Minimally Invasive Multidisciplinary Approach to Chronic Giant Inguinoscrotal Hernias.

Background. Giant inguinoscrotal hernias (GIH) are defined as groin hernias extending below the mid-thigh when standing, often significantly encumbering activities of daily living. To date, there are no reports utilizing the combination of progressive pneumoperitoneum (PPP), botulinum toxin A injection (BTI), and enhanced view-totally extraperitoneal (eTEP) technique for GIH repair. In this report, we present 2 such cases of this unique minimally invasive multidisciplinary approach to address GIH. Series Presentation. Two individuals with lifelong complaints of GIH presented for elective hernia repair, each with significant morbidity relating to their pathology and profound loss of abdominal domain. Four weeks prior to surgery, BTI was administered to the lateral abdominal compartment muscles to facilitate regional paralysis, followed by PPP to develop larger intraabdominal domain. Utilizing the eTEP access technique and transversus abdominis release, a wide retromuscular dissection was performed to aid in the increase of intraabdominal domain and to develop a large space for mesh placement. Reconstruction including partial scrotectomy and scrotoplasty using adjacent tissue transfer technique was completed. Both patients tolerated the procedures well without recurrence in the first postoperative year. Conclusion. In this article, we present the first series of GIH patients undergoing combined PPP, BTI, and eTEP access approach to retromuscular dissection. This multidisciplinary approach to patient care has proven both safe and effective.

Novel Interventional Nonopioid Therapies in Headache Management.

PURPOSE OF REVIEW: Headaches encompass a broad-based category of a symptom of pain in the region of the head or neck. For those patients who unfortunately do not obtain relief from conservative treatment, interventional techniques have been developed and are continuing to be refined in an attempt to treat this subset of patients with the goal of return of daily activities. This investigation reviews various categories of headaches, their pathophysiology, and types of interventional treatments currently available. RECENT FINDINGS: Injection of botulinum toxin has been shown to increase the number of headache free days for patients suffering from chronic tension-type headaches. Suboccipital steroid injection has been demonstrated as a successful treatment option for patients suffering from cluster headache. Occipital nerve stimulation (ONS) has been described as a treatment for all types of trigeminal autonomic cephalgias. Percutaneous ONS is a minimally invasive and reversible approach to manage occipital neuralgia performed utilizing subcutaneous electrodes placed superficial to the cervical muscular fascia in the suboccipital area. Radiofrequency lesioning is another commonly used treatment in the management of chronic pain syndromes of the head and neck. If a diagnostic sphenopalatine ganglion block successfully resolves the patient's symptoms, neurolysis can be employed as a more permanent solution. Although many patients who suffer from headaches can be treated with conservative, less-invasive treatments, there still remains at present an ever-increasing need for those patients who are refractory to conservative measures and thus require interventional treatments. These procedures are continually evolving to become safer, more precise, and more readily available for clinicians to provide to their patients.

Comparative Genomics of Clostridium baratii Reveals Strain-Level Diversity in Toxin Abundance.

Clostridium baratii strains are rare opportunistic pathogens associated with botulism intoxication. They have been isolated from foods, soil and be carried asymptomatically or cause botulism outbreaks. Is not taxonomically related to Clostridium botulinum, but some strains are equipped with BoNT/F7 cluster. Despite their relationship with diseases, our knowledge regarding the genomic features and phylogenetic characteristics is limited. We analyzed the pangenome of C. baratii to understand the diversity and genomic features of this species. We compared existing genomes in public databases, metagenomes, and one newly sequenced strain isolated from an asymptomatic subject. The pangenome was open, indicating it comprises genetically diverse organisms. The core genome contained 28.49% of the total genes of the pangenome. Profiling virulence factors confirmed the presence of phospholipase C in some strains, a toxin capable of disrupting eukaryotic cell membranes. Furthermore, the genomic analysis indicated significant horizontal gene transfer (HGT) events as defined by the presence of prophage genomes. Seven strains were equipped with BoNT/F7 cluster. The active site was conserved in all strains, identifying a missing 7-aa region upstream of the active site in C. baratii genomes. This analysis could be important to advance our knowledge regarding opportunistic clostridia and better understand their contribution to disease.