Does Full Wound Rupture following Median Pilonidal Closure Alter Long-Term Recurrence Rate?

Objective

The purpose of this study was to examine the recurrence rate of wound rupture in primary pilonidal sinus disease (PSD) after median closure.

Subjects and Methods

A total of 583 patients from the German military cohort were interviewed. We compared the choice of surgical therapy, wound dehiscence (if present) and long-term recurrence-free survival for patients with primary open treatment, marsupialization and primary median treatment (closed vs. secondary open, respectively). Actuarial recurrence rate was determined using the Kaplan-Meier calculation with a follow-up of up to 20 years after primary PSD surgery.

Results

Patients with excision followed by primary open wound treatment showed a significantly lower 5- than 10-year recurrence rate (8.3 vs. 11.2%) compared to the patients with primary midline closure (17.4 vs. 20.5%, p = 0.03). The 20-year recurrence rate was 28% in primary open wound treatment versus 44% in primary midline closure without wound rupture. In contrast to these findings, long-term recurrence rates following secondary open wound treatment (12.2% at 5 years vs. 17.1% at 10 years) tended to be higher (although not significantly, p = 0.57) compared to primary open treatment (8.3% at 5 years vs. 11.2% at 10 years). There was no statistical difference in long-term recurrence rates between secondary open and primary midline closure (p = 0.7). Hence, despite only a short wound closure time experienced before wound rupture, the patient does not fully benefit from an open wound treatment in terms of recurrence rate.

Conclusion

The postoperative pilonidal sinus wound rupture of primary midline closures did not significantly increase the 5- and 10-year long-term recurrence rates compared to uneventfully healing primary midline closures.Key Words: Pilonidal sinus, Primary disease, Recurrence, Long-term recurrence rate, Primary wound closure, Wound dehiscence, Wound rupture, Surgery, Open wound treatment     

Can Benign Etiologies Predict Benign Outcomes in High-Risk Syncope Patients?

Background: We previously studied and validated risk factors for adverse outcomes or need for critical intervention in syncope. Objective: To determine whether high-risk patients, diagnosed with benign etiologies of syncope after a normal emergency department (ED) work-up, sustain favorable outcomes. Methods: Prospective, observational cohort of consecutive ED patients aged ≥ 18 years with syncope. Benign etiology was defined as vasovagal syncope or dehydration. Patients were followed up to 30 days to identify adverse outcomes including death, myocardial infarction, dysrhythmia, alterations in antidysrhythmics, percutaneous intervention, pulmonary embolus, stroke, metabolic catastrophe, or significant hemorrhage. Results: Patients presented with benign etiologies in 164/293, 56% (95% confidence interval [CI] 50–62%) of cases. Of these, pathologic conditions were identified during ED evaluation in 11/164, 7% (95% CI 3–11%) of cases. This includes ED findings/treatments of blood transfusion, severe electrolyte disturbance, incarcerated hernia, rhabdomyolysis, subarachnoid hemorrhage, bowel obstruction, dysrhythmia, and transient ischemic attack. The remaining 153 with benign presentations had no adverse outcomes at 30 days, while 57/129 (44%) patients with non-benign etiologies had adverse outcomes in the hospital or within 30 days. Previously, we demonstrated a 48% reduction in admission rate if only patients with risk factors for adverse outcome were admitted. If patients with both benign etiologies and a negative ED work-up were sent home, even if they had risk factors for an adverse outcome, an additional 19% (95% CI 14–25%) reduction in hospital admissions would have occurred. Conclusions: In patients with presentations consistent with a benign etiology of syncope (vasovagal or dehydration) where the ED work-up was normal, we found no patients who would benefit from hospitalization based on risk factors alone.     

Postoperative Tachycardia: Clinically Meaningful or Benign Consequence of Orthopedic Surgery?

Objective

To determine the clinical significance of tachycardia in the postoperative period.

Does lack of sleep cause diabetes?

Several lines of evidence indicate that chronic lack of sleep may contribute to the risk of type 2 diabetes mellitus. Adequate sleep and good sleep hygiene should be included among the goals of a healthy lifestyle, especially for patients with diabetes. We urge clinicians to recommend at least 7 hours of uninterrupted sleep per night as part of a healthy lifestyle.     

Does neuroimaging of suggestion elucidate hypnotic trance?

Contemporary studies in the cognitive neuroscience of attention and suggestion shed new light on the underlying neural mechanisms that operationalize these effects. Without adhering to important caveats inherent to imaging of the living human brain, however, findings from brain imaging studies may enthrall more than explain. Scholars, practitioners, professionals, and consumers must realize that the influence words exert on focal brain activity is measurable but that these measurements are often difficult to interpret. While recent brain imaging research increasingly incorporates variations of suggestion and hypnosis, correlating overarching hypnotic experiences with specific brain substrates remains tenuous. This article elucidates the mounting role of cognitive neuroscience, including the relative merits and intrinsic limitations of neuroimaging, in better contextualizing trance-like concepts.     

Benign or malignant thrombosis of the jugular vein? - Differentiation with colour-Doppler sonography

Thrombosis can lead to physical impairment and cost-intensive investigations. In some cases, a thrombosis is caused by infiltration of an adjacent tumour. It is therefore important to differentiate between a benign or malignant thrombosis. We report the case of a woman with a malignant thrombosis of the jugular vein. She was hospitalised for suspected malignant disease of unknown origin. Her family doctor had made the diagnosis of a "partially organised thrombosis". At sonography, vessels with an arterial blood flow were detected in the thrombus. A carcinoma of the thyroid gland was therefore suspected and confirmed by histology. This case report demonstrates that the differentiation between a benign and malignant thrombosis is possible with colour-Doppler sonography.     

Endoscopic Balloon Dilatation of Benign Esophageal Stricture—A Nonhazardous Procedure?

Balloon dilatation of benign esophageal strictures has been widely used since its introduction. We have performed 224 dilatation procedures in 52 patients. Dilatation was done as an outpatient procedure. Strictures were due to reflux esophagitis in 25 patients, anastomatic stenosis in 6, achalasia in 5, complications of sclerotherapy in 5, corrosive lesions in 3, and long-standing nasogastric intubation in 2. The cause was unknown in 6 cases. The intention was to dilate all strictures up to 20 mm. Three major complications occurred, and one of these patients died. The risk of perforation seems to be higher after repeated procedures than during the first one.