Five-year recurrence after endoscopic approach to pilonidal sinus disease: A multicentre experience.

PURPOSE: The aim of this study was to evaluate the 5-year recurrence rate of pilonidal sinus disease (PSD) after endoscopic sinusectomy and identify risk factors for recurrence. METHODS: All consecutive patients from September 2011 through December 2017 who underwent endoscopic sinusectomy at seven referral centres for pilonidal sinus treatment were retrospectively analysed from a prospectively maintained database. RESULTS: Out of 290 patients (185 males versus 105 female, with a mean age of 25.5±6.9), 73 presented recurrence at 5-year follow-up with a recurrence rate of 25.2%. The number of pilonidal sinus with pits off the midline (p = 0.001) and the mean (SD) distance from the most lateral orifice to the midline (p = 0.001) were higher in the group of patients with recurrence at 5-year follow-up. Multivariate analysis demonstrated that the position of the pits off the midline (p = 0.001) and the distance of the most lateral orifice from the midline (p = 0.001) were independent risk factors for recurrence at 5-year follow-up. Receiver operating characteristic (ROC) curve analysis showed that the distance of lateral orifice from midline predicted an 82.2% possibility of recurrence at 5-year follow-up and Youden's test identified the best cut-off as 2 cm for this variable. Out of 195 cases with the most lateral orifice less than 2 cm from the midline, 13 presented recurrence at 5-year follow-up with a recurrence rate of 6.7%. Out of 95 cases with the most lateral orifice more than 2 cm from midline, 60 showed recurrence at 5-year follow-up with a recurrence rate of 63.2%. CONCLUSIONS: This data may help guide which disease characteristics predict the optimal use of an endoscopic pilonidal sinus technique.

Axillary ectopic breast tissue in the adolescent.

AIM: Ectopic breast tissue (EBT) includes a spectrum of disease that entails other entities based on the presence of glandular tissue, nipple, or areola. The diagnosis in adolescents is infrequent. METHODS: A retrospective study was performed including girls with axillary EBT (class IV or V of Kajava's Classification) operated in 2006-2020. Imagining studies, clinical and surgical reports, and histopathology were reviewed. RESULTS: Eleven girls from 13 to 16 years old were included. Two patients (18.2%) presented bilateral EBT. The most frequent clinical manifestation was 2-5 cm mass (100%), associating cyclic pain with menstruation (45%) and fluctuating volume (36%). Bilateral axillary ultrasonography allowed preoperative diagnosis. All of them were treated by open excision, through small incisions located in an axillary y fold. Clinical and aesthetic results were self-assessed as "very good", with normalization of the axillary y hollow and imperceptible scars. No recurrences were observed after one year of follow-up. An immediate postoperative hematoma was reported, which did not require drainage. Histopathology showed mature breast tissue without atypia. CONCLUSIONS: Axillary accessory breasts must be included in differential diagnosis of pediatric axillary masses. Bilateral ultrasonography is recommended for the preoperative diagnosis. Excision through minimal incision at this age seems to be safe and effective.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of pilonidal disease.

Pilonidal disease (PD) is a relatively common, benign but challenging condition of the natal cleft. This consensus statement was drawn up by a panel of surgeons, identified by the Italian Society of Colorectal Surgery (SICCR) as having a "special interest" in PD, with the aim of recommending the best therapeutic options according to currently available scientific evidence. A three-step modified-Delphi process was adopted, implying: (1) choice of the panelists; (2) development of a discussion outline and of target issues; and (3) a detailed systematic review of the current literature. The agreement/disagreement level was scored on a five-point Likert scale as follows: "A + : strongly agree; A-: agree; N: unsure/no opinion; D-: disagree; D + : strongly disagree. Each panelist contributed to the production of this manuscript, and the final recommendations were reviewed by the Clinical Practice Guidelines Committee.

Lift and VAAFT for high trans-sphincteric anal fistula: a single center retrospective analysis.

PURPOSE: The management of complex anal fistulas remains a challenge, mainly due to the considerable risk of incontinence. We compared LIFT and VAAFT in the treatment of complex anal fistulas in terms of healing time, recurrence, continence, morbidity, and postoperative pain, focusing also on patients with local abscess at the time of surgery. METHODS: We include all patients with high trans-sphincteric anal fistula even with abscess at the time of surgery. Anorectal manometry, endoanal ultrasound, Cleveland Clinic fecal incontinence score, VAS score, and number of previous fistula treatment were recorded. The clinical examination defined healing, insufficiency or recurrence of the fistula. RESULTS: Fifty-four consecutive patients are undergoing surgery: 26 patients underwent LIFT and 28 underwent VAAFT. During the 18 months of follow-up there were no differences in terms of AM, CCFIS and VAS scores. Days of healing, failure, and recurrence rate were comparable in both groups. The subgroup of patients with local abscess undergoing LIFT showed worse results in terms of failure and recurrence rate (p < 0.05). CONCLUSIONS: Both techniques are safe and effective and can offer long-term benefits. LIFT should not be used as a first treatment in high trans-sphincteric fistula with perianal abscess.

Sphinkeeper™ for faecal incontinence: a preliminary report.

AIM: A new artificial anal sphincter placed into the intersphincteric space, SphinKeeper™, has recently been proposed to improve outcomes in the treatment of faecal incontinence (FI). We report our preliminary results with short-term follow-up, comparing preoperative and postoperative data after implant of SphinKeeper™ in patients suffering from FI. METHODS: All patients older than 18 years were included with FI of at least 6 months, incontinence episodes occurring more than once a week and resistance to other conservative treatments. Anorectal manometry, endoanal ultrasound, Cleveland Clinic FI Score, FI Quality of Life score and total number of episodes of FI per week were recorded preoperatively and at the end of the 6-month follow-up period. RESULTS: Thirteen consecutive patients were treated with SphinKeeper™. No intra-operative nor postoperative complications were reported. Two cases of prosthesis extrusion occurred, and in one case an anterior dislocation was detected. Maximum resting pressure, total number of episodes of FI per week and Cleveland Clinic FI Score were improved after 6 months (P < 0.05). CONCLUSIONS: SphinKeeper™ could be a minimally invasive procedure for FI with good postoperative outcomes. If these results are confirmed by studies with more patients and longer follow-up, it could be a first-line approach in FI.

MicroRNAs expression in pituitary tumors: differences related to functional status, pathological features, and clinical behavior.

BACKGROUND: MicroRNAs (miRNAs) are small non-coding RNA molecules that regulate gene expression at post-transcriptional level, having a role in many biological processes, such as control of cell proliferation, cell cycle, and cell death. Altered miRNA expression has been reported in many neoplasms, including pituitary adenomas (PAs). PURPOSE: In this study, we aimed to evaluate the expression of 20 miRNAs involved in pathways relevant to pituitary pathophysiology, in PAs and normal pituitary tissue and to correlate their expression profile with clinical and pathological features. METHODS: Pituitary tumor samples were obtained during transphenoidal surgery from patients with non-functioning (NFPA, n = 12) and functioning (n = 11, 5 GH-, 3 ACTH-, 3 PRL-omas) PAs. The expression of selected miRNAs in PAs and in normal pituitary was analyzed by RT-qPCR. miRNAs expression was correlated with demographic, clinical, and neuroradiological data and with histopathological features including pituitary hormones immunostaining, Ki-67 proliferation index, and p53 immunohistochemistry evaluation. RESULTS: All evaluated miRNAs except miR-711 were expressed in both normal and tumor pituitary tissue. Seventeen miRNAs were significantly down-regulated in pituitary tumors compared to normal pituitary. miRNAs were differentially expressed in functioning PAs or in NFPAs, as in the latter group miR-149-3p (p = 0.036), miR-130a-3p (p = 0.014), and miR-370-3p (p = 0.026) were significantly under expressed as compared to functioning tumors. Point-biserial correlation analysis demonstrated a negative correlation between miR-26b-5p and Ki-67 (p = 0.031) and between miR-30a-5p and 'atypical' morphological features (p = 0.038) or cavernous sinus invasion (p = 0.049), while 508-5p was inversely correlated with clinical aggressiveness (p = 0.043). CONCLUSIONS: In this study, we found a significant down-regulation of 17 miRNAs in PAs vs normal pituitary, with differential expression profile related to functional status and tumor aggressiveness.

Increased removal of cadmium by Chlamydomonas reinhardtii modified with a synthetic gene for γ-glutamylcysteine synthetase.

Bioremediation with genetically modified microalgae is becoming an alternative to remove metalloids and metals such as cadmium, a contaminant produced in industrial processes and found in domestic waste. Its removal is important in several countries including Mexico, where the San Luis Potosi region has elevated levels of it. We generated a construct with a synthetic gene for γ-glutamylcysteine synthetase and employed it in the chloroplast transformation of Chlamydomonas reinhardtii. In dose-response kinetics with media containing from 1 to 20 mg/L of cadmium, both the transplastomic clone and the wild-type strain grew similarly, but the former removed up to 32% more cadmium. While the growth of both decreased with higher concentrations of cadmium, the transplastomic clone removed 20 ± 9% more than the wild-type strain. Compared to the wild-type strain, in the transplastomic clone the activity of glutathione S-transferase and the intracellular glutathione increased up to 2.1 and 1.9 times, respectively, in media with 2.5 and 10 mg/mL of cadmium. While 20 mg/L of cadmium inhibited the growth of both, the transplastomic clone gradually duplicated. These results confirm the expression of the synthetic gene gshA in the transformed strain as revealed in its increased removal uptake and metabolic response.

Fat Injection for Cases of Severe Burn Outcomes: A New Perspective of Scar Remodeling and Reduction.

BACKGROUND: Despite civilization and progress, burns occur frequently in the world. Remarkable discoveries of wound healing mechanisms have been reported. On the other hand, long-term outcomes from burn injuries represent a barrier to improvement of patients' social, functional, and psychological condition. Lipofilling, described since the 1980s, currently is used for several clinical applications. This study aimed to verify whether lipofilling could ameliorate scar remodeling in three clinical cases. METHODS: Three adult patients with hemifacial hypertrophic scars and keloids resulting from severe burns 2 to 13 years previously were selected. The patients were treated by injection of adipose tissue harvested from abdominal subcutaneous fat and processed according to Coleman's technique. Two injections (with a 13-month interval between) were administered at the dermohypodermal junction. Histologic examination of scar tissue punch biopsies (hematoxylin-eosin staining) before and after the treatment was performed as well as magnetic resonance scan with contrast. RESULTS: The clinical appearance and subjective patient feelings after a 6-month follow-up period suggest considerable improvement in the mimic features, skin texture, and thickness. Histologic examination shows patterns of new collagen deposition, local hypervascularity, and dermal hyperplasia in the context of new tissue, with high correspondence to the original. CONCLUSIONS: The preliminary results show that lipofilling improves scar quality and suggest a tissue regeneration enhancing process.

Arthropathy in acromegaly: a questionnaire-based estimation of motor disability and its relation with quality of life and work productivity.

PURPOSE: Arthropathy is a common and disabling complication of acromegaly. Since in this condition radiological findings rarely correspond to functional impairment, we elected to quantify in a large cohort of acromegalic patients: the degree of motor disability compared with data from general population, the impact of joint involvement on quality of life and work productivity, and to look for associated factors. METHODS: In 211 acromegalic patients, 131 with controlled disease and 80 with active disease, eight validated scales were used to evaluate the (i) prevalence and distribution of arthropathy, (ii) degree of motor disability and joint symptoms (VAS, AIMS symptoms and WOMAC), (iii) quality of life (AcroQoL and PASQ) and work capability (WPAI:GH) as consequences of joint complications. RESULTS: Using the WOMAC questionnaire, for which population based normative values are available, a significantly higher prevalence and severity of motor disability was detected in acromegalics compared to the general population from literature. The results provided by the different questionnaires turned out to be highly concordant. All measures of motor disability correlated both with impaired quality of life and motor disability and were worse in females and in patients with higher BMI. CONCLUSIONS: The questionnaires VAS, AIMS symptoms, and WOMAC (this latter both as a whole and with its functionality subscale), with their scores, proved to be the most adequate tools to evaluate motor disability and its consequences on both quality of life and work productivity in acromegaly. Female gender and higher BMI are associated with worse articular symptoms.

Arsenic removal using Chlamydomonas reinhardtii modified with the gene acr3 and enhancement of its performance by decreasing phosphate in the growing media.

Arsenic contamination of groundwater is a significant problem in countries like Mexico, where San Luis Potosi is among the regions registering severe levels of it. Bioremediation with microalgae capable to absorb and metabolize metals or metalloids like arsenic reduces their toxicity and is a cost-effective approach compared to physical-chemical processes. We evaluated the capability of Chlamydomonas reinhardtii to remove arsenate and compared it with an acr3-modified recombinant strain, which we produced by transforming the wild-type strain with Agrobacterium tumefaciens using the construct pARR1 including a synthetic, optimized acr3 gene from Pteris vittata, a hyper-accumulator of arsenic. We monitored the growth of both strains in media with arsenate, containing a standard or a 10-fold decreased amount of phosphate. Comparing both strains in media initially with 0.5, 1, and 1.5 mg/L of arsenate, the acr3-modified strain removed 1.5 to 3 times more arsenic than the wild-type strain. Moreover, the arsenic uptake rate increased 1.2 to 2.3 times when growing the acr3-modified strain in media with decreased phosphate, while the uptake rate for the wild-type strain scarcely changed under the same conditions. These results confirm the expression of the acr3 gene in C. reinhardtii and its potential application to remove arsenic.

Towards the use of diffuse reflectance spectroscopy for real-time in vivo detection of breast cancer during surgery.

BACKGROUND: Breast cancer surgeons struggle with differentiating healthy tissue from cancer at the resection margin during surgery. We report on the feasibility of using diffuse reflectance spectroscopy (DRS) for real-time in vivo tissue characterization. METHODS: Evaluating feasibility of the technology requires a setting in which measurements, imaging and pathology have the best possible correlation. For this purpose an optical biopsy needle was used that had integrated optical fibers at the tip of the needle. This approach enabled the best possible correlation between optical measurement volume and tissue histology. With this optical biopsy needle we acquired real-time DRS data of normal tissue and tumor tissue in 27 patients that underwent an ultrasound guided breast biopsy procedure. Five additional patients were measured in continuous mode in which we obtained DRS measurements along the entire biopsy needle trajectory. We developed and compared three different support vector machine based classification models to classify the DRS measurements. RESULTS: With DRS malignant tissue could be discriminated from healthy tissue. The classification model that was based on eight selected wavelengths had the highest accuracy and Matthews Correlation Coefficient (MCC) of 0.93 and 0.87, respectively. In three patients that were measured in continuous mode and had malignant tissue in their biopsy specimen, a clear transition was seen in the classified DRS measurements going from healthy tissue to tumor tissue. This transition was not seen in the other two continuously measured patients that had benign tissue in their biopsy specimen. CONCLUSIONS: It was concluded that DRS is feasible for integration in a surgical tool that could assist the breast surgeon in detecting positive resection margins during breast surgery. Trail registration NIH US National Library of Medicine-clinicaltrails.gov, NCT01730365. Registered: 10/04/2012 https://clinicaltrials.gov/ct2/show/study/NCT01730365.

Optical signature of nerve tissue-Exploratory ex vivo study comparing optical, histological, and molecular characteristics of different adipose and nerve tissues.

BACKGROUND: During several anesthesiological procedures, needles are inserted through the skin of a patient to target nerves. In most cases, the needle traverses several tissues-skin, subcutaneous adipose tissue, muscles, nerves, and blood vessels-to reach the target nerve. A clear identification of the target nerve can improve the success of the nerve block and reduce the rate of complications. This may be accomplished with diffuse reflectance spectroscopy (DRS) which can provide a quantitative measure of the tissue composition. The goal of the current study was to further explore the morphological, biological, chemical, and optical characteristics of the tissues encountered during needle insertion to improve future DRS classification algorithms. METHODS: To compare characteristics of nerve tissue (sciatic nerve) and adipose tissues, the following techniques were used: histology, DRS, absorption spectrophotometry, high-resolution magic-angle spinning nuclear magnetic resonance (HR-MAS NMR) spectroscopy, and solution 2D 13 C-1 H heteronuclear single-quantum coherence spectroscopy. Tissues from five human freshly frozen cadavers were examined. RESULTS: Histology clearly highlights a higher density of cellular nuclei, collagen, and cytoplasm in fascicular nerve tissue (IFAS). IFAS showed lower absorption of light around 1200 nm and 1750 nm, higher absorption around 1500 nm and 2000 nm, and a shift in the peak observed around 1000 nm. DRS measurements showed a higher water percentage and collagen concentration in IFAS and a lower fat percentage compared to all other tissues. The scattering parameter (b) was highest in IFAS. The HR-MAS NMR data showed three extra chemical peak shifts in IFAS tissue. CONCLUSION: Collagen, water, and cellular nuclei concentration are clearly different between nerve fascicular tissue and other adipose tissue and explain some of the differences observed in the optical absorption, DRS, and HR-NMR spectra of these tissues. Some differences observed between fascicular nerve tissue and adipose tissues cannot yet be explained but may be helpful in improving the discriminatory capabilities of DRS in anesthesiology procedures. Lasers Surg. Med. 50:948-960, 2018. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Nerve detection using optical spectroscopy, an evaluation in four different models: In human and swine, in-vivo, and post mortem.

OBJECTIVE: Identification of peripheral nerve tissue is crucial in both surgery and regional anesthesia. Recently, optical tissue identification methods are presented to facilitate nerve identification in transcutaneous procedures and surgery. Optimization and validation of such techniques require large datasets. The use of alternative models to human in vivo, like human post mortem, or swine may be suitable to test, optimize and validate new optical techniques. However, differences in tissue characteristics and thus optical properties, like oxygen saturation and tissue perfusion are to be expected. This requires a structured comparison between the models. STUDY DESIGN: Comparative observational study. METHODS: Nerve and surrounding tissues in human (in vivo and post mortem) and swine (in vivo and post mortem) were structurally compared macroscopically, histologically, and spectroscopically. Diffuse reflective spectra were acquired (400-1,600 nm) after illumination with a broad band halogen light. An analytical model was used to quantify optical parameters including concentrations of optical absorbers. RESULTS: Several differences were found histologically and in the optical parameters. Histologically nerve and adipose tissue (subcutaneous fat and sliding fat) showed clear similarities between human and swine while human muscle enclosed more adipocytes and endomysial collagen. Optical parameters revealed model dependent differences in concentrations of ß-carotene, water, fat, and oxygen saturation. The similarity between optical parameters is, however, sufficient to yield a strong positive correlation after cross model classification. CONCLUSION: This study shows and discusses similarities and differences in nerve and surrounding tissues between human in vivo and post mortem, and swine in vivo and post mortem; this could support the discussion to use an alternative model to optimize and validate optical techniques for clinical nerve identification. Lasers Surg. Med. 50:253-261, 2018. © 2017 Wiley Periodicals, Inc.

Nerve detection during surgery: optical spectroscopy for peripheral nerve localization.

Precise nerve localization is of major importance in both surgery and regional anesthesia. Optically based techniques can identify tissue through differences in optical properties, like absorption and scattering. The aim of this study was to evaluate the potential of optical spectroscopy (diffuse reflectance spectroscopy) for clinical nerve identification in vivo. Eighteen patients (8 male, 10 female, age 53 ± 13 years) undergoing inguinal lymph node resection or resection or a soft tissue tumor in the groin were included to measure the femoral or sciatic nerve and the surrounding tissues. In vivo optical measurements were performed using Diffuse Reflectance Spectroscopy (400-1600 nm) on nerve, near nerve adipose tissue, muscle, and subcutaneous fat using a needle-shaped probe. Model-based analyses were used to derive verified quantitative parameters as concentrations of optical absorbers and several parameters describing scattering. A total of 628 optical spectra were recorded. Measured spectra reveal noticeable tissue specific characteristics. Optical absorption of water, fat, and oxy- and deoxyhemoglobin was manifested in the measured spectra. The parameters water and fat content showed significant differences (P < 0.005) between nerve and all surrounding tissues. Classification using k-Nearest Neighbor based on the derived parameters revealed a sensitivity of 85% and a specificity of 79%, for identifying nerve from surrounding tissues. Diffuse Reflectance Spectroscopy identifies peripheral nerve bundles. The differences found between tissue groups are assignable to the tissue composition and structure.

High frequency continuous birefringence-induced oscillations in spin-polarized vertical-cavity surface-emitting lasers.

Sustained, large amplitude and tunable birefringence-induced oscillations are obtained in a spin-vertical cavity surface-emitting laser (spin-VCSEL). Experimental evidence is provided using a spin-VCSEL operating at 1300 nm, under continuous-wave optical pumping and at room temperature. Numerical and stability analyses are performed to interpret the experiments and to identify the combined effects of pump ellipticity, spin relaxation rate, and cavity birefringence. Importantly, the frequency of the induced oscillations is determined by the device's birefringence rate, which can be tuned to very large values. This opens the path for ultrafast spin-lasers operating at record frequencies exceeding those possible in traditional semiconductor lasers and with ample expected impact in disparate disciplines (e.g., datacomms, spectroscopy).

Validation of a predictive model for identifying febrile young infants with altered urinalysis at low risk of invasive bacterial infection.

In 2015, a predictive model for invasive bacterial infection (IBI) in febrile young infants with altered urine dipstick was published. The aim of this study was to externally validate a previously published set of low risk criteria for invasive bacterial infection in febrile young infants with altered urine dipstick. Retrospective multicenter study including nine Spanish hospitals. Febrile infants ≤90 days old with altered urinalysis (presence of leukocyturia and/or nitrituria) were included. According to our predictive model, an infant is classified as low-risk for IBI when meeting all the following: appearing well at arrival to the emergency department, being >21 days old, having a procalcitonin value <0.5 ng/mL and a C-reactive protein value <20 mg/L. IBI was considered as secondary to urinary tract infection if the same pathogen was isolated in the urine culture and in the blood or cerebrospinal fluid culture. A total of 391 patients with altered urine dipstick were included. Thirty (7.7 %) of them developed an IBI, with 26 (86.7 %) of them secondary to UTI. Prevalence of IBI was 2/104 (1.9 %; CI 95% 0.5-6.7) among low-risk patients vs 28/287 (9.7 %; CI 95% 6.8-13.7) among high-risk patients (p < 0.05). Sensitivity of the model was 93.3 % (CI 95% 78.7-98.2) and negative predictive value was 98.1 % (93.3-99.4). Although our predictive model was shown to be less accurate in the validation cohort, it still showed a good discriminatory ability to detect IBI. Larger prospective external validation studies, taking into account fever duration as well as the role of ED observation, should be undertaken before its implementation into clinical practice.

T1 colon cancer in the era of screening: risk factors and treatment.

BACKGROUND: The aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit. METHODS: The sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases. RESULTS: Out of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN. CONCLUSIONS: Some factors associated with an increase in detection of positive LN were identified. However, further studies are needed to identify more sensitive markers and avoid surgical overtreatment. There is a need to raise the minimum LN count and to use the LN count as an indicator of surgical quality.