Surgical treatment of stage IV colorectal cancer with synchronous liver metastases : a systematic review and network meta-analysis

Background: The ideal treatment approach for colorectal cancer (CRC) with synchronous liver metastases (SCRLM) remains debated. We performed a network meta-analysis (NMA) comparing the 'bowel-first' approach (BFA), simultaneous resection (SIM), and the 'liver-first' approach (LFA). Methods: A systematic search of comparative studies in CRC with SCRLM was undertaken using the Embase, PubMed, Web of Science, and CENTRAL databases. Outcome measures included postoperative complications, 30- and 90-day mortality, chemotherapy use, treatment completion rate, 3- and 5-year recurrence-free survival, and 3- and 5-year overall survival (OS). Pairwise and network meta-analysis were performed to compare strategies. Heterogeneity was assessed using the Higgins I-2 statistic. Results: One prospective and 43 retrospective studies reporting on 10 848 patients were included. Patients undergoing the LFA were more likely to have rectal primaries and a higher metastatic load. The SIM approach resulted in a higher risk of major morbidity and 30-day mortality. Compared to the BFA, the LFA more frequently resulted in failure to complete treatment as planned (34% versus 6%). Pairwise and network meta-analysis showed a similar 5-year OS between LFA and BFA and a more favorable 5-year OS after SIM compared to LFA (odds ratio 0.25-0.90, p = 0.02, I-2 = 0%), but not compared to BFA. Conclusion: Despite a higher tumor load in LFA compared to BFA patients, survival was similar. A lower rate of treatment completion was observed with LFA. Uncertainty remains substantial due to imprecise estimates of treatment effects. In the absence of prospective trials, treatment of stage IV CRC patients should be individually tailored. (C) 2020 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved

A subcutaneous infection mimicking necrotizing fasciitis due to Butyricimonas virosa

Introduction: Butyricimonas virosa is a Gram-negative rod who was first identified in rat faces in 2009. Since then only six human infections have been described in literature of which five bacteremia and one bone abscess. We report a clinical case of a subcutaneous infection mimicking necrotizing fasciitis due to B. virosa. Patient and methods: A 78-year-old man was referred to our hospital because of a wound infection at the surgical site with suspicion of necrotizing fasciitis. Treatment consisted of immediate surgical exploration with obtainment of intra-operative specimens for microbiologic examination, 15 d of negative pressure wound therapy (NPWT) and antibiotic treatment with piperacillin-tazobactam (12 d) plus vancomycin (9 d). Results: Surgical exploration did not show necrotising fasciitis but a subcutaneous infection mimicking necrotising fasciitis. The results of the intra-operative specimens revealed the presence of B.virosa and Finegoldia magna. Cultures taken during the NPWT replacements became negative and the patient was able to leave the hospital after 18 d. Conclusions: Considering there was no necrotizing infection present it may have been possible to safely close the wound sooner. However, it is difficult to differentiate between an actual necrotizing fasciitis and a subcutaneous infection mimicking necrotizing fasciitis. Therefore further studies on effective assessment tools to diagnose necrotizing fasciitis, such as the (modified) laboratory risk indicator for necrotizing fasciitis (LRINEC) score and enhanced computed tomography (CT), could be helpful

Quality of life after open versus laparoscopic preperitoneal mesh repair for unilateral inguinal hernias

Background: Both the open transinguinal preperitoneal repair (TIPP) and the laparoscopic total extraperitoneal mesh repair (TEP) show excellent outcomes. Direct comparative data between these 2 preperitoneal techniques is lacking. The aim of this study was to assess postoperative outcomes and quality of life (QoL) for these open and laparoscopic preperitoneal repair techniques. Methods: Between 2014 and 2016, 204 male patients underwent unilateral inguinal hernia repair through TIPP (n = 135) or TEP (n = 69). Data recorded include demographic profile, preoperative and intraoperative variables, postoperative complications and postoperative quality of life. Two validated hernia-specific QoL questionnaires, the Carolinas Comfort Scale (CCS) and the European Registry for Abdominal Wall Hernias Quality of Life score (EuraHS QoL) were used to assess postoperative QoL. Results: The TIPP group consisted of 135 patients, the TEP group of 69 patients. The mean age of patients was significantly higher in TIPP (64.07 ± 17.10 years) than in TEP (59.0 ± 15.53 years) (p = 0.022). A total of 96 patients (47.1%) responded to our invitation for longterm follow-up: 58 in the TIPP group (43%) and 38 in the TEP group (55.1%). There was no difference in mean follow-up time between the surgical procedure and filling in the questionnaires: 37.4 ± 12.8 months for TIPP and 33.5 ± 11.3 months for TEP group (p = 0.13). No significant differences in quality of life were found between TIPP and TEP for all explored domains. Conclusion: TIPP and TEP show equivalent results considering postoperative quality of life. Compared to existing literature on mesh repair for unilateral inguinal hernias, we may conclude that the preperitoneal location of the mesh probably is a more decisive factor for quality of life than the surgical approach used

Implementing preoperative Botulinum toxin A and progressive pneumoperitoneum through the use of an algorithm in giant ventral hernia repair

Background Repair of large ventral hernias with loss of domain can be facilitated by preoperative Botulinum toxin A (BTA) injections and preoperative progressive pneumoperitoneum (PPP). The aim of this study is to evaluate the outcomes of ventral hernioplasty using a standardized algorithm, including component separation techniques, preoperative BTA and PPP. Methods All patients between June 2014 and August 2018 with giant hernias (either primary or incisional) of more than 12 cm width were treated according to a previously developed standardized algorithm. Retrospective data analysis from a prospectively collected dataset was performed. The primary outcome was closure of the anterior fascia. Secondary outcomes included complications related to the preoperative treatment, postoperative complications, and recurrences. Results Twenty-three patients were included. Median age was 65 years (range 28-77) and median BMI was 31.4 (range 22.7-38.0 kg/m(2)). The median loss of domain was 29% (range 12-226%). For the primary and secondary endpoints, 22 patients were analyzed. Primary closure of the anterior fascia was possible in 82% of all patients. After a median follow-up of 19.5 months (range 10-60 months), 3 patients (14%) developed a hernia recurrence and 16 patients (73%) developed 23 surgical site occurrences, most of which were surgical site infections (54.5%). Conclusion Our algorithm using both anterior or posterior component separation, together with preoperative BTA injections and PPP, achieved an acceptable fascial closure rate. Further studies are needed to explore the individual potential of BTA injections and PPP, and to research whether these methods can prevent the need for component separation, as postoperative wound morbidity remains high in our study

Field assessment of guar gum stabilized microscale zerovalent iron particles for in-situ remediation of 1,1,1-trichloroethane

A pilot injection test with guar gum stabilized microscale zerovalent iron (mZVI) particles was performed at test site V (Belgium) where different chlorinated aliphatic hydrocarbons (CAHs) were present as pollutants in the subsurface. One hundred kilograms of 56 μm-diameter mZVI (~ 70 g/L) was suspended in 1.5 m3 of guar gum (~ 7 g/L) solution and injected into the test area. In order to deliver the guar gum stabilized mZVI slurry, one direct push bottom-up injection (Geoprobe) was performed with injections at 5 depths between 10.5 and 8.5 m bgs. The direct push technique was preferred above others (e.g. injection at low flow rate via screened wells) because of the limited hydraulic conductivity of the aquifer, and to the large size of the mZVI particles. A final heterogeneous distribution of the mZVI in the porous medium was observed explicable by preferential flow paths created during the high pressure injection. The maximum observed delivery distance was 2.5 m. A significant decrease in 1,1,1-TCA concentrations was observed in close vicinity of spots where the highest concentration of mZVI was observed. Carbon stable isotope analysis (CSIA) yielded information on the success of the abiotic degradation of 1,1,1-TCA and indicated a heterogeneous spatio-temporal pattern of degradation. Finally, the obtained results show that mZVI slurries stabilized by guar gum can be prepared at pilot scale and directly injected into low permeable aquifers, indicating a significant removal of 1,1,1-TCA

Prospecting environmental mycobacteria: combined molecular approaches reveal unprecedented diversity

Background: Environmental mycobacteria (EM) include species commonly found in various terrestrial and aquatic environments, encompassing animal and human pathogens in addition to saprophytes. Approximately 150 EM species can be separated into fast and slow growers based on sequence and copy number differences of their 16S rRNA genes. Cultivation methods are not appropriate for diversity studies; few studies have investigated EM diversity in soil despite their importance as potential reservoirs of pathogens and their hypothesized role in masking or blocking M. bovis BCG vaccine. Methods: We report here the development, optimization and validation of molecular assays targeting the 16S rRNA gene to assess diversity and prevalence of fast and slow growing EM in representative soils from semi tropical and temperate areas. New primer sets were designed also to target uniquely slow growing mycobacteria and used with PCR-DGGE, tag-encoded Titanium amplicon pyrosequencing and quantitative PCR. Results: PCR-DGGE and pyrosequencing provided a consensus of EM diversity; for example, a high abundance of pyrosequencing reads and DGGE bands corresponded to M. moriokaense, M. colombiense and M. riyadhense. As expected pyrosequencing provided more comprehensive information; additional prevalent species included M. chlorophenolicum, M. neglectum, M. gordonae, M. aemonae. Prevalence of the total Mycobacterium genus in the soil samples ranged from 2.3×107 to 2.7×108 gene targets g−1; slow growers prevalence from 2.9×105 to 1.2×107 cells g−1. Conclusions: This combined molecular approach enabled an unprecedented qualitative and quantitative assessment of EM across soil samples. Good concordance was found between methods and the bioinformatics analysis was validated by random resampling. Sequences from most pathogenic groups associated with slow growth were identified in extenso in all soils tested with a specific assay, allowing to unmask them from the Mycobacterium whole genus, in which, as minority members, they would have remained undetected

Enhanced biodegradation of PAHs in historically contaminated soil by M. gilvum inoculated biochar

The inoculation of rice straw biochar with PAH-degrading Mycobacterium gilvum (1.27 × 1011 ± 1.24 × 1010 cell g−1), and the subsequent amendment of this composite material to PAHs contaminated (677 mg kg−1) coke plant soil, was conducted in order to investigate if would enhance PAHs biodegradation in soils. The microbe-biochar composite showed superior degradation capacity for phenanthrene, fluoranthene and pyrene. Phenanthrene loss in the microbe-biochar composite, free cell alone and biochar alone treatments was, respectively, 62.6 ± 3.2%, 47.3 ± 4.1% and non-significant (P > 0.05); whereas for fluoranthene loss it was 52.1 ± 2.3%; non-significant (P > 0.05) and non-significant (P > 0.05); and for pyrene loss it was 62.1 ± 0.9%; 19.7 ± 6.5% and 13.5 ± 2.8%. It was hypothesized that the improved remediation was underpinned by i) biochar enhanced mass transfer of PAHs from the soil to the carbonaceous biochar “sink”, and ii) the subsequent degradation of the PAHs by the immobilized M. gilvum. To test this mechanism, a surfactant (Brij 30; 20 mg g−1 soil), was added to impede PAHs mass transfer to biochar and sorption. The surfactant increased solution phase PAH concentrations and significantly (P < 0.05) reduced PAH degradation in the biochar immobilized M. gilvum treatments; indicating the enhanced degradation occurred between the immobilized M. gilvum and biochar sorbed PAHs

Evaluation of skin prick location on the forearm using a novel skin prick automated test device

BackgroundThe skin prick test (SPT) is the gold standard for identifying allergic sensitization in individuals suspected of having an inhalant allergy. Recently, it was demonstrated that SPT using a novel skin prick automated test (SPAT) device showed increased reproducibility and tolerability compared to the conventional SPT, among other benefits.ObjectiveThis study aimed to evaluate prick location bias using the novel SPAT device.MethodsA total of 118 volunteers were enrolled in this study and underwent SPATs with histamine (nine pricks) and glycerol control (one prick) solutions on the volar side of their forearms. Imaging of the skin reactions was performed using the SPAT device, and the physician determined the longest wheal diameter by visually inspecting the images using a web interface. Prick location bias was assessed along the medial vs. lateral and proximal vs. distal axes of the forearm.ResultsIn total, 944 histamine pricks were analyzed. Four medial and four lateral histamine pricks were grouped, and wheal sizes were compared. The longest wheal diameters were not significantly different between the medial and lateral prick locations (p = 0.41). Furthermore, the pricks were grouped by two based on their position on the proximal–distal axis of the forearm. No significant difference was observed among the four groups of analyzed prick locations (p = 0.73).ConclusionThe prick location on the volar side of the forearm did not influence wheal size in SPAT-pricked individuals

Clinical Characterization and Diagnostic Approaches for Patients Reporting Hypersensitivity Reactions to Quinolones

[EN] BACKGROUND: Quinolones are the second most frequent cause of hypersensitivity reactions (HSRs) to antibiotics. A marked increase in the number of patients with HSRs to quinolones has been detected. OBJECTIVE: To describe the clinical characteristics of patients with HSRs to quinolones and present methods for their diagnosis. METHODS: Patients attending the allergy unit due to reactions suggestive of HSRs to quinolones were prospectively evaluated between 2005 and 2018. Diagnosis was achieved using clinical history, skin tests (STs), basophil activation tests (BATs), and drug provocation tests (DPTs) if ST and BAT results were negative. RESULTS: We included 128 subjects confirmed as having HSRs to quinolones and 42 found to be tolerant. Anaphylaxis was the most frequent entity in immediate HSRs and was most commonly induced by moxifloxacin. Patients were evaluated a median of 150 days (interquartile range, 60-365 days) after the reaction. Of patients who underwent ST and BAT, 40.7% and 70%, respectively, were positive. DPT with a quinolone was performed in 48 cases, giving results depending on the culprit drug: when moxifloxacin was involved, 62.5% of patients gave a positive DPT result to ciprofloxacin, whereas none reacted to levofloxacin. The risk of HSR was 96 times higher in subjects who reported moxifloxacin-induced anaphylaxis and 18 times higher in those reporting immediate reactions compared with clinical entities induced by quinolones other than moxi-floxacin and nonimmediate reactions. CONCLUSIONS: The diagnosis of HSR to quinolones is complex. The use of clinical history is essential as a first step. BAT shows higher sensitivity than STs. DPTs can be useful for finding safe alternative quinolones.The present study has been supported by the Institute of Health "Carlos III" of the Ministry of Economy and Competitiveness (grants cofounded by European Regional Development Fund: RETIC ARADYALRD16/0006/0001, RD16/0006/0010, RD16/0006/0019, and RD16/0006/0030). I.D. is a clinical investigator (B0001-2017) from Consejeria de Salud of the Andalusian government, Junta de Andalucia. N.P.-S. holds a Rio Hortega research contract (CM17/0014), and E.B. a Juan Rodes research contract (JR18/00049), both from the Institute of Health "Carlos III," Spanish Ministry of Economy and Competitiveness (grants cofounded by the European Social Fund).Doña, I.; Pérez-Sánchez, N.; Salas, M.; Barrionuevo, E.; Ruiz-San Francisco, A.; Hernández Fernández De Rojas, D.; Martí-Garrido, J.... (2020). Clinical Characterization and Diagnostic Approaches for Patients Reporting Hypersensitivity Reactions to Quinolones. 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