Pilonidal sinus surgery: could we predict postoperative complications?

Pilonidal sinus surgery could, as of now, be considered a surgery tailored more to the surgeon than to the patient. In an attempt to give to surgeons an objective instrument of decision, we have evaluated which variables could be considered predictive of postoperative complications after pilonidal sinus surgery. A prospective electronic database of all patients treated for sacrococcygeal pilonidal disease was analysed. Sex, age, obesity, smoking, recurrent disease, the presence of multiple orifices and the distance between the most lateral orifice and midline were recorded and correlated with the occurrence of postoperative complications (infection and recurrence); 1006 patients were evaluated. Excision with primary mid‐line closure was performed on all the patients. Mean follow‐up was 7·3 ± 3·6 years. A total of 158 patients with postoperative complications (infection and/or recurrence) were recorded during this period. A multivariate analysis showed that, after adjusting for major clinical and demographic characteristics, only a recurrent disease [odds ratio (OR): 3·41, 95% confidence interval (CI): 1·89–6·15, P < 0·001] and the distance of lateral orifice from midline (OR: 26·3, 95% CI: 12·2–56·7, P < 0·001) were independent predictors of overall postoperative complications. Focussing on the distance from midline, the receiver operative characteristic (ROC) analysis showed that the distance of lateral orifice from midline predicted 79·2% of complications and the Youden's test identified the best cut‐off as 2·0 cm for this variable. An evidence‐based tool for deciding on the type of surgical intervention could be developed and validated by further ad hoc prospective studies evaluating our results in comparison to other different types of surgical techniques. Our results support the use of these variables as an effective way to tailor pilonidal sinus surgery to the patient, so as to obtain the best results in patient care.     

Frequency-dependent myosin light chain phosphorylation in isolated myocardium

A specific light chain subunit (P-light chain) of myosin from striated and smooth muscles is phosphorylated by Ca2+ calmodulin-dependent myosin light chain kinase. Phosphorylation of cardiac P-light chain was examined in isolated perfused rabbit ventricular septae to determine the effect of contraction frequency on this Ca2+-dependent reaction. Muscles stimulated at 42 beats/min had 0.23 mol phosphate/mol P-light chain which decreased to 0.12 mol phosphate/mol P-light chain when the muscles were made quiescent (0 beats/min in the presence of 22 mM K+ for 30 min). Rephosphorylation of P-light chain to 0.24 mol phosphate/mol P-light chain occurred in muscles stimulated at 84 beats/min for 90 min but not in muscles stimulated at 42 beats/min for 30 min (0.15 mol phosphate/mol P-light chain). Stimulation at frequencies ranging from 0 to 126 beats/min for 30 min produced a frequency-dependent increase in P-light chain phosphorylation from 0.1 to 0.4 mol phosphate/mol P-light chain. Increased inotropy for 30 s with isoproterenol was not associated with significant increases in P-light chain phosphorylation in muscles stimulated at 42 beats/min. The rates of myosin P-light chain phosphorylation and dephosphorylation in ventricular muscle are much slower than the reported rates of phosphorylation in either fast-twitch skeletal or smooth muscles. The extent of cardiac P-light chain phosphorylation appears dependent upon the steady-state frequency of contraction.     

Orofacial neuralgia associated with a middle cerebral artery aneurysm

Chronic orofacial pain of neuropathic origin can present diagnostic and management dilemmas to dental practitioners and also affects the patient's quality of life. Intracranial aneurysms are a potential cause of stroke (e.g. sub‐arachnoid haemorrhage) that is usually associated with, high rates of mortality and morbidity. A patient who had been previously managed for symptoms of temporomandibular joint disorder (TMD) presented with sharp, shooting pain of moderate intensity. It was precipitated by swallowing, and radiated to the right throat, posterior border of the mandible, ear and temporomandibular joint. Clinical and radiological investigations ruled out odontogenic pain, TMD and other more common types of facial pain. Magnetic resonance imaging revealed a 7 × 6 mm aneurysm in the right middle cerebral artery (MCA) which was subsequently surgically clipped. Interestingly, the facial pain resolved after this procedure. Compression of the insular region of the brain innervated by the trigeminal, glossopharyngeal and vagus nerves provides a plausible explanation for the pain reported. To our knowledge, this is the first case of facial neuralgia associated with an aneurysm in the MCA which emphasizes the importance of a multidisciplinary approach in the diagnosis and management of unusual cases of chronic orofacial pain.     

Analyzing growth and change: latent variable growth curve modeling with an application to clinical trials

Objective Typical methods of analyzing data from clinical trials have shortcomings, notably comparisons of group means, use of change scores from pre- and post-treatment assessments, ignoring intervening assessments, and focusing on direct effects of treatment. A comparison of group means disregards the likelihood that individuals have different trajectories of change. Moreover, change scores ignore intervening assessments that may provide useful information about change. This paper compares results from traditional regression-based methods for analyzing data from a clinical trial (e.g., regression with change scores) with those of latent growth curve modeling (LGM). Methods LGM is a method that uses structural equation modeling techniques to model individual change, assess treatment effects and the relationship among multiple outcomes simultaneously, and model measurement error. The consequence is more precise parameter estimates while using data from all available time points. Results Results demonstrate that LGM can yield stronger parameter estimates than the traditional regression-based approach and explain more variance in the outcome. In trials where there is a true effect, but it is non-significant or marginally significant using the traditional methods, LGM may provide evidence of this effect. Conclusions Analysts are encouraged to consider LGM as an additional and informative tool for analyzing clinical trial or other longitudinal data. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Laryngeal papillomas: the epidemiology in a Danish subpopulation 1965–1984

The incidence rate of laryngeal papillomas in a Danish subpopulation (approximately 2.8 million inhabitants) was 3.84 × 10^-6 per year in the period 1968–1984. For juvenile papillomas the incidence rate was 3.62 × 10^-6, compared with 3.94 × 10^-6 for laryngeal papillomas of adult onset. When comparing different time periods a significantly low incidence was found in the time 1965–1968, while the incidence remained constant in 1969–1984. The low incidence rate in the early period may be real, but selectional bias may have played a part. It is in general anticipated that maternal genital HPV-infections may serve as an HPV-reservoir, and that juvenile laryngeal papilloma is a result of HPV transmission from the mother to the child during birth. In the period in question cervical HPV-infections have been recorded with increasing frequency in younger women, indicating that the prevalence is rising. However, this is not reflected in the incidence of laryngeal papillomas.     

Liver transplantation in tyrosinaemia type 1: the dilemma of timing the operation

Four children with tyrosinaemia type 1 received liver transplants. The metabolic disorder was corrected and all four had normal liver function on an unrestricted diet. Two children, transplanted at age five and seven years, proved to have occult hepatocellular carcinoma and both subsequently developed pulmonary metastases. One child was well 32 months after removal of a single pulmonary metastasis but the other child died with multiple metastases. The two younger children, transplanted at age 19 and 21 months, were well 28 and 44 months after operation, one after a second liver transplant. Our experience confirms the high risk of hepatocellular carcinoma in this disease and the potential value of early liver transplantation.