The Madrid Posterior Component Separation: An Anatomical Approach for Effective Reconstruction of Complex Midline Hernias.

Introduction: In recent years, Posterior Component Separation (PCS) with the Madrid modification (Madrid PCS) has emerged as a surgical technique. This modification is believed to enhance the dissection of anatomical structures, offering several advantages. The study aims to present a detailed description of this surgical technique and to analyse the outcomes in a large cohort of patients. Materials and Methods: This study included all patients who underwent the repair of midline incisional hernias, with or without other abdominal wall defects. Data from patients at three different centres specialising in abdominal wall reconstruction was analysed. All patients underwent the Madrid PCS, and several variables, such as demographics, perioperative details, postoperative complications, and recurrences, were assessed. Results: Between January 2015 and June 2023, a total of 223 patients underwent the Madrid PCS. The mean age was 63.4 years, with a mean BMI of 33.3 kg/m2 (range 23-40). According to the EHS classification, 139 patients had a midline incisional hernia, and 84 had a midline incisional hernia with a concomitant lateral incisional hernia. According to the Ventral Hernia Working Group (VHWG) classification, 177 (79.4%) patients had grade 2 and 3 hernias. In total, 201 patients (90.1%) were ASA II and III. The Carolinas Equation for Determining Associated Risks (CeDAR) was calculated preoperatively, resulting in 150 (67.3%) patients with a score between 30% and 60%. A total of 105 patients (48.4%) had previously undergone abdominal wall repair surgery. There were 93 (41.7%) surgical site occurrences (SSO), 36 (16.1%) surgical site infections (SSI), including 23 (10.3%) superficial and 7 (3.1%) deep infections, and 6 (2.7%) organ/space infections. Four (1.9%) recurrences were assessed by CT scan with an average follow-up of 23.9 months (range 6-74). Conclusion: The Madrid PCS appears to be safe and effective, yielding excellent long-term results despite the complexity of abdominal wall defects. A profound understanding of the anatomy is crucial for optimal outcomes. The Madrid modification contributes to facilitating a complete retromuscular preperitoneal repair without incision of the transversus abdominis. The extensive abdominal wall retromuscular dissection obtained enables the placement of very large meshes with minimal fixation.

[Incisional hernia: open abdominal wall reconstruction. Current state of the technique and results]. / Narbenhernien: offene Operationsverfahren und Ergebnisse einer Kohortenstudie mit 343 Patienten.

The treatment of complex midline hernias remains a particular challenge. The currently refined knowledge of the anatomy in the cadaver laboratory and advancing clinical experience have changed our present approach. The aim of this review is to present a description of the updated surgical procedures and outcomes. We favor the retromuscular or preperitoneal layer for mesh implantation, including the Rives-Stoppa procedure (sublay mesh) and posterior component separation with the Madrid modification. We operated on 334 complex midline incisional hernias: 6.3% retromuscular preperitoneal, 15% after Rives-Stoppa, 2.4% anterior component separation and 76% posterior component separation. A bridging procedure was used in 31%. A complication occurred in 35.3%, most of which were wound healing disorders (SSO). The average length of hospital stay was 7.2 days. We recorded a very low incidence of long-term complications: 3.3% recurrence, 0.9% chronic pain (daily use of pain medication), 6% bulging, 1.8% chronic seroma and 2.6% chronic mesh infection. Despite the associated morbidity, retromuscular/preperitoneal treatment offers excellent long-term results.

Recurrence after retromuscular repair or posterior components separation: How to address them. A retrospective multicentre cohort study.

Abdominal wall hernias are common entities that represent important issues. Retromuscular repair and component separation for complex abdominal wall defects are considered useful treatments according to both short and long-term outcomes. However, failure of surgical techniques may occur. The aim of this study is to analyze results of surgical treatment for hernia recurrence after prior retromuscular or posterior components separation. We have retrospectively reviewed patient charts from a prospectively maintained database. This study was conducted in three different hospitals of the Madrid region with surgical units dedicated to abdominal wall reconstruction. We have included in the database 520 patients between December 2014 and December 2021. Fifty-one patients complied with the criteria to be included in this study. We should consider offering surgical treatment for hernia recurrence after retromuscular repair or posterior components separation. However, the results might be associated to increased peri-operative complications.

Anti-reflux surgery vs. bariatric surgery as anti-GERD and hiatal hernia treatment in obese patient. New surgical proposals.

The persistence of obesity favors the failure of the Fundoplication (FP) in the treatment of Gastroesophageal Reflux (GER). However, the weight loss obtained with the performance of a Gastric Bypass (GBP) allows a good resolution of symptoms, without increasing the incidence of postoperative complications. All of this leads us to consider that while FP is the indication in patients with BMI < 30, in those patients with BMI > 35, GBP appears to be the procedure of choice. But there is still no position in the case of patients with a BMI between 30 and 35, although we must take into account that an increase in GER recurrence has been described after FP in patients with a BMI > 30. Although Sleeve Gastrectomy (SG) is one of the most frequently used bariatric procedures in recent years, its association with a high rate of postoperative GER has led several authors to propose its performance associated with an anti-reflux procedure in patients with GER symptoms. Likewise, if the existence of an Hiatal Hernia is verified, it must be treated by hiatoplasty, both during the performance of a GBP and a SG. This simultaneous treatment is not associated with an increase in complications.

Two-Stage Treatment of Chronic Periprosthetic Knee Infections With the Use of Gentamicin-Articulated Spacers: Success Rate and Predictors of Failure at the Minimum Seven-Year Follow-Up.

Background: The purpose of this study was to assess the survivorship rates of 2-stage treatment with gentamicin-impregnated polymethylmethacrylate articulated knee spacer in patients with chronic periprosthetic joint infection and to identify risk factors associated with failure. Methods: We conducted a retrospective study among 73 patients with chronic periprosthetic joint infection after primary total knee replacement with articulated polymethylmethacrylate gentamicin-impregnated spacers (Subiton, Medical Labs, Ind Argentina), performed in a single institution with a minimum follow-up of 7 years. Clinical and functional assessment was performed with Knee Society Score and Western and Ontario McMaster Universities Osteoarthritis Index. A univariate and multivariate analysis was performed to identify the variables that influenced the success and failure rates. Results: We included 73 patients. There were 53 (71.3%) monomicrobial, 11 (15%) polymicrobial, and 10 (13.7%) negative cultures infections. The success and failure rates were 90.5% (n = 66) and 9.5% (n = 7), respectively. Multivariate analysis identified that age (odds ratio = 1.77; P = .039), greater erythrocyte sedimentation rate values prior to the first stage (odds ratio = 1.04; P = .006), and polymicrobial infections (odds ratio = 7.32; P = .0003) were independent variables associated with failure. Conclusions: Two-stage revision with polymethylmethacrylate gentamicin-impregnated knee spacers is an effective strategy for the treatment of chronic periprosthetic joint infection after total knee arthroplasty. Age, higher erythrocyte sedimentation rate values prior first stage, and polymicrobial infections were independent risk factors for treatment failure.

SOD1G93A Astrocyte-Derived Extracellular Vesicles Induce Motor Neuron Death by a miRNA-155-5p-Mediated Mechanism.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by upper and lower motor neuron (MN) degeneration. Astrocytes surrounding MNs are known to modulate ALS progression. When cocultured with astrocytes overexpressing the ALS-linked mutant Cu/Zn superoxide dismutase (SOD1G93A) or when cultured with conditioned medium from SOD1G93A astrocytes, MN survival is reduced. The exact mechanism of this neurotoxic effect is unknown. Astrocytes secrete extracellular vesicles (EVs) that transport protein, mRNA, and microRNA species from one cell to another. The size and protein markers characteristic of exosomes were observed in the EVs obtained from cultured astrocytes, indicating their abundance in exosomes. Here, we analyzed the microRNA content of the exosomes derived from SOD1G93A astrocytes and evaluated their role in MN survival. Purified MNs exposed to SOD1G93A astrocyte-derived exosomes showed reduced survival and neurite length compared to those exposed to exosomes derived from non-transgenic (non-Tg) astrocytes. Analysis of the miRNA content of the exosomes revealed that miR-155-5p and miR-582-3p are differentially expressed in SOD1G93A exosomes compared with exosomes from non-Tg astrocytes. Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis indicates that miR-155-5p and miR-582-3p predicted targets are enriched in the neurotrophin signaling pathway. Importantly, when levels of miR-155-5p were reduced by incubation with a specific antagomir, SOD1G93A exosomes did not affect MN survival or neurite length. These results demonstrate that SOD1G93A-derived exosomes are sufficient to induce MN death, and miRNA-155-5p contributes to this effect. miRNA-155-5p may offer a new therapeutic target to modulate disease progression in ALS.

Effectiveness of two-stage revision with commercial polymethylmethacrylate articulated hip spacer: similar outcomes against monomicrobial and polymicrobial hip periprosthetic joint infections.

Background: orthopaedic surgeons still struggle against a devastating complication - periprosthetic joint infection (PJI). A two-stage revision is considered the gold standard for chronic PJI for several authors, with success rates over 90 %. This strategy implies the remotion of the prosthesis and the implantation of an antibiotic-impregnated cement spacer in the joint. The primary objective of this study was to assess the effectiveness of a two-stage revision approach using a commercial prefabricated antibiotic-impregnated cement hip spacer for the treatment of hip PJI regarding monomicrobial and polymicrobial infections. Secondly, to assess risk factors for failure of two-stage revision. Material and methods: we conducted a retrospective study on patients that underwent revision of total hip arthroplasty (THA) between January 2002 and January 20218. We included adult patients with a diagnosis of chronic hip PJI that underwent two-stage revision using a prefabricated gentamicin-impregnated cement of polymethylmethacrylate (PMMA) hip spacer. We assessed whether it was monomicrobial or polymicrobial infections and comorbidities. Treatment success was defined when eradication of the infection was observed and no further procedures or mortality were registered after the second stage. Persistence or recurrence of infection was considered a failure of treatment. Results: the final series consisted of 84 patients treated with the same hip spacer: 60 (71.4 %) monomicrobial and 24 (28.6 %) polymicrobial joint infections with an overall follow-up of 59.0 (36.0-84.0) months. The overall success rate was 90.5 %. Eight (9.5 %) patients failed. Smoking and BMI greater than 30 m kg-2 were identified independent risk factors for failure in multivariate analysis. Conclusion: our study suggests that prefabricated gentamicin-impregnated PMMA spacer is an effective tool for the treatment of PJI, achieving similar outcomes whether it is monomicrobial or polymicrobial infections. Randomized prospective studies are needed to obtain more reliable conclusions.

Does the distal nail position impact the rates of misalignment and bone union in distal tibial fractures?

PURPOSE: This retrospective study aimed to assess the impact of distal nail placement on misalignment and healing rates in distal tibial fractures. METHODS: We reviewed all patients with distal tibial fracture treated with intramedullary nailing between 2015 and 2021, and a minimum follow-up of 12 months. Distal nail positioning was determined according to the Triantafillou zones. We related these positioning zones to misalignments (alignment ≥ 3°) and too bony union disorders (delayed union, non-union). RESULTS: Out of the 62 patients included, 56 (90.3%) show bone union without additional procedure, 3 (4.8%) with dynamization, and 3 (4.8%) showed non-union. Twenty-one (33.8%) presented misalignment, with valgus in the coronal plane being the most frequent (76.19%). In patients with and without misalignment, the most frequent distal nail position was 2-2 in 47.6% and 80.5%, respectively (p = 0.01). In multivariate analysis, distal nail positioning in the 2-2 zone showed a significant protective effect against misalignment (OR 0.18; p = 0.018), while nail positioning in the 3-2 zone generated a significant risk of misalignment (OR 18.55; p = 0.009). CONCLUSION: In intramedullary nailing of distal tibial fractures, distal positioning of the nail slightly lateral to the center of the talus in the coronal plane and slightly posterior in the sagittal plane (zone 2-2) allows high alignment percentages to be obtained. Positioning medial to this point in the coronal plane (zone 3) is associated with more significant misalignment and should be avoided.

Extracorporeal membrane oxygenation (ECMO) and beyond in near fatal asthma: A comprehensive review.

The treatment of choice in severe asthma exacerbations with respiratory failure includes ventilatory support, both invasive and/or non-invasive, along with different kinds of asthma medication. Of note, the rate of mortality of patients with asthma has decreased substantially in recent years mainly due to significant advances in pharmacological treatment and other management strategies. However, the risk of death in patients with severe asthma who require invasive mechanical ventilation has been estimated between 6.5% and 10.3%. When conventional measures fail, rescue strategies, such as extracorporeal membrane oxygenation (ECMO) or extracorporeal CO2 removal (ECCO2R) may need to be implemented. While ECMO does not constitute a definitive treatment per se, it can minimize further ventilator associated lung injury (VALI) and can enable diagnostic-therapeutic maneuvers that cannot be performed without ECMO such as bronchoscopy and transfer for diagnostic imaging. Asthma is one of the diseases that is associated with excellent outcomes for patients with refractory respiratory failure requiring ECMO support, as shown by the Extracorporeal Life Support Organization (ELSO) registry. Moreover, in such situations, the use of ECCO2R for rescue has been described and utilized in both children and adults and is more widely spread in different hospitals than ECMO. In this article, we aim to review the evidence for the usefulness of extracorporeal respiratory support measures in the management of severe asthma exacerbations that lead to respiratory failure.

Pre-fracture ambulation capacity, Charlson comorbidity index, and dementia as predictors of functional impairment after bipolar hemiarthroplasty for unstable intertrochanteric fracture. A retrospective analysis in 158 octogenarian patients.

Background: the primary purpose of this study was to assess the ambulatory capacity 12 months after surgery in patients that underwent bipolar hemiarthroplasty (BH) due to unstable intertrochanteric fractures (UITF). Secondly, to identify which preoperative variables influenced these modifications. Methods: We retrospectively analyzed a consecutive series of patients older than 80 years with UITF treated with BH between 2010 and 2019. Ambulatory capacity was assessed before surgery, at 3 and 12 months postoperatively, using Koval's classification and the modified Harris Hip Score (mHHS). The registered variables were: gender, age, osteoporosis, Charlson comorbidity index (CCI), ASA classification, body mass index (BMI), and dementia. The identification of variables that impaired postoperative functionality was performed by uni- and multivariate analysis. Results: 158 patients were included with a median age of 87 (range 80-102) years and a follow-up of 29.2 (range 12-56) months. The 1-year overall ambulatory capacity impairment was 28.5% and significantly affected pre-fracture community walkers (p = 0.001). A CCI >4 (OR 2.72; p = 0.044), dementia (OR 14.13; p = 0.0001), and a Koval 2-3 (OR 12.84; p = 0.001) were identified as risk factors for this impairment. Conclusion: Ambulation impairment at one year was 28.5%. The predictive characteristics found in this study help to identify patients with a greater risk of ambulation impairment and to focus rehabilitation plans to reduce this impact.

Dimensionality reduction and ensemble of LSTMs for antimicrobial resistance prediction.

Bacterial resistance to antibiotics has been rapidly increasing, resulting in low antibiotic effectiveness even treating common infections. The presence of resistant pathogens in environments such as a hospital Intensive Care Unit (ICU) exacerbates the critical admission-acquired infections. This work focuses on the prediction of antibiotic resistance in Pseudomonas aeruginosa nosocomial infections at the ICU, using Long Short-Term Memory (LSTM) artificial neural networks as the predictive method. The analyzed data were extracted from the Electronic Health Records (EHR) of patients admitted to the University Hospital of Fuenlabrada from 2004 to 2019 and were modeled as Multivariate Time Series. A data-driven dimensionality reduction method is built by adapting three feature importance techniques from the literature to the considered data and proposing an algorithm for selecting the most appropriate number of features. This is done using LSTM sequential capabilities so that the temporal aspect of features is taken into account. Furthermore, an ensemble of LSTMs is used to reduce the variance in performance. Our results indicate that the patient's admission information, the antibiotics administered during the ICU stay, and the previous antimicrobial resistance are the most important risk factors. Compared to other conventional dimensionality reduction schemes, our approach is able to improve performance while reducing the number of features for most of the experiments. In essence, the proposed framework achieve, in a computationally cost-efficient manner, promising results for supporting decisions in this clinical task, characterized by high dimensionality, data scarcity, and concept drift.

Distal articular involvement in tibial shaft fractures: an evaluation of 125 consecutive cases.

PURPOSE: To report the incidence and morphology of ipsilateral distal articular involvement (DAI) in a consecutive series of tibial shaft fractures. METHOD: A retrospective review was performed on 115 patients who underwent intramedullary nailing for tibia shaft fractures. Ankle evaluations included preoperative radiographs and computed tomography (CT) scans in all patients. RESULTS: Thirty-two patients (27.8%) in our series presented with tibial shaft fractures associated with DAI. Tibial spiral fractures (42A1) were significantly related to DAI (RR: 1788). In 28 (87.5%; 28/32) articular fractures, posterior malleolus fractures (PMF) were present; 22 were isolated, and six (18.8%) occurred in combination with medial malleolus or anterolateral fractures. The remaining (12.5%; 4/32) were isolated medial malleolus fractures. Ten (31.2%; 10/32) articular fractures were occult on the radiographs and only detected on CT scan. CONCLUSION: DAI is common in tibial shaft fractures. CT evaluation is mandatory due to the high number of occult fractures. Although isolated PMF is the most frequent pattern of DAI involvement, 31.3% of the cases exhibited different patterns.

Incisions in Hepatobiliopancreatic Surgery: Surgical Anatomy and its Influence to Open and Close the Abdomen.

Incisions performed for hepato-pancreatic-biliary (HPB) surgery are diverse, and can be a challenge both to perform correctly as well as to be properly closed. The anatomy of the region overlaps muscular layers and has a rich vascular and nervous supply. These structures are fundamental for the correct functionality of the abdominal wall. When performing certain types of incisions, damage to the muscular or neurovascular component of the abdominal wall, as well as an inadequate closure technique may influence in the development of long-term complications as incisional hernias (IH) or bulging. Considering that both may impair quality of life and that are complex to repair, prevention becomes essential during these procedures. With the currently available evidence, there is no clear recommendation on which is the better incision or what is the best method of closure. Despite the lack of sufficient data, the following review aims to correlate the anatomical knowledge learned from posterior component separation with the incisions performed in hepato-pancreatic-biliary (HPB) surgery and their consequences on incisional hernia formation. Overall, there is data that suggests some key points to perform these incisions: avoid vertical components and very lateral extensions, subcostal should be incised at least 2 cm from costal margin, multilayered suturing using small bites technique and consider the use of a prophylactic mesh in high-risk patients. Nevertheless, the lack of evidence prevents from the possibility of making any strong recommendations.

Stress shielding in total knee replacements: Comparative analysis between titanium and all-polyethylene bases at 10 years follow-up.

Objective: The aim of this retrospective study was to assess bone resorption due to stress shielding in total knee replacement (TKR), comparing titanium bases (TiB) versus all polyethylene bases (APB), analyzing its incidence, progression and mechanical consequences after 10 years of follow-up. Methods: We evaluated two groups of patients undergoing TKR, one treated with TiB and the other with APB, operated consecutively between 2004 and 2009 with a diagnosis of idiopathic gonarthrosis and a minimum of 10 years of follow-up. Deen's radiographical method was used to assess tibial bone resorption. We assessed its incidence, progression, relationship with the femoro-tibial and prosthetic alignment, clinical outcomes and mechanical loosening. Results: Eighty-six patients were treated with TiB and 80 with APB with a median follow-up of 11 (range 10-15) years. The bone resorption rate in TiB was 24.41% and in APB was 1.25% (p < 0.0001). The type 2 of Deen's classification was the most frequently observed. Bone resorption was strongly correlated with preoperative varus femoro-tibial alignment and varus placement of the tibial component, also showing a significant association with postoperative femoro-tibial alignment correction (p 0.009). We observed no significant differences in functional scores or revision rates due to mechanical loosening after 10 years of follow-up between the groups. Conclusion: Titanium tibial bases in TKR showed a significantly higher incidence of medial tibia resorption compared to all-polyethylene bases. Our results suggest that bone resorption does not influence long-term mechanical loosening.

Diagnostic evaluation and incorporation of PSA density and the prostate imaging and data reporting system (PIRADS) version 2 classification in risk-nomograms for prostate cancer.

PURPOSE: The diagnostic approach for prostate cancer still depends on PSA and DRE. OBJECTIVES: to evaluate the diagnostic validity of PSA-Density and PIRADSv2 as diagnostic tests regarding biopsy results, and to design nomograms that include all diagnostic variables for malignancy, significant tumor (ST) and high-grade tumor. METHODS: Cross-sectional study which included men with PSA ≥ 4 ng/ml and/or suspicious DRE, PIRADSv2 ≥ 3 lesions on multiparametric MRI and prostate biopsy. The gold standard test was the maximum ISUP of the targeted biopsy per patient (malignancy: ISUP ≥ 1, ST: ISUP ≥ 2, high-grade tumor: ISUP ≥ 4). Association and logistic regression tests were used and diagnostic validity parameters using PSA-Density and PIRADSv2 classification was analyzed. Nomograms were designed for malignancy, ST, and high-grade tumor using the best model selection procedure from all possible equations. RESULTS: 336 men with median age, PSA and PSA-Density of 67.7 years (IQR:12.6), 6.3 ng/ml (IQR:3.3) and 0.12 ng/ml/cc (IQR:0.10), respectively; 63 index lesions were PIRADS3, 204 PIRADS4, and 69 PIRADS5. 65.8% and 37.8% were malignant and ST, respectively. The significant positive association highlighted between malignancy and ST with age, DRE, PSA-Density and PIRADSv2. PSA-Density and PIRADSv2 ≥ 3 presented the highest sensitivity to detect malignancy, and their combination showed sensitivity nearly 95% (AUC:0.803). Nomograms for malignancy and ST included the variables age, DRE, PSA-Density, and PIRADSv2 with a sensitivity closely 91% (AUC:0.833), and a specificity of almost 85% for ST, exposing risk < 5% for ST when PSA-Density is < 0.15, not suspicious DRE and PIRADS3. CONCLUSION: PSA-Density and PIRADSv2 classification in risk nomograms can provide highly relevant information to increase the accuracy in the diagnosis of PC and ST.

Efficacy and Tolerability of 6-Month Treatment with Tamsulosin Plus the Hexanic Extract of Serenoa repens versus Tamsulosin Plus 5-Alpha-Reductase Inhibitors for Moderate-to-Severe LUTS-BPH Patients: Results of a Paired Matched Clinical Study.

The objective of this subset analysis was to evaluate and compare the efficacy and tolerability of two combination treatments for men with moderate-to-severe lower urinary tract symptoms associated with benign prostatic hyperplasia (LUTS/BPH). Data were from a real-world, open-label, prospective, and multicenter study performed in outpatient urology clinics. Men with moderate-to-severe LUTS/BPH received 6-month treatment with tamsulosin (TAM) in combination with either the hexanic extract of S. repens (HESr) or a 5-alpha-reductase inhibitor (5ARI). Changes in urinary symptoms and quality of life were measured using the IPSS and BII questionnaires, respectively. Treatment tolerability was assessed by recording adverse effects (AEs). Patients in the two study groups were matched using iterative and propensity score matching approaches. After iterative matching, data were available from 136 patients (n = 68 treated with TAM + 5ARI, n = 68 with TAM + HESr). After 6 months of treatment, mean (SD) IPSS total score improved by 7.7 (6.3) and 6.7 (5.0) points in the TAM + 5ARI and TAM + HESr groups, respectively (p = 0.272); mean BII total scores improved by 3.1 (2.9) and 2.9 (2.4) points (p = 0.751), respectively. AEs were reported by 26.5% and 10.3% of patients in the same groups, mostly affecting sexual function (p < 0.027). When used in a real-world setting to treat patients with moderate-severe LUTS/BPH, 6-month treatment with TAM + HESr was as effective as TAM + 5ARI, but with better tolerability.