Commentary on packing vs non-packing of pilonidal sinus cavities after incision and drainage.

Pilonidal sinus disease (PSD) manifests as an inflammatory skin condition typically emerging within the anal cleft. The prevalence of this disease varies in high income countries. This disease is associated with significant physical and psychosocial distress. Surgery is an option for managing PSD; yet, surgical methods vary, and a universally accepted gold standard approach is lacking, leading to current practices that are diverse and subject to ongoing debate. One such point of contention revolves around the decision to use packing or opt for a non-packing approach following surgery. Mohamedahmed et al (2021) conducted a systematic review to evaluate the comparative outcomes of packing versus non-packing of an abscess cavity following incision and drainage of cutaneous abscess on any part of the body. This commentary aims to critically appraise the methods used within the review by Mohamedahmed et al (2021) and expand upon the findings in the context of treatment and management of PSD.

Parental perception of contrast enhanced voiding ultrasonography urodynamics vs fluoroscopic urodynamics.

INTRODUCTION/OBJECTIVES: Contrast enhanced voiding ultrasonography (ceVUS) has not been widely reported to be used during video urodynamics (UDS). We previously reported on the feasibility of this. In this study, we aimed to understand how parents perceived their child's experience of undergoing ceVUS during UDS compared to fluoroscopic (fluoro) UDS. METHODS: Children who underwent both fluoro UDS and ceVUS UDS were recruited. Parents were asked to complete a questionnaire to evaluate their experience with both studies. Demographics including gender, age at study, and diagnosis were collected to account for differences in perception. Statistical analysis was performed. RESULTS: 53 patients were included: 31 girls, 22 boys. Diagnoses included myelomeningocele (67.9%), low/tethered cord (13.2%), closed spinal dysraphism (9.4%), posterior urethral valve (1.9%), cloacal anomaly (1.9%), caudal regression (1.9%), myeloschisis (1.9%), and cerebral palsy (1.9%). There was no statistical difference in mean age at fluoro UDS and ceVUS UDS (77.3 months vs 99.7 months respectively, p = 0.09). All 53 parents (100%) were satisfied/very satisfied with their ceVUS experience; 48 parents (90.6%) preferred ceVUS, 3 parents (5.7%) preferred fluoro UDS, and 2 (3.8%) were neutral. On average, parents perceived ceVUS to be more comfortable (72.7%) and produce better results (67.4%) than fluoro UDS. The majority felt that both studies allowed the same contact with their child (52.3%) and took the same amount of time (50.0%). However 29.5% felt ceVUS was faster and 34.1% felt ceVUS allowed more contact with their child (Fig. 1). 26 parents (49.1%) specifically noted no radiation as the reason why they preferred ceVUS over fluoro. The average age at ceVUS UDS was younger in those who preferred ceVUS UDS compared to those who preferred fluoro UDS (94.6 months vs 180.0 months, p = 0.03). The average age at fluoro UDS was younger in those who preferred ceVUS UDS vs fluoro UDS (73.1 months vs 144 months, p = 0.03). Gender's influence on preference approached significance (p = 0.07); all 3 parents who preferred fluoro UDS had male children. CONCLUSIONS: The majority of parents preferred ceVUS over fluoro UDS. ceVUS was perceived to be more comfortable and provide better results. Many parents highlighted no radiation and no fluoroscopic machinery as factors in preference of ceVUS over fluoro. The parents who preferred ceVUS UDS had children who had both studies done at an earlier age compared to the parents who preferred fluoro UDS.

Rates of Influenza and Pneumococcal Vaccination and Correlation With Survival in Multiple Myeloma Patients.

BACKGROUND: Infections are a common reason for hospitalization and death in multiple myeloma (MM). Although pneumococcal vaccination (PV) and influenza vaccination (FV) are recommended for MM patients, data on vaccination status and outcomes are limited in MM. MATERIALS AND METHODS: We utilized data from the global, prospective, observational INSIGHT MM study to analyze FV and PV rates and associated outcomes of patients with MM enrolled 2016-2019. RESULTS: Of the 4307 patients enrolled, 2543 and 2500 had study-entry data on FV and PV status. Overall vaccination rates were low (FV 39.6%, PV 30.2%) and varied by region. On separate multivariable analyses of overall survival (OS) by Cox model, FV in the prior 2 years and PV in the prior 5 years impacted OS (vs. no vaccination; FV: HR, 0.73; 95% CI, 0.60-0.90; P = .003; PV: HR, 0.51; 95% CI, 0.42-0.63; P < .0001) when adjusted for age, region, performance status, disease stage, cytogenetics at diagnosis, MM symptoms, disease status, time since diagnosis, and prior transplant. Proportions of deaths due to infections were lower among vaccinated versus non-vaccinated patients (FV: 9.8% vs. 15.3%, P = .142; PV: 9.9% vs. 18.0%, P = .032). Patients with FV had generally lower health resource utilization (HRU) versus patients without FV; patients with PV had higher or similar HRU versus patients without PV. CONCLUSION: Vaccination is important in MM and should be encouraged. Vaccination status should be recorded in prospective clinical trials as it may affect survival. This trial was registered at www. CLINICALTRIALS: gov as #NCT02761187.

Perspectives on the Risk-Stratified Treatment of Multiple Myeloma.

The multiple myeloma treatment landscape has changed dramatically. This change, paralleled by an increase in scientific knowledge, has resulted in significant improvement in survival. However, heterogeneity remains in clinical outcomes, with a proportion of patients not benefiting from current approaches and continuing to have a poor prognosis. A significant proportion of the variability in outcome can be predicted on the basis of clinical and biochemical parameters and tumor-acquired genetic variants, allowing for risk stratification and a more personalized approach to therapy. This article discusses the principles that can enable the rational and effective development of therapeutic approaches for high-risk multiple myeloma.

Upper pole pathologies in duplex kidneys: an analysis of predictive factors for surgery and urinary tract infections from the Mid-Atlantic Pediatric Academic Consortium.

BACKGROUND/OBJECTIVE: While there is significant data on the natural history and outcomes for prenatal hydronephrosis in simplex kidneys, duplex kidneys tend to be less studied. Management can be quite variable based on provider preference. We aimed to describe practice patterns from several tertiary academic institutions, identify clinical predictors for surgical intervention and urinary tract infection (UTI) for upper pole pathology, and demonstrate the natural history of lower pole vesicoureteral reflux (VUR). METHODS: We conducted a retrospective review of patients from 4 Mid-Atlantic institutions between 2015 and 2020. Inclusion criteria included patients with a duplex kidney with upper pole pathology and/or lower pole VUR. The primary outcome was predictive factors for surgical intervention and UTI. The secondary outcome was to assess the natural history of lower pole VUR including resolution rates by grade. Linear regression identified clinical predictors for UTI events. Multivariate logistic regression identified predictors of surgical intervention, UTI, and lower pole VUR resolution. Descriptive statistics and regression modeling analyses were performed using SAS. RESULTS: Two hundred forty-two patients were included with a total of 271 duplex renal units. Hydronephrosis grade (both SFU and UTD grading) and number of prior UTI events were statistically significant predictors for surgical intervention (p = 0.03/0.001 and p = 0.002 respectively). Ectopic ureter (p = 0.004), ureterocele (p = 0.02), and obstruction (p = 0.04) were the only pathologies predictive for surgery. Male gender and circumcision were significantly associated with decreased UTI risk (p = 0.03 and p = 0.01). On linear regression modeling, antibiotic prophylaxis after the first year of life was associated with decreased risk of further UTI events (p = 0.03); however, antibiotic prophylaxis within the first year of life did not decrease UTI risk (p = 0.14). For VUR outcomes, 65.0% of grades 1-3 VUR and 52.2% of grades 4-5 had resolution/improvement at mean time of 2.1 years. There were no predictive factors for resolution/improvement of VUR. CONCLUSIONS: Hydronephrosis grade and UTI events were significant predictors for surgical intervention for upper pole pathology. Pathologies that were predictive for surgery included ectopic ureter, ureterocele and obstruction. Male gender, circumcision and antibiotic prophylaxis after the first year of life were associated with a decreased UTI risk. Roughly 58% of lower pole VUR spontaneously improved/resolved. Identification of these risk factors aids in standardization of care practices to reduce long-term UTI risk and inform counseling with families about possible need for surgical intervention and expectations for long term outcomes.