clavien-Dindo classification. Quality of life (SF-12 score), quality of sexual life [Female Sexual Function Index (FSFI) score] and continence [Cleveland Clinic Incontinence Score (CCIS)] were also determined pre- and postoperatively. RESULTS: The mean follow-up was 42 ± 29 months (range 3-101 months). The overall success rate was 91.3% (22/24 patients). The median operation time was 50 min (range 45-70 min), and the median hospital stay was 3.5 days (range 3-5 days). No major complications occurred. Pre- and postoperative CCIS did not differ [1 (range 0-3.5)]. The postoperative SF-12 score improved both in terms of the physical (33.6 ± 7.2 vs 50.8 ± 7.8; P < 0.001) and mental (32.6 ± 6.7 vs 56.3 ± 7.8; P < 0.001) components. FSFI improved from 19.5 ± 6.6 to 24.4 ± 6.3 (P < 0.001). CONCLUSION: The Martius procedure should be considered as the first-line method of treatment in carefully selected cases of LRVF.

Anatomical evaluation of the extent of spread in the erector spinae plane block: a cadaveric study.

PURPOSE: The erector spinae plane (ESP) block is an interfascial analgesic technique first described as an alternative for pain control at the thoracic level. The objective of this observational study was to determine the anatomical spread of dye following a T7 ESP block in a cadaveric model. METHODS: An ultrasound-guided ESP block was performed in four fresh human cadavers using an in-plane approach with a linear probe in a longitudinal orientation and a puncture in a craniocaudal direction. Twenty millilitres of an iodinated contrast/methylene blue solution was injected deep to the erector spinae muscle at the distal end of the T7 transverse process bilaterally in two of the specimens, and unilaterally in the other two (six ESP blocks in total). Subsequently, the specimens were subjected to a multi-slice computed tomography (CT) scan with three-dimensional reconstruction. Two of the specimens were dissected to evaluate the distribution of the contrast solution, and a sectional study was performed in the other two. RESULTS: In the six samples, evaluated by CT scan and anatomical dissection, a craniocaudal spread of the dye was observed in the dorsal region from T1-T11 with lateral extension towards the costotransverse region. No diffusion of contrast solution or dye to the anterior region (paravertebral space) was observed by CT scan or dissection. CONCLUSIONS: The results suggest that the ESP block reaches a wide range of the posterior rami of spinal nerves without diffusion into the paravertebral space or involvement of the anterior rami.

RéSUMé: OBJECTIF: Le bloc du plan des muscles érecteurs du rachis (ESP) est une technique analgésique interfasciale qui avait d'abord été décrite comme une alternative pour contrôler la douleur au niveau thoracique. L'objectif de cette étude observationnelle était de déterminer la propagation anatomique d'un colorant après la réalisation d'un bloc ESP au niveau T7 dans un modèle cadavérique. MéTHODE: Un bloc ESP a été réalisé sous échoguidage sur quatre cadavres humains frais en utilisant une approche dans le plan avec une sonde linéaire en orientation longitudinale et une ponction en direction cranio-caudale. Vingt millilitres d'une solution de contraste iodée / bleu de méthylène ont été injectés postérieurement aux muscles érecteurs du rachis à l'extrémité distale de l'apophyse transverse T7, bilatéralement dans deux des spécimens et unilatéralement dans les deux autres (soit six blocs ESP au total). Par la suite, les spécimens ont été soumis à une tomodensitométrie multicoupe avec reconstruction en 3D. Deux des spécimens ont été disséqués afin d'évaluer la distribution de la solution de contraste, et une étude sectionnelle a été réalisée sur les deux autres spécimens. RéSULTATS: Dans les six échantillons évalués par tomodensitométrie et dissection anatomique, une propagation cranio-caudale du colorant a été observée dans la région dorsale de T1­T11 avec une extension latérale vers la région costo-transverse. La tomodensitométrie et la dissection n'ont révélé aucune propagation de la solution de contraste ou du colorant à la région antérieure (espace paravertébral). CONCLUSION: Ces résultats suggèrent que le bloc ESP atteint de nombreux rameaux postérieurs des nerfs rachidiens sans diffusion dans l'espace paravertébral ou atteintes des rameaux antérieurs.