Long-term cosmetic results of video-assisted thyroidectomy: a comparison with conventional surgery.

PURPOSE: We present the long-term cosmetic results of the video-assisted thyroidectomy (MIVAT) in comparison to the conventional operation. METHODS: Forty-eight patients (four males, 44 females; mean age 47.4 ± 12.5 years) constituted the video-assisted group (VA-Group). These were compared with 48 patients (10 males, 38 females; mean age 47.4 ± 12.5 years) operated by conventional surgery (C-Group). The patients were selected from all thyroid operations performed between January 2016 and June 2017. Patient Scar Assessment Scale (PSAS) and Observer Scar Assessment Scale (OSAS) were used for the evaluation performed by an independent surgeon. Both scales contained six items scored numerically on a ten-step scale ranging from 1 (normal skin) to 10 (worst result). Moreover, photos of all scars were taken and analyzed by six team surgeons using modified OSAS. RESULTS: The mean follow-up time was 31.7 ± 6.4 months for the MIVAT group and 32.9 ± 4.6 months for the conventional group (p = 0.39). The mean scar length in the VA-Group was 2.6 cm vs. 3.8 cm in the C-Group (p < 0.0001). The total score of PSAS was 9.93 (6-35) for MIVAT and 9.72 (6-29) for conventional thyroidectomy (p = 0.22). The total OSAS score by the independent surgeon showed a better cosmetic outcome for conventional surgery (13.19 vs. 12.33; p = 0.01). The total OSAS score by the six team surgeons did not differ between both groups in five of six ratings; one surgeon favored MIVAT (12.2 vs. 13.6; p = 0.04). CONCLUSIONS: This study does not find cosmetic advantages of minimally invasive video-assisted thyroidectomy compared to conventional thyroidectomy.

[Endoscopic diagnosis, treatment, and follow-up of polyps of the upper gastrointestinal tract]. / Endoskopische Diagnostik, Therapie und Nachsorge von Polypen des oberen Gastrointestinaltrakts.

Polyps occur significantly less frequently in the upper gastrointestinal tract compared to the lower gastrointestinal tract. They are usually incidental findings at esophagogastroduodenoscopy. A distinction is made between epithelial lesions and subepithelial tumors. Endoscopic screening is not recommended in Germany (exception: hereditary risk groups). Polyps are sometimes symptomatic, generally in the case of advanced tumor size. In this case, or in the case of potential for malignant transformation, resection is necessary and can usually be performed endoscopically. Surgical resections are rarely necessary. Epithelial lesions are removed by means of endoscopic mucosal resection (EMR). For subepithelial tumors, advanced procedures such as endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER), or endoscopic full-thickness resection are available. These procedures should primarily be performed at centers with appropriate expertise. Endoscopic follow-up is primarily determined by the tumor entity and the resection status.

Enhanced visualization of parathyroid glands during video-assisted neck surgery.

PURPOSE: Visualization and precise dissection of the parathyroid glands are a crucial step of thyroidectomy. Moreover, identification of parathyroid adenoma in patients with primary hyperparathyroidism can be challenging due to the possible abnormal location of the enlarged parathyroid. Near-infrared fluorescence (NIR) can be adopted during video-assisted neck surgery in addition to standard endoscopic magnification to enhance the visualization of the parathyroid tissue. METHODS: Between July and August 2017, five patients (one male, four females) underwent video-assisted neck surgery at our hospital. One patient suffered from primary hyperparathyroidism. The four remaining patients underwent thyroidectomy for multinodular goiter or Graves' disease. The parathyroid glands were firstly identified by the video-assisted approach and then confirmed by the NIR visualization of the endogenous autofluorescence of the parathyroid tissue. Low-dose (2.5 mg/ml) indocyanine green was administered to visualize the vascular supply during and/or after the dissection. The standard dose of 2.5 mg (1 ml per injection) was used to allow repeated injection during the same procedure. RESULTS: An endogenous parathyroid autofluorescence could be visualized by the NIR camera in all patients. The right upper parathyroid adenoma could be detected prior to fully dissection of the gland from the surrounding tissue. Twelve out of 16 parathyroid glands have been visually identified during four total thyroidectomies. Eleven glands showed an autofluorescence prior to indocyanine green (ICG) injection. Further, ICG injection has been used for guiding the dissection of the gland in three cases and for confirmation of the vascular supply at the end of the procedure in the remaining cases. There were neither intraoperative nor postoperative complications. CONCLUSION: The 5-mm 30° NIR camera allows for enhanced visualization of the parathyroid tissue during video-assisted thyroidectomy. This promising tool can become standard for video-assisted neck surgery.

[Experience in measuring the quality of treatment in interventional pain therapy : The Activity Index on a touchscreen PC]. / Erfahrungen bei der Messung der Ergebnisqualität in der interventionellen Schmerztherapie : Der Activity Index auf einem Touchscreen-PC.

BACKGROUND: There is a growing interest in patient-related outcome measurement. In this field questionnaires on touch screens are becoming more common. This study was designed to identify problems in usability and feasibility of a web-based questionnaire. STUDY PARTICIPANTS AND METHODS: Patients who underwent a lumbar infiltration were recruited in 5 centers and 50 patients participated of which half were older than 62 years. One third of the patients had basically no former experience with computers or touch screens. The outcome was assessed before treatment and during follow-up on a simple web-based patient questionnaire, the Activity Index. Results were presented graphically and discussed during consultation. Patients, nurses and doctors were asked for standardized feedback. RESULTS: Of the patients 84% completed the questionnaire in up to 6 min. An adapted form of the system usability scale (SUS) achieved an acceptance score of 71.8%. Problems in handling occurred mostly in older patients (>65 years). The system was scored with 72.9% and 78.5% in efficiency and handling, respectively, by the nurses. The attending physicians rated the usefulness and comprehensibility of the graphical representation of the results on average as 83.3% and both were scored neutral to positive; however, an average of 11.6% rated some aspects of the report to be suboptimal. CONCLUSION: This web-based questionnaire is the first of its kind to be evaluated in everyday practice of interventional pain therapy for lumbar back pain. The vast majority of the patients were able to efficiently complete the questionnaire. The questionnaire was highly acceptable to patients, nurses and doctors. We found some usability problems but mainly in the older age group.

[Pyoderma gangrenosum and Sweet's syndrome : Cutaneous manifestations of autoinflammatory disorders]. / Pyoderma gangraenosum und Sweet-Syndrom : Hautmanifestationen autoinflammatorischer Erkrankungen.

Pyoderma gangrenosum and Sweet's syndrome are rare diseases that belong to the group of neutrophilic dermatoses and share several common characteristics. Although the two disorders differ clinically from each other, both diseases show pronounced dermal infiltration of neutrophils without evidence of primary vasculitis and respond well to immunosuppressive drugs. In addition, both diseases are often associated with other systemic and hematological disorders. Recent findings show that the neutrophil dermatoses can be considered as cutaneous manifestations of autoinflammation, demonstrating an interesting new aspect in the development of the diseases and additional therapeutic avenues.

[Endoscopic full-thickness resection]. / Die endoskopische Vollwandresektion.

Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are powerful tools for the treatment of gastrointestinal (GI) neoplasms. However, those techniques are limited to the superficial layers of the GI wall (mucosa and submucosa). Lesions without lifting sign (usually arising from deeper layers) or lesions in difficult anatomic positions (appendix, diverticulum) are difficult - if not impossible - to resect using conventional techniques, due to the increased risk of complications. For larger lesions (>2 cm), ESD appears to be superior to the conventional techniques because of the en bloc resection, but the procedure is technically challenging, time consuming, and associated with complications even in experienced hands. Since the development of the over-the-scope clips (OTSC), complications like bleeding or perforation can be endoscopically better managed. In recent years, different endoscopic full-thickness resection techniques came to the focus of interventional endoscopy. Since September 2014, the full-thickness resection device (FTRD) has the CE marking in Europe for full-thickness resection in the lower GI tract. Technically the device is based on the OTSC system and combines OTSC application and snare polypectomy in one step. This study shows all full-thickness resection techniques currently available, but clearly focuses on the experience with the FTRD in the lower GI tract.

Canakinumab in adults with steroid-refractory pyoderma gangrenosum.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare, neutrophilic, ulcerative skin disease that is difficult to treat, especially when unresponsive to steroids. OBJECTIVES: To determine whether canakinumab is an effective and safe treatment in PG. METHODS: Five adult patients with clinically and histologically confirmed steroid-refractory PG were enrolled in this prospective open-label study. They received canakinumab 150 mg subcutaneously at week 0 with an optional 150 mg at week 2 in case of an inadequate response [Physician's Global Assessment (PGA) ≥ 2], and an optional 150-300 mg at week 8 depending on PGA. The primary clinical end point was clinical improvement (PGA at least -1 from baseline) and/or complete remission (PGA 0 or 1) at week 16. Real-time quantitative polymerase chain reaction was performed on skin samples to quantify cytokine mRNA levels. RESULTS: Interleukin (IL)-1ß and its known target genes IL6, CXCL8 and IL36A were significantly increased in lesional skin of PG. Under canakinumab therapy, four of five patients showed a decrease in target-lesion size, PGA and Dermatology Life Quality Index (DLQI), and three of five achieved complete remission. The mean diameter of target lesions decreased from 4·32 ± 2·6 cm at visit 1 to 0·78 ± 1·3 cm at visit 7 (P = 0·03). Mean DLQI decreased from 15 ± 5 at visit 1 to 8 ± 4 by visit 7 (P = 0·01). Adverse effects were reported in two patients: fatigue in one and worsening of disease at a nontarget lesion in the other. CONCLUSIONS: Our data indicate that IL-1ß plays a key pathogenic role in PG and canakinumab may represent a therapeutic option for steroid-refractory PG.

Diagnostic value and clinical impact of complementary CT scan prior to surgery for non-localized primary hyperparathyroidism.

INTRODUCTION: Successful localization is mandatory for focused parathyroidectomy. If ultrasound and sestamibi scan are negative, bilateral neck exploration is necessary. We examined the contribution of complementary computed tomography (CT) scan to identify the affected parathyroid gland. METHODS: Between November 1999 and April 2014, 25 patients (20 females and 5 males; mean age 67 ± 11 years) with negative or dubious standard imaging (ultrasound and sestamibi scan) underwent CT scan prior to parathyroidectomy and were included in this study. Fifteen patients had had previous neck surgery for parathyroidectomy (n = 11) or thyroidectomy (n = 4). Thin-slice CT (n = 9) or four-dimensional (4D) CT imaging (n = 16) was used. Cure was defined as >50 % post-excision fall of intraoperatively measured parathyroid hormone or fall into the normal range, confirmed by normocalcaemia at least 6 months after surgery. RESULTS: Preoperative CT scan provided correct localization in 13 out of 25 patients (52 %) and was false positive once. Parathyroidectomy was performed by a focused approach in 11 of these 13 patients as well as in 1 patient guided by intraoperatively measured parathyroid hormone (ioPTH). Thirteen patients required bilateral neck exploration. The cure rate was 96 % (24/25 patients). One patient has persistent primary hyperparathyroidism (pHPT) and one a recurrent disease. Six patients presented a multiglandular disease. CONCLUSION: A CT scan identifies about half of abnormal parathyroid glands missed by conventional imaging and allows focused surgery in selected cases.

Intraoperative neuromonitoring for surgical training in thyroid surgery: its routine use allows a safe operation instead of lack of experienced mentoring.

BACKGROUND: The aim of the present study was to evaluate the influence of intraoperative neuromonitoring (NM) on surgical training. The results of thyroidectomy performed by inexperienced surgeons under the supervision of a consultant surgeon without intraoperative neuromonitoring (ioNM) were compared to those of the operations performed without experienced assistance but under neuromonitoring control. MATERIALS AND METHODS: The study included the thyroid operations performed in our Department between 2005 and 2012. Among them, residents or fellows performed 1,116 procedures. Seven hundred sixty-five operations were conducted without neuromonitoring (NV group) and 351 with NM group. In the NV group 375 unilateral and 390 bilateral operations were performed. In the NM group 149 unilateral and 202 bilateral operations were performed. Primary end point of the study was the incidence of postoperative recurrent laryngeal nerve palsy. A secondary end point was the impact of ioNM on operating time and operative strategy. RESULTS: The incidence of recurrent laryngeal nerve (RLN) palsy was 2.6 % in the NV group and 2.7 % in the NM group [p = ns]. One case of bilateral RLN palsy was observed in the NV group. The operative time was longer in the NM group for both lobectomy and total thyroidectomy (50 vs. 56 min and 76 vs. 81 min, respectively; p < 0.05). CONCLUSIONS: The routine use of intermittent intraoperative neuromonitoring during thyroid operations does not reduce the incidence of RLN palsy. Nevertheless, it allows inexperienced surgeons to perform a safe operation with a complication rate comparable to that obtained under supervision of an experienced surgeon. Moreover, ioNM could avoid the unfortunate occurrence of a bilateral RLN palsy.

The evolution of human rights in World Health Organization policy and the future of human rights through global health governance.

The World Health Organization (WHO) was intended to serve at the forefront of efforts to realize human rights to advance global health, and yet this promise of a rights-based approach to health has long been threatened by political constraints in international relations, organizational resistance to legal discourses, and medical ambivalence toward human rights. Through legal research on international treaty obligations, historical research in the WHO organizational archives, and interview research with global health stakeholders, this research examines WHO's contributions to (and, in many cases, negligence of) the rights-based approach to health. Based upon such research, this article analyzes the evolving role of WHO in the development and implementation of human rights for global health, reviews the current state of human rights leadership in the WHO Secretariat, and looks to future institutions to reclaim the mantle of human rights as a normative framework for global health governance.

Airborne antibiotic and metal resistance genes - A neglected potential risk at e-waste recycling facilities.

Heavy metal-rich environments can promote the selection of metal-resistance genes (MRGs) in bacteria, often leading to the simultaneous selection of antibiotic-resistance genes (ARGs) through a process known as co-selection. To comprehensively evaluate the biological pollutants at electronic-waste (e-waste) recycling facilities, air, soil, and river samples were collected at four distinct Swiss e-waste recycling facilities and analyzed for ARGs, MRGs, mobile genetic elements (MGEs), endotoxins, and bacterial species, with correlations drawn to heavy metal occurrence. To our knowledge, the present work marks the first attempt to quantify these bio-pollutants in the air of e-waste recycling facilities, that might pose a significant health risk to workers. Although ARG and MRG's profiles varied among the different sample types, intl1 consistently exhibited high relative abundance rates, identifying it as the predominant MGE across all sample types and facilities. These findings underscore its pivol role in driving diverse bacterial adaptations to extreme heavy metal exposure by selection and dissemination of ARGs and MRGs. All air samples exhibited consistent profiles of ARGs and MRGs, with blaTEM emerging as the predominant ARG, alongside pbrT and nccA as the most prevalent MRGs. However, one facility, engaged in batteries recycling and characterized by exceptionally high concentrations of heavy metals, showcased a more diverse resistance gene profile, suggesting that bacteria in this environment required more complex resistance mechanisms to cope with extreme metal exposure. Furthermore, this study unveiled a strong association between gram-negative bacteria and ARGs and less with MRGs. Overall, this research emphasizes the critical importance of studying biological pollutants in the air of e-waste recycling facilities to inform robust safety measures and mitigate the risk of resistance gene dissemination among workers. These findings establish a solid foundation for further investigations into the complex interplay among heavy metal exposure, bacterial adaptation, and resistance patterns in such distinctive ecosystems.

Practical use of dabigatran etexilate for stroke prevention in atrial fibrillation.

Atrial fibrillation (AF) is associated with an increased risk of thromboembolism, and is the most prevalent factor for cardioembolic stroke. Vitamin K antagonists (VKAs) have been the standard of care for stroke prevention in patients with AF since the early 1990s. They are very effective for the prevention of cardioembolic stroke, but are limited by factors such as drug-drug interactions, food interactions, slow onset and offset of action, haemorrhage and need for routine anticoagulation monitoring to maintain a therapeutic international normalised ratio (INR). Multiple new oral anticoagulants have been developed as potential replacements for VKAs for stroke prevention in AF. Most are small synthetic molecules that target thrombin (e.g. dabigatran etexilate) or factor Xa (e.g. rivaroxaban, apixaban, edoxaban, betrixaban, YM150). These drugs have predictable pharmacokinetics that allow fixed dosing without routine laboratory monitoring. Dabigatran etexilate, the first of these new oral anticoagulants to be approved by the United States Food and Drug Administration and the European Medicines Agency for stroke prevention in patients with non-valvular AF, represents an effective and safe alternative to VKAs. Under the auspices of the Regional Anticoagulation Working Group, a multidisciplinary group of experts in thrombosis and haemostasis from Central and Eastern Europe, an expert panel with expertise in AF convened to discuss practical, clinically important issues related to the long-term use of dabigatran for stroke prevention in non-valvular AF. The practical information reviewed in this article will help clinicians make appropriate use of this new therapeutic option in daily clinical practice.

Manifestation of an abdominal immune reconstitution inflammatory syndrome associated with a nontuberculous mycobacterial infection - a case report.

Immune reconstitution inflammatory syndrome (IRIS) is an inflammatory reaction in HIV-infected patients after initiation of antiretroviral therapy. It results from restored immunity to specific infectious or non-infectious antigens. We describe the case of a 47-year-old female patient who presented with an unspecific painful pressure in the abdomen and weight loss that was diagnosed as intra-abdominal (unmasking) IRIS due to nontuberculous mycobacterial infection (Mycobacterium avium complex). Antiretroviral therapy had been initiated six months earlier when pneumocystis pneumonia led to the diagnosis of HIV infection with a viral load of 123 000 copies/ml and a CD 4 cell count of 6/µl. Although IRIS is a known complication after initiation of antiretroviral therapy in HIV-infected patients this case with a rare site of manifestation and symptoms that are common in all day gastroenterological clinic highlights a differential diagnosis that requires a high index of suspicion and the need for the careful use of diagnostic tools.

[Cardiovascular cooperation with the BPKIHS Hospital, in Dharan Bazar, Nepal]. / Coopération cardiovasculaire avec l'Hôpital BPKIHS, à Dharan Bazar, Népal.

Thanks to a collaboration project that was developed by Swiss cardiologists, the Coeur de la Tour Foundation, and BPKIHS, a teaching hospital in Dharan, it has been possible, within two years and using a "hybrid approach", to set up the first independent invasive and interventional program in East Nepal. 496 patients have been investigated and/or treated since January 2011, during an initial period of 23 months (coronary angiographies, coronary angioplasties, temporary and permanent pacemaker implantations, pericardiocenteses, etc.). In parallel with this, our Foundation, in the same area of the country, has also supported a pre-existing cardiovascular prevention program and has helped start a population-based study of rheumatic heart disease prevalence and treatment outcome among school children.

Nature of T-cell macrophage interaction in helper-cell induction in vitro. II. Two stages of T-helper-cell differentiation analyzed in irradiation and allophenic chimeras.

The genetic restriction in the T-cell-macrophage-like cell interaction in helper cell induction was investigated with allophenic and irradiation chimeras of various types. Using T cells from P leads to F1 chimeras, there was a restriction of cooperation with the parental haplotype accessory cells, unless the chimeric mice were repopulated with macrophages of the opposite haplotype before priming. T cells from primed or unprimed F1 leads to P chimeras only cooperated with recipient type accessory cells. These observations led to the hypothesis that there are two stages in the genesis of immunocompetence of T helper cells, one dependent on the thymus, and the other on peripheral macrophage-like cells. Purified T cells from P1 + P2 leads to F1 irradiation chimeras behaved in an unexpected manner in the unprimed state, preferring to cooperate with their own haplotype macrophages. This self preference was lost after antigen priming in vivo and was not noted in allophenic chimeras. This loss of self preference was restricted to the haplotypes represented in the chimeras, and did not extend to third party haplotypes. While these in vitro induced helper cells from chimeric mice show clear genetic restrictions at the T-cell macrophage-like cell interaction, there was no evidence for a matching T-B genetic restriction.

Dithiocarbamates as potent inhibitors of nuclear factor kappa B activation in intact cells.

Dithiocarbamates and iron chelators were recently considered for the treatment of AIDS and neurodegenerative diseases. In this study, we show that dithiocarbamates and metal chelators can potently block the activation of nuclear factor kappa B (NF-kappa B), a transcription factor involved in human immunodeficiency virus type 1 (HIV-1) expression, signaling, and immediate early gene activation during inflammatory processes. Using cell cultures, the pyrrolidine derivative of dithiocarbamate (PDTC) was investigated in detail. Micromolar amounts of PDTC reversibly suppressed the release of the inhibitory subunit I kappa B from the latent cytoplasmic form of NF-kappa B in cells treated with phorbol ester, interleukin 1, and tumor necrosis factor alpha. Other DNA binding activities and the induction of AP-1 by phorbol ester were not affected. The antioxidant PDTC also blocked the activation of NF-kappa B by bacterial lipopolysaccharide (LPS), suggesting a role of oxygen radicals in the intracellular signaling of LPS. This idea was supported by demonstrating that treatment of pre-B and B cells with LPS induced the production of O2- and H2O2. PDTC prevented specifically the kappa B-dependent transactivation of reporter genes under the control of the HIV-1 long terminal repeat and simian virus 40 enhancer. The results from this study lend further support to the idea that oxygen radicals play an important role in the activation of NF-kappa B and HIV-1.

The conformation of acetylcholine at its target site in the membrane-embedded nicotinic acetylcholine receptor.

The conformation of the neurotransmitter acetylcholine bound to the fully functional nicotinic acetylcholine receptor embedded in its native membrane environment has been characterized by using frequency-selective recoupling solid-state NMR. Six dipolar couplings among five resolved (13)C-labeled atoms of acetylcholine were measured. Bound acetylcholine adopts a bent conformation characterized with a quaternary ammonium-to-carbonyl distance of 5.1 A. In this conformation, and with its orientation constrained to that previously determined by us, the acetylcholine could be docked satisfactorily in the agonist pocket of the agonist-bound, but not the agonist-free, crystal structure of a soluble acetylcholine-binding protein from Lymnaea stagnali. The quaternary ammonium group of the acetylcholine was determined to be within 3.9 A of five aromatic residues and its acetyl group close to residues C187/188 of the principle and residue L112 of the complementary subunit. The observed >C O chemical shift is consistent with H bonding to the nicotinic acetylcholine receptor residues gammaY116 and deltaT119 that are homologous to L112 in the soluble acetylcholine-binding protein.

Prevention of rupture of abdominal aortic aneurysm.

BACKGROUND AND AIMS: Two thirds of patients with an abdominal aortic aneurysm (AAA) have relevant coronary artery disease (CAD). AAAs are prevalent in up to 16% of smokers with CAD. General screening of AAA is controversial. Aim was to assess the potential of finding AAA prior to rupture among patients with known CAD. Main endpoint was whether AAA could have been found during follow-up by sonography or at other time of cardiovascular evaluation. MATERIAL AND METHODS: Retrospective study. 213 consecutive, formerly unknown emergently operated AAAs, treated emergently for symptoms (n = 91) or rupture (n = 122) (rAAA) between January 1998 and June 2005. Patient charts were analysed and primary care physicians contacted. RESULTS: At presentation, mean age was 71 (+/-9) years, twenty (9%) were female. AAA had a mean diameter of 7.6 cm. Two thirds (143) were clinically obese (BMI 27 +/-5). 137 (64%) were active smokers, 32 (15%) had diabetes, 151 (71%) were hypertensive, and 80 (38%) received statin treatment. CAD had been diagnosed in 95 (45%) 9 years earlier and followed up. Thirty-five (16%) had had myocardial infarction. Echocardiography had been performed in 52 (24%). Thirty day mortality after open surgery was 25 (21%). CONCLUSION: All patients with rAAA had been seen by a GP or cardiologist within a year prior to presentation. The cost effectiveness of selective AAA screening should be evaluated in a larger study.