Squamous cell carcinoma arising from chronic sacrococcygeal pilonidal disease: a case report.

BACKGROUND: Sacrococcygeal pilonidal disease is a chronic, well-recognized entity, characterized by the recurrent formation of an abscess or draining sinus over the sacrococcygeal area. It is one of the most common surgical problems. Rarely, chronic inflammation and recurrent disease leads to malignant transformation, most commonly to squamous cell carcinoma (SCC). CASE PRESENTATION: We describe an extremely unusual case of SCC developing in a 60-year-old patient with a chronic pilonidal sinus complicated by an anal fistula. After wide surgical excision of the pilonidal sinus and fistulas and because of the poor healing process 6 months later, colonoscopy and a percutaneous fistulography were performed, revealing an anal canal-pilonidal fistula. Patient was treated with a more radical surgical resection with a prophylactic loop colostomy, but healing was not accelerated. Multiple biopsies were then taken from the surgical site at the time, which revealed the development of SCC. CT and MRI imaging techniques revealed SCC partial invasion of the coccyx and sacrum. As a result, aggressive surgical approach was decided. Histological examination revealed moderately to poorly differentiated SCC, and the patient was treated with adjuvant radiation therapy postoperatively. Nine months later, recurrence was found in the sacrum and para-aorta lymph nodes and the patient died shortly after. We discuss the clinical features, pathogenesis, treatment options, and prognosis of this rare malignant transformation. CONCLUSIONS: The development of SCC in chronic pilonidal disease is a rare but serious complication. Symptoms are usually attributed to the sacrococcygeal pilonidal disease (SPD), and diagnosis is often made late by histological examination of biopsies. Malignant transformation should be suspected in chronic SPD with recurrent episodes of inflammation, repeated purulent discharge, poor healing, and chronic complex fistulas.

Mixed corticomedullary adrenal carcinoma.

Truly mixed corticomedullary tumors (MCMTs) are extremely rare and present as a single tumor mass composed of an intimately admixed population of both adrenal cortical cells and pheochromocytes. The current study describes the first case of a mixed corticomedullary adrenal carcinoma. In addition, we also review the published data on MCMTs to determine their clinical features, biochemical characteristics, pathological findings, and management. In order to compose this review, a search of the international literature for MCMTs was conducted. Fifteen related articles were found. The clinical and pathological information was obtained for all reported cases. MCMTs were found almost exclusively in females. In the vast majority of patients, the symptoms were related to the tumor's hormone hypersecretion. Hypertension and diabetes were present in 80 and 40 % of cases, respectively. Cushing's syndrome was reported in eight cases (53.33 %). A final diagnosis was made in all cases after surgery based on the pathological results. As of the writing of this article, all published cases of MCMTs had benign clinical behavior, with no instances of metastasis or death due to the tumor. MCMTs are currently considered to be benign tumors. Ours is the first case of malignant MCMT reported in the literature. The potential for malignancy should therefore be considered for these tumors.

The Minimum Effective Training Dose Required for 1RM Strength in Powerlifters.

The aim of this multi-experiment paper was to explore the concept of the minimum effective training dose (METD) required to increase 1-repetition-maximum (1RM) strength in powerlifting (PL) athletes. The METD refers to the least amount of training required to elicit meaningful increases in 1RM strength. A series of five studies utilising mixed methods, were conducted using PL athletes & coaches of all levels in an attempt to better understand the METD for 1RM strength. The studies of this multi-experiment paper are: an interview study with elite PL athletes and highly experienced PL coaches (n = 28), an interview and survey study with PL coaches and PL athletes of all levels (n = 137), two training intervention studies with intermediate-advanced PL athletes (n = 25) and a survey study with competitive PL athletes of different levels (n = 57). PL athletes looking to train with a METD approach can do so by performing ~3-6 working sets of 1-5 repetitions each week, with these sets spread across 1-3 sessions per week per powerlift, using loads above 80% 1RM at a Rate of Perceived Exertion (RPE) of 7.5-9.5 for 6-12 weeks and expect to gain strength. PL athletes who wish to further minimize their time spent training can perform autoregulated single repetition sets at an RPE of 9-9.5 though they should expect that strength gains will be less likely to be meaningful. However, the addition of 2-3 back-off sets at ~80% of the single repetitions load, may produce greater gains over 6 weeks while following a 2-3-1 squat-bench press-deadlift weekly training frequency. When utilizing accessory exercises in the context of METD, PL athletes typically utilize 1-3 accessory exercises per powerlift, at an RPE in the range of 7-9 and utilize a repetition range of ~6-10 repetitions.

"Just One More Rep!" - Ability to Predict Proximity to Task Failure in Resistance Trained Persons.

In resistance training, the use of predicting proximity to momentary task failure (MF, i.e., maximum effort), and repetitions in reserve scales specifically, is a growing approach to monitoring and controlling effort. However, its validity is reliant upon accuracy in the ability to predict MF which may be affected by congruence of the perception of effort compared with the actual effort required. The present study examined participants with at least 1 year of resistance training experience predicting their proximity to MF in two different experiments using a deception design. Within each experiment participants performed four trials of knee extensions with single sets (i.e., bouts of repetitions) to their self-determined repetition maximum (sdRM; when they predicted they could not complete the next repetition if attempted and thus would reach MF if they did) and MF (i.e., where despite attempting to do so they could not complete the current repetition). For the first experiment (n = 14) participants used loads equal to 70% of a one repetition maximum (1RM; i.e., the heaviest load that could be lifted for a single repetition) performed in a separate baseline session. Aiming to minimize participants between day variability in repetition performances, in the second separate experiment (n = 24) they used loads equal to 70% of their daily isometric maximum voluntary contraction (MVC). Results suggested that participants typically under predicted the number of repetitions they could perform to MF with a meta-analytic estimate across experiments of 2.0 [95%CIs 0.0 to 4.0]. Participants with at least 1 year of resistance training experience are likely not adequately accurate at gauging effort in submaximal conditions. This suggests that perceptions of effort during resistance training task performance may not be congruent with the actual effort required. This has implications for controlling, programming, and manipulating the actual effort in resistance training and potentially on the magnitude of desired adaptations such as improvements in muscular hypertrophy and strength.

Retroperitoneal ganglioneuroma in an adult patient: a case report and literature review of the last decade.

Ganglioneuromas arise from the neural crest and are highly differentiated and benign. The case of a 43-year-old female who presented with a 6.5 cm primary extra-adrenal retroperitoneal ganglioneuroma (RGN) is presented, and the relevant English literature from the last decade is reviewed. Histology showed mature ganglion cells and nerve fibers without any malignancy (S-100 and neuron- specific enolase [NSE] positive). Hospitalization lasted four days. The patient has shown no signs of recurrence. Radical excision of the tumor is unnecessary, especially when vascular structures are endangered. RGN-related hospitalization is short and the prognosis is good.

Adrenal Gland Lymphangiomas.

Lymphangiomas of the adrenal glands (ALs) are benign vascular lesions. Approximately, 53 cases have been reported in the literature. The current study reviews and analyzes the clinical and pathologic features of all reported ALs and additionally illustrates a typical case of adrenal lymphangioma (AL). In order to perform the review analysis, a search of the international literature for ALs in adults was conducted. Thirty-eight related articles were found. Clinical and pathological information were obtained for all the reported cases and a database was created. ALs were detected more frequently in women than men. The mean age of occurrence was 39.5 years, while their mean size was 8.86 cm. Fifty-nine percent of ALs were right-sided. Size and localization were responsible for the presenting symptoms, though 30.4 % were asymptomatic. Diagnosis was made postoperatively in all cases by histological results. ALs are rare and benign lesions. They usually present as an incidental finding after abdominal imaging. The diagnosis is made after the surgical removal by histological and immunohistochemical examinations.

Cross reactivity between venomous, mildly venomous, and non-venomous snake venoms with the Commonwealth Serum Laboratories Venom Detection Kit.

OBJECTIVE: Studies have noted the relatively common occurrence of positive urine results with the Commonwealth Serum Laboratories Venom Detection Kit (VDK) when testing patients with suspected snakebite who are not envenomed. Possible explanations have been false positive test results or subclinical envenoming. We investigated a third possibility, that there is potential for the venom (or saliva) from mildly venomous and non-venomous snakes to give a positive reading with the VDK. METHODS: Venoms/saliva from three non-venomous and seven mildly venomous snake species were tested in the laboratory with the VDK, along with control venoms from four of the five major snake genera (Brown snake, Tiger snake, Death adder and Black snake). RESULTS: Two of the venom/saliva samples, from Gould's hooded snake (Parasuta gouldii), a mildly venomous snake, and the Black-headed python (Aspidites melanocephalus), a non-venomous snake, caused a positive test for the tiger snake genus. There was also cross-reactivity between black snake venoms and the tiger snake well of the VDK. CONCLUSIONS: This study provides a further possible explanation for 'false positive' VDK results, that is venom/saliva presence or absorption from mildly or non-venomous snakes and cross reactivity with venomous snakes on VDK testing. It has implications for antivenom use should it ever be required for more severe envenoming syndromes from mildly or moderately venomous snakes, and for further research. It reinforces the practice of only using VDK testing in patients who show definite evidence of envenoming.

Patterns in the parathyroid response to sodium bicarbonate infusion test in healthy volunteers.

BACKGROUND: The sodium bicarbonate infusion test evaluates the function of the parathyroid glands. The present study aims to evaluate the range of parathyroid response in healthy individuals and the potential influence of various factors. METHODS: Fifty healthy volunteers were subjected to the test. Levels of vitamin D, calcium, albumin, and PTH were measured before infusion. PTH was measured at 3, 5, 10, 30, and 60 minutes after infusion. RESULTS: A curve describing the response of parathyroids to the test was drawn. Twenty percent of the subjects had blunted PTH response. No significant difference was observed between normal and blunted responders concerning age, BMI, baseline PTH, or calcium levels. Nonetheless, there was a significant difference in vitamin D levels (P = 0.024). INTERPRETATION: The test is easy to perform and may be used for everyday screening. It has to be clarified whether our observations are, at least partly, produced due to the presence of individuals with a constitutively blunted response or if low levels of vitamin D decrease the ability of the parathyroids to respond. Whichever the case, PTH response of normal individuals to sodium bicarbonate infusion test is more varied than previously thought and vitamin D levels influence it.

Necrotizing cellulitis of the abdominal wall, caused by Pediococcus sp., due to rupture of a retroperitoneal stromal cell tumor.

INTRODUCTION: Soft tissue necrotizing infections are a significant cause of morbidity and mortality. The aim of this study is to present a patient with necrotizing infection of abdominal wall resulting from the rupture of a retroperitoneal stromal tumor. PRESENTATION OF CASE: We present a 60-year-old Caucasian male patient with necrotizing infection of abdominal wall secondary to the rupture of a retroperitoneal stromal tumor. The patient was initially treated with debridement and fasciotomy of the anterior abdominal wall. Laparotomy revealed purulent peritonitis caused by infiltration and rupture of the splenic flexure by the tumor. Despite prompt intervention the patient died 19 days later. The isolated microorganism causing the infection was the rarely identified as cause of infections in humans Pediococcus sp., a gram-positive, catalase-negative coccus. DISCUSSION: Necrotizing infections of abdominal wall are usually secondary either to perineal or to intra-abdominal infections. Gastrointestinal stromal cell tumors could be rarely complicated with perforation and abscess formation. In our case, the infiltrated by the extra-gastrointestinal stromal cell tumor ruptured colon was the source of the infection. The pediococci are rarely isolated as the cause of severe septicemia. CONCLUSION: Ruptured retroperitoneal stromal cell tumors are extremely rare cause of necrotizing fasciitis, and before this case, Pediococcus sp. has never been isolated as the responsible agent.

Small bowel perforation due to CMV enteritis infection in an HIV-positive patient.

BACKGROUND: Cytomegalovirus infection of the gastrointestinal tract is common and is more often seen in patients with acquired immunodeficiency syndrome (AIDS). Although small bowel infection is less common than infection of other parts of the gastrointestinal system, it may lead to perforation, an acute complication, with dreadful results. CASE PRESENTATION: This article reports a case of Cytomegalovirus ileitis with multiple small bowel perforations in a young man with human immunodeficiency virus (HIV) infection. The patient developed abdominal pain with diarrhea and fever, and eventually acute abdomen with pneumoperitoneum. The patient had poor prognosis and deceased despite the prompt surgical intervention and the antiviral therapy he received. At pathology a remarkable finding was the presence of viral inclusions in smooth muscle fibers. The destruction of muscle cells was the main cause of perforation. CONCLUSION: Morbidity and mortality associated with perforation from CMV enteritis in AIDS patients are high and the life expectancy is short. Cytomegalovirus disease is multifocal; therefore, excision of one portion of the gastrointestinal tract may be followed by a complication elsewhere. Our case elucidate that muscle cell destruction by the virus is a significant cause leading to perforation.

Typical image of splenic hydatidosis.

This is a typical case of a splenic hydatid cysts. We present the clinical features, the diagnostic work-up and the management of the disease.

Intraoperative stimulation neuromonitoring versus intraoperative continuous electromyographic neuromonitoring in total thyroidectomy: identifying laryngeal complications.

BACKGROUND: Laryngeal complications occur in thyroidectomies as a result of several factors, but especially because of nerve damage. We compared intraoperative stimulation neuromonitoring (IONM) with intraoperative continuous electromyographic neuromonitoring (IEM) to evaluate their ability to identify postoperative laryngeal complications. METHODS: This prospective clinical trial included 174 patients (348 nerves) who had both IONM and IEM. We recorded age, sex, pathology, vocal fold motility, and complications. RESULTS: IONM identified 334 nerves, whereas IEM identified 348. Five patients had transient laryngeal complications, 2 bilateral, and 3 unilateral recurrent laryngeal nerve paresis. In addition, in 2 patients IEM showed placement of the tracheal tube balloon on the vocal folds, which led to correction. Sensitivity and specificity were 96.48% and 100% for IONM and 100% and 100% for IEM, respectively. IONM had a positive predictive value of 100% and a negative predictive value of 36.84%. The positive and negative predictive values of IEM were 100%. CONCLUSIONS: Both techniques identify recurrent laryngeal nerve injuries; however, IEM seems to have an advantage concerning the nonsurgical laryngeal complications and may play a role in preventing morbidity.

The value of vacuum-assisted closure in septic patients treated with laparostomy.

The ideal method of temporary abdominal closure (TAC) should allow rapid closure, easy maintenance, and wound repair with minimal tissue damage. The aim of this retrospective study is to compare open abdomen outcomes between patients managed with vacuum-assisted closure (VAC), and patients managed with other methods of TAC, when septic abdomen is present. Two groups of patients with septic open abdomen: 27 treated with VAC versus 31 treated with other techniques of TAC. We studied open abdomen duration, number of dressing changes, re-exploration rate, successful abdominal closure rate, overall mortality, and development of enteroatmospheric fistulas. The VAC device demonstrated its superiority concerning open abdomen duration (P < 0.001), number of dressing changes (P < 0.001), re-exploration rate (P < 0.002), successful abdominal closure rate (P < 0.0001), and development of enteroatmospheric fistulas (P < 0.00001). Compared with other methods of TAC, our experience with the VAC device demonstrated its advantages concerning clinical feasibility. The high rates of direct fascia closure with an acceptable rate of ventral hernias are further benefits of this technique.

Enterobius vermicularis: a rare cause of appendicitis.

OBJECTIVE: Although appendicitis is one of the most common causes of emergency surgery, parasites are rarely found associated with inflammation of the appendix. The aim of this study is to establish the prevalence of Enterobius vermicularis in surgically removed appendices, as well as to determine its possible role in the pathogenesis of appendicitis. METHODS: A retrospective analysis of all the appendices removed during the last 20 years at a tertiary university hospital. Appendices removed during the course of another intra-abdominal procedure were excluded from the study. RESULTS: All 1085 surgical specimens removed from patients with clinical appendicitis were evaluated. Enterobius vermicularis was found in seven appendices (0.65%) with clinical symptoms of appendicitis. The parasite was most frequently identified in appendices without pathological changes (6/117). There was no case of chronic appendicitis presenting E. vermicularis infestation, while the parasite was rarely related to histological changes of acute appendicitis (1/901). CONCLUSION: The results suggest that the presence of E. vermicularis in the appendix might cause appendiceal pain (colic), but can rarely be associated with pathologic findings of acute appendicitis.

Confronting gastrocutaneous fistulas.

A gastrocutaneous fistula (GCF) represents a fistula connecting the stomach with the skin. The aim of the present review is to clarify the entity of a GCF and to discuss the various treating strategies employed. In order to elucidate GCFs as an entity etiology was pointed out and relative pathogenetic mechanisms were explored. Moreover, diagnostic modalities are discussed with a special focus on GCFs following bariatric operations. Finally, the treating strategies currently employed when confronting GCFs are presented, as well as their effectiveness.

Abdominal compliance, linearity between abdominal pressure and ascitic fluid volume.

BACKGROUND: Drainage of ascitic fluid is a common practice in order to relief the respiratory discomfort of patients. AIM: To determine the relation between the intra-abdominal pressure (IAP) and extracted volume of the ascitic fluid, in order to calculate abdominal compliance (Cabd). SETTINGS AND DESIGN: A study was designed at AHEPA University Hospital and analysed with prospectively collected data. MATERIALS AND METHODS: Fifteen patients with tension ascites that had transcutaneous drainage with a wide catheter. The ascitic fluid removed was measured, while the IAP and a Visual Analogue Scale (VAS) score for dyspnea were recorded before and 15 min after the puncture. Cabd was calculated. STATISTICAL ANALYSIS: The data were analysed with descriptive statistics, paired Student's t-test and Pearson coefficiency. RESULTS: The predrainage IAP was 18.26 mmHg (SD 1.67 mmHg), while the postdrainage was 14.46 mmHg (SD 1.34 mmHg) (P<0.001). The mean volume of ascitic fluid removed was 1624 mL (SD 861 mL). Cabd after drainage was 414.01 mL/mmHg (SD 139.15 mL/mmHg). A linear correlation was found between ascitic fluid removal and IAP variations. The dyspnea VAS score was 7.5 (SD=0.8) before the drainage and 4.3 (SD=1.0) after the drainage (P<0.001). CONCLUSIONS: The drainage of ascitic fluid reduces IAP, facilitating in this way respiration. Moreover, IAP variation seems to be in linear relation with the volume of ascitic fluid removed. This linear relation between IAP and volume may probably predict the Cabd quite accurately and vice versa. However, larger studies are necessary to safely draw predicting ΔIAP - ΔV (Cabd) diagrams, and determine the optimal ascitic fluid removal to achieve best comforting of the patient and slower fluid reformation.

Acute appendicitis caused by endometriosis: a case report.

INTRODUCTION: Endometriosis is a well-recognized gynecological condition in the reproductive age group. Surgical texts present the gynecological aspects of the disease in detail, but the published literature on unexpected manifestations, such as appendiceal disease, is inadequate. The presentation to general surgeons may be atypical and pose diagnostic difficulty. Thus, a definitive diagnosis is likely to be established only by the histological examination of a specimen. CASE PRESENTATION: We report a case of endometriosis of the appendix in a 25-year-old Caucasian woman who presented with symptoms of acute appendicitis and was treated by appendectomy, which resulted in a good outcome. CONCLUSIONS: We discuss special aspects of acute appendicitis caused by endometriosis to elucidate the pathologic entity of this variant of acute appendicitis.

Umbilical endosalpingiosis: a case report.

INTRODUCTION: Endosalpingiosis describes the ectopic growth of Fallopian tube epithelium. Pathology confirms the presence of a tube-like epithelium containing three types of cells: ciliated, columnar cells; non-ciliated, columnar secretory mucous cells; and intercalary cells.We report the case of a woman with umbilical endosalpingiosis and examine the nature and characteristics of cutaneous endosalpingiosis by reviewing and combining the other four cases existing in the international literature. CASE PRESENTATION: A 50-year-old Caucasian, Greek woman presented with a pale brown nodule in her umbilicus. The nodule was asymptomatic, with no cyclical discomfort or variation in size. Her personal medical, surgical and gynecologic history was uneventful. An excision within healthy margins was performed under local anesthesia. A cystic formation measuring 2.7×1.7×1 cm was removed. Histological examination confirmed umbilical endosalpingiosis. CONCLUSIONS: Umbilical endosalpingiosis is a very rare manifestation of the non-neoplasmatic disorders of the Müllerian system. It appears with cyclic symptoms of pain and swelling of the umbilicus, but not always. The disease is diagnosed using pathologic findings and surgical excision is the definitive treatment.

Superficial selective cervical plexus block following total thyroidectomy: a randomized trial.

BACKGROUND: Pain after thyroid surgery is of moderate intensity and short duration. Bilaterally superficial cervical plexus block (BSCPB) may reduce analgesic requirements. However, its effectiveness in decreasing pain after thyroidectomy is debated. METHODS: This double-blind, randomized placebo-controlled study in 100 patients undergoing total thyroidectomy evaluates the effects of BSCPB done with 20 mL of 0.75% ropivacaine. Additional parecoxib was administrated immediately postoperatively and 12 hours later. RESULTS: Postoperative pain was assessed by visual analogue rating scale. All parameters were recorded at 0, 3, 6, 9, 12, and 24 hours after surgery. The control group had higher values than the ropivacaine group at all moments (p < .05) except H12 (p = .76). Additional analgesia was needed for 7 patients (14%) in the control group and for 8 patients (16%) in the group with ropivacaine (p = .96). CONCLUSION: Two-point bilateral BSCPB has a major analgesic effect on patients after total thyroidectomy, with a statistically significant reduction in postoperative pain scores. However, no significant difference was noted in the proportion of patients that required additional analgesics.

UltraCision harmonic scalpel versus clamp-and-tie total thyroidectomy: a clinical trial.

BACKGROUND: Hemostasis is important in thyroid surgery to avoid complications. Our aim was to evaluate the effectiveness of the harmonic scalpel in patients undergoing total thyroidectomy. METHODS: In this study, 90 patients were randomized into group A (classic technique of tying and knots) and group B (harmonic scalpel). We recorded the following: age, sex, pathology, thyroid weight, hemostatic technique, duration of operation, change in calcemia (DeltaCa), change in hematocrit (DeltaHt), change in hemoglobin (DeltaHgb), change in white blood cell count (DeltaWBC), vocal motility, operative difficulty, postoperative vocal alteration, postoperative pain, complications, blood in the drains, operating time, mass of gland excised per minute, and hospitalization. RESULTS: Differences (p < .05) were observed concerning duration of surgery, operative difficulty, postoperative pain, hospitalization, DeltaWBC, and quantity of gland removed per minute. No recurrent laryngeal nerve (RLN) palsies were observed. CONCLUSIONS: Use of the Harmonic Scalpel in total thyroidectomy is more effective than the clamp-and-tie technique: the duration of surgery, intraoperative difficulty, postoperative pain, and hospitalization are reduced. Both techniques are equivalent concerning RLN injuries, postoperative vocal alterations, and blood loss.