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Background: Karydakis published his advancement flap technique to treat pilonidal sinus disease (PSD) in 1973 (GEK73) and reported a very low recurrence rate in 1992 (GEK92) in a large series of cases. Since then, the procedure has been widely adapted without replicating his results., Aim: To compare the outcomes of the Karydakis 1992 report to the global literature and evaluate reasons for the major discrepancy in recurrence rates., Methods: From an international database including all PSD studies, we identified 113 other studies encompassing 9878 patients undergoing the Karydakis advancement flap surgery. Recurrence rates at 5- and 10-year follow-ups were compared to the data presented in the Karydakis 1992 paper., Results: The Karydakis 1992 study reports a recurrence rate < 1% with a follow-up ranging between 2 and 20 years. In the global literature, the 10-year recurrence rate is 8.8% in RCTs and 14.6% in nonRCTs which is 11.6- and 19.2-fold higher., Conclusion: The standard for recurrence rates after the Karydakis advancement flap set by Karydakis has not since been replicated in the global literature. For surgeons and patients alike it is important to have realistic expectations of short- and long-term outcomes., (© 2025 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Aim: Pilonidal sinus disease (PSD) is a common condition particularly affecting young men. Females affected by the condition account for about 20% of patients and are rarely mentioned, much less studied specifically. In this study we evaluate the surgical outcomes in a female population following Bascom's cleft lift (BCL) surgery in primary extensive disease, non-healing wounds after previous surgery and recurrent disease in a large Danish cohort from a high-volume centre., Method: The study is based on a prospective database established at Randers Regional Hospital in 2016. All patients undergoing BCL surgery from June 2016 until October 2022 were included in this study., Results: In all, 560 patients underwent BCL surgery at our centre during this period. Eighty-eight (15.7%) were women. Only 10 (11.3%) were operated due to primary extensive manifestations. The rest presented with either non-healing wounds after previous surgery (47.7%) or recurrent PSD (41%). Risk of recurrence in female patients was 30% higher than in male patients (risk ratio 1.30, 95% CI 0.79-2.09) and the risk of prolonged healing after BCL surgery was 46% higher in women compared to men (risk ratio 1.46, 95% CI 1.02-2.14)., Conclusion: Female PSD patients may represent a subcategory of patients at higher risk of treatment failure and should be dealt with as such. Initially, few present with the need for extensive surgery. However, given the common occurrence of prolonged healing and recurrence, we recommend a minimal invasive approach when possible., (© 2025 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Aim: Pilonidal sinus disease (PSD) is a common condition particularly affecting the young population. The disease is incompletely understood, and optimal treatment is still debated. However, off-midline closure techniques have become the standard of care in more advanced cases. The literature is, however, lacking disease stratification in evaluation of surgical results. The aim of this study was to evaluate the surgical outcomes in a prospective cohort following Bascom's cleft lift (BCL) in primary extensive disease, nonhealing wounds after previous surgery and recurrence on a large Danish cohort from a high-volume centre., Method: The study is based on a prospective database established at Randers Regional Hospital in 2016. All patients undergoing BCL surgery from June 2016 until June 2020 were included in this study., Results: Three hundred and ninety two patients (326 men/66 women) underwent BCL surgery over a 4-year period. Of these, 127 (32.4%) presented with primary extensive PSD, 136 (34.7%) with nonhealing wounds and 129 (33.9%) with recurrent PSD. Overall, 87% healed uneventfully within the first 3 months, and 17% had recurrence at a median follow-up of 60 months (45-73 months). However, the risk of recurrence was higher among patients with nonhealing wounds (20%) and recurrence (17%) compared with primary extensive manifestation (13%)., Conclusion: Treatment of advanced PSD remains challenging with a high rate of wound complications and recurrences, stressing the need for dedicated care. Patients with either failed surgery or recurrence need particular attention., (© 2024 Association of Coloproctology of Great Britain and Ireland.)

Aim: Pilonidal sinus disease (PSD) is a common condition, but no data on disease occurrence exist outside highly selected settings. The aim of this study was to assess time trends in the incidence of PSD in a nationwide setting., Method: Using data from nationwide Danish registries, we identified 48 247 patients recorded with diagnostic or surgical procedure codes representing PSD between 1996 and 2021. We stratified by sex and computed the age-adjusted and age-specific incidence rate, comparing 5-year intervals with the incidence rate ratio (IRR)., Results: The overall incidence of PSD increased from 26.1 to 39.6/100 000 person-years (PY) from the period 1996-2000 to the period 2016-2021 (IRR 1.52, 95% CI 0.78-2.94). The incidence increased from 35.8 to 56.9/100 000 PY (IRR 1.59, 95% CI 0.52-4.89) in male patients and from 16.4 to 22.5/100 000 PY (IRR 1.37, 95% CI 0.68-2.76) in female patients. The peak of age-specific incidence was 215.7/100 000 PY (95% CI 206.1-245.4) among 20-year-old men and 107.9/100.000 PY (95% CI 100.0-114.0) among 18-year-old women. Over the study period, the median age at first hospital contact decreased from 27 years [interquartile range (IQR) 22-34 years) to 25 years (IQR 20-34 years) in men but remained stable around 23 years (IQR 18-32 years) in women. However, for both sexes, the highest increase in incidence was seen in early adolescence., Conclusion: The incidence of PSD has increased significantly over the last decades. The increase is driven primarily by men and boys, with the highest increase in incidence seen in early adolescence. The increased burden of disease is not reflected in the literature, and more studies are warranted to understand the drivers of this development., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Aim: Pilonidal sinus disease (PSD) is a common condition. Despite a relatively large proportion of patients presenting as post-pubertal adolescents, only small cohorts focusing on this PSD subcategory have been published, and surgical treatment remains challenging., Method: The study is based on a prospective database established at Randers Regional Hospital in 2016. All patients undergoing Bascom's cleft lift (BCL) surgery from June 2016 until June 2020 were included in this study, focusing on patients ≤18 years of age comparing them to adult patients. Indications for BCL surgery were primary extensive manifestation, non-healing disease after previous elective surgery or disease recurrence., Results: In total, n = 380 PSD patients were operated, of which n = 79 were post-pubertal adolescents with a median age at time of surgery of 17.2 years (interquartile range 16.3, 18.0). Sixty-six (84%) were boys. Twenty-seven (34%) presented with primary extensive manifestation, 34 (43%) due to non-healing wounds and 18 (23%) due to recurrence. Fifty-four patients (69%) healed uneventfully. There was no difference between the indications of surgery groups in terms of overall healing or time to healing if prolonged (P = 0.6). The median follow-up was 62 months (interquartile range 48, 73), with a 5-year recurrence rate of 19%, compared to 17% (P = 0.6) in the adult population., Conclusion: Our study is the first to investigate long-term clinical outcomes of BCL surgery for PSD in post-pubertal adolescent patients. Recurrences seem to occur more frequently compared to adults. However, we demonstrate that post-pubertal adolescent patients with advanced PSD can be treated with BCL surgery with acceptable outcomes., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Trk (NTRK) receptor and NTRK gene fusions are oncogenic drivers of a wide variety of tumors. Although Trk receptors are typically activated at the cell surface, signaling of constitutive active Trk and diverse intracellular NTRK fusion oncogenes is barely investigated. Here, we show that a high intracellular abundance is sufficient for neurotrophin-independent, constitutive activation of TrkB kinase domains. In HEK293 cells, constitutive active TrkB kinase and an intracellular NTRK2-fusion oncogene (SQSTM1-NTRK2) reduced actin filopodia dynamics, phosphorylated FAK, and altered the cell morphology. Atypical cellular responses could be mimicked with the intracellular kinase domain, which did not activate the Trk-associated MAPK/ERK pathway. In glioblastoma-like U87MG cells, expression of TrkB or SQSTM1-NTRK2 reduced cell motility and caused drastic changes in the transcriptome. Clinically approved Trk inhibitors or mutating Y 705 in the kinase domain, blocked the cellular effects and transcriptome changes. Atypical signaling was also seen for TrkA and TrkC. Moreover, hallmarks of atypical pTrk kinase were found in biopsies of Nestin-positive glioblastoma. Therefore, we suggest Western blot-like immunoassay screening of NTRK-related (brain) tumor biopsies to identify patients with atypical panTrk or phosphoTrk signals. Such patients could be candidates for treatment with NTRK inhibitors such as Larotrectinhib or Entrectinhib., (© 2024. The Author(s).)

Cross-clamping of the descending thoracic aorta is one of the operative maneuvers, that can be necessitated in an Emergency Department Thoracotomy and it is important for the Emergency Department medical staff to theoretically familiarize itself with its technique before need arises., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The study aims to determine the survival and recurrence rates of pilonidal sinus disease (PSD) carcinoma., Methods: The data were collected retrospectively by searching the worldwide literature for all reports of carcinoma developing on the background of PSD. The results were presented using Kaplan-Meier curves., Results: Between 1900 and 2022, 140 cases of PSD carcinoma were published in 103 papers, with follow-up data available in 111 cases. Squamous cell carcinoma constituted 94.6% of the cases (n = 105). The disease-specific survival rate was 61.7% for 3 years, 59.8% for 5 years, and 53.2% for 10 years. There was a significant survival difference between stages: 80.0% in stages I and II, 70.8% in stage III, and 47.8% in stage IV (p = 0.01). The 5-year survival in G1-tumors was better than G2 and G3-tumors at 70.5% and 32.0%, respectively (p = 0.002). Recurrence occurred in 46.6% of the patients. The time-to-recurrence in patients treated with curative intention averaged 15.1 months (1-132 months). Local, regional, and distant recurrence was observed in 75.6%, 33.3%, and 28.9% of the recurrent tumors, respectively., Conclusions: Pilonidal sinus carcinoma has a worse prognosis than primary cutaneous squamous cell carcinoma. Poor prognostic factors include advanced-stage disease and poor differentiation., (© 2023 The Authors. Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Erdheim-Chester disease (ECD) is a rare type of non-Langerhans cell histiocytosis. However, its prevalence has increased significantly the past few years due to increased awareness about the disorder, and 1500 cases have been reported worldwide. It is often a multisystemic disease with skeletal, cardiovascular, urologic, renal, retroperitoneal, pulmonary, endocrine, cutaneous, and neurologic involvement. MAPK pathway mutations, such as BRAF activating and MAP2K1 mutations, play a key role in its pathogenesis. In addition to the characteristic clinical, radiological, and histopathological findings, identifying underlying mutations helps diagnose and treat patients with highly effective targeted therapies such as BRAF and MEK inhibitors. We report a case of a man, aged 55 years, with an extensive and prolonged course of an unexplained multisystemic disease, later diagnosed with BRAF V600E-negative and MAP2K1-positive ECD on cell-free DNA testing. Additionally, we review common clinical manifestations, mutations, diagnoses, and targeted therapies for ECD.

Leukemic-stem-cell-specific targeting may improve the survival of patients with acute myeloid leukemia (AML) by avoiding the ablative effects of standard regimens on normal hematopoiesis. Herein, we perform an unbiased screening of compounds targeting cell surface proteins and identify clinically used DPP4 inhibitors as strong suppressors of AML development in both murine AML models and primary human AML cells xenograft model. We find in retrovirus-induced AML mouse models that DPP4-deficient AML cell-transplanted mice exhibit delay and reversal of AML development, whereas deletion of DPP4 has no significant effect on normal hematopoiesis. DPP4 activates and sustains survival of AML stem cells that are critical for AML development in both human and animal models via binding with Src kinase and activation of nuclear factor κB (NF-κB) signaling. Thus, inhibition of DPP4 is a potential therapeutic strategy against AML development through suppression of survival and stemness of AML cells., Competing Interests: Declaration of interests The authors declare no competing interests., (Published by Elsevier Inc.)

Purpose: There are only rough estimates of the worldwide incidence of pilonidal sinus carcinoma. The purpose of the study is to explore the demographic characteristics of this disease and to provide more precise information about its incidence., Methods: The study included questioning the surgeons and pathologists in Germany in addition to a literature research. The literature investigation included all published articles about pilonidal carcinoma in all languages. The questionnaire included 1050 pathologists and all 834 hospitals with a surgical division in Germany. The outcome measures included the total number of cases, the language of publication, gender, age, country of origin, interval until the diagnosis of carcinoma, and reported incidence based on local studies., Results: From 1900 to 2022, we found 140 cases of pilonidal sinus carcinoma in 103 articles. The investigation revealed two additional unpublished cases from Germany. The male-to-female ratio was 7.75:1. The countries with the most cases were the USA (35 cases, 25.0%), Spain (13 cases, 9.3%), and Turkey (11 cases, 7.6%). The average age was 54.0 ± 11.8 years and the interval between the diagnosis of the disease and the development of carcinoma was 20.1 ± 14.1 years. There was a parallel increase in reported cases of pilonidal sinus disease and pilonidal carcinoma over the last century. The reported incidence varied from 0.03% to 5.56%. The worldwide calculated incidence equaled 0.17%., Conclusion: Due to underreporting and other causes, the incidence of carcinoma emerging on the background of pilonidal sinus disease is higher than reported., (© 2023. The Author(s).)

Superconducting magnets used for Magnetic Resonance Imaging (MRI) scanners need to keep temperature gradients minimized in order to retain thermal and operating current margin. We have used 3D finite element analysis (FEA) simulation in COMSOL Multiphysics software that includes both conductive heat transfer and radiative heating to calculate the temperature distribution both along the winding direction and across the cross-section of an MRI segment coil at its equilibrium operating temperature. We have also modelled the evolution of the thermal properties during cool-down from ambient temperature. The heat capacity and thermal conductivity of the magnet winding were computed for use within this simulation. The heat capacity as a function of temperature was calculated using a rule of mixtures. This procedure was also used for the thermal conductivity along the direction of the wire. However, the thermal conductivity within the composite cross section ( x - and y -directions) was computed using a 2D FEA model. Based on this, a time-dependent, 3D coil model was built to calculate the coil temperature throughout the winding during cool-down in our test cryostat system. The model included a heat leak component to the coil current contacts via conduction through the current leads as well as a radiative component from the surfaces of the cryostat. A key result was that a maximum coil Δ T max = 5.1 K (=maximum temperature within the winding -minimum temperature in the winding) was seen and a coil I c margin of 12.75 A was predicted at steady state, with our first current lead design. A second set of more optimized current leads significantly lowered the Δ T max within the coil at the steady state. The coil I c margin has been analyzed for different current lead designs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Fungi causing wood canker diseases are major factors limiting productivity and longevity of almond and walnut orchards. The goal of this study was to compare pathogen profiles from spore traps with those of plant samples collected from symptomatic almond and walnut trees and assess if profiles could be influenced by orchard type and age, rainfall amount and frequency, and/or neighboring trees. Three almond orchards and one walnut orchard with different characteristics were selected for this study. Fungal inoculum was captured weekly from nine trees per orchard using a passive spore-trapping device, during a 30-week period in the rainy season (October to April) and for two consecutive years. Fungal taxa identified from spore traps were compared with a collection of fungal isolates obtained from 61 symptomatic wood samples collected from the orchards. Using a culture-dependent approach coupled with molecular identification, we identified 18 known pathogenic species from 10 fungal genera ( Ceratocystis destructans , Collophorina hispanica , Cytospora eucalypti , Diaporthe ampelina , Diaporthe chamaeropis / rhusicola , Diaporthe eres , Diaporthe novem , Diplodia corticola , Diplodia mutila , Diplodia seriata , Dothiorella iberica , Dothiorella sarmentorum , Dothiorella viticola , Eutypa lata , Neofusicoccum mediterraneum , Neofusicoccum parvum , Neoscytalidium dimidiatum , and Pleurostoma richardsiae ), plus two unidentified Cytospora and Diaporthe species. However, only four species were identified with both methods ( Diplodia mutila , Diplodia seriata , Dothiorella Iberica , and E . lata ), albeit not consistently across orchards. Our results demonstrate a clear disparity between the two diagnostic methods and caution against using passive spore traps to predict disease risks. In particular, the spore trap approach failed to capture: insect-vectored pathogens such as Ceratocystis destructans that were often recovered from almond trunk and scaffold; Diaporthe chamaeropis / rhusicola commonly isolated from wood samples likely because Diaporthe species have a spatially restricted dispersal mechanism, as spores are exuded in a cirrus; and pathogenic species with low incidence in wood samples such as P. richardsiae and Collophorina hispanica . We propose that orchard inoculum is composed of both endemic taxa that are characterized by frequent and repeated trapping events from the same trees and isolated from plant samples, as well as immigrant taxa characterized by rare trapping events. We hypothesize that host type, orchard age, precipitation, and alternative hosts at the periphery of orchards are factors that could affect pathogen profile. We discuss the limitations and benefits of our methodology and experimental design to develop guidelines and prediction tools for fungal wood canker diseases in California orchards.

Efficient operating room (OR) management is a constant balancing act between optimal OR capacity, allocation of ORs to surgeons, assignment of staff, ordering of materials, and reliable scheduling, while according the highest priority to patient safety. We provide an overview of common concepts in OR management, specifically addressing the areas of strategic, tactical, and operational decision making (DM), and parameters to measure OR efficiency. For optimal OR productivity, a surgical suite needs to define its main stakeholders, identify and create strategies to meet their needs, and ensure staff and patient satisfaction. OR planning should be based on real-life data at every stage and should apply newly developed algorithms., Competing Interests: Declaration of competing interest RDU reports unrelated fees/funding from AcelRx, Pfizer, Merck, and Medtronic. The other authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Numerous patient-related clinical parameters and treatment-specific variables have been identified as causing or contributing to the severity of peritonitis. We postulated that a combination of clinical and surgical markers and scoring systems would outperform each of these predictors in isolation. To investigate this hypothesis, we developed a multivariable model to examine whether survival outcome can reliably be predicted in peritonitis patients treated with open abdomen. This single-center retrospective analysis used univariable and multivariable logistic regression modeling in combination with repeated random sub-sampling validation to examine the predictive capabilities of domain-specific predictors (i.e., demography, physiology, surgery). We analyzed data of 1,351 consecutive adult patients (55.7% male) who underwent open abdominal surgery in the study period (January 1998 to December 2018). Core variables included demographics, clinical scores, surgical indices and indicators of organ dysfunction, peritonitis index, incision type, fascia closure, wound healing, and fascial dehiscence. Postoperative complications were also added when available. A multidomain peritonitis prediction model (MPPM) was constructed to bridge the mortality predictions from individual domains (demographic, physiological and surgical). The MPPM is based on data of n = 597 patients, features high predictive capabilities (area under the receiver operating curve: 0.87 (0.85 to 0.90, 95% CI)) and is well calibrated. The surgical predictor "skin closure" was found to be the most important predictor of survival in our cohort, closely followed by the two physiological predictors SAPS-II and MPI. Marginal effects plots highlight the effect of individual outcomes on the prediction of survival outcome in patients undergoing staged laparotomies for treatment of peritonitis. Although most single indices exhibited moderate performance, we observed that the predictive performance was markedly increased when an integrative prediction model was applied. Our proposed MPPM integrative prediction model may outperform the predictive power of current models., (© 2021. The Author(s).)

Introduction: Carcinoma secondary to pilonidal disease is very rare with fewer than 130 reported cases so far. It is presumed that underreporting and underpublishing contribute to the low reported incidence., Methods: A post was published on a closed Facebook group with about 30,000 Syrian doctors asking if anyone had ever seen a patient with pilonidal carcinoma before. The patients' data were collected retrospectively from the treating physicians., Results: Between 2010 and 2019, we identified eight patients with pilonidal carcinoma. All patients were males with a mean age of 55.5 years. The mean interval between diagnosis of pilonidal disease and diagnosis of carcinoma was 6.9 years. A growing ulcer on the background of a pilonidal sinus disease was the presenting complaint in 50% of cases. Three patients were lost from follow-up after the diagnosis due to referral. All other five patients underwent surgical resection and three of them received postoperative chemoradiation. Four patients were followed for six months or longer: two died of metastases, one survived after recurrence and re-excision, and one survived with no recurrence., Conclusion: This paper presents the largest cohort of pilonidal carcinoma so far and the first that describes the disease in the Syrian population. Due to underreporting, the real incidence of pilonidal carcinoma exceeds what is reported so far in the literature., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Safadi et al.)

Background: Minimally invasive methods in pilonidal sinus disease (PSD) surgery are becoming standard. Although long-term results are available for some techniques, long-term outcome data of patients after pit picking is lacking. We aimed at investigating perioperative and long-term outcomes of patients undergoing pit picking, Limberg flap or primary open surgery to treat PSD., Methods: In a single-centre observational study, we evaluated the outcomes of 327 consecutive patients undergoing PSD surgery between 2011 and 2020., Results: PSD had recurred in 22% of Limberg flap patients and 62% of pit picking patients at 5 years (p=0.0078; log rank test). Previous pilonidal surgeries, smoking, body mass index, immunodeficiency, and diabetes did not significantly influence the long-term recurrence rate. Primary open treatment was performed for 72% of female patients presenting with primary disease., Conclusions: Due to its especially dismal long-term results, pit picking should be abandoned, and Limberg flap should be promoted instead, even for primary disease and in females., (© 2022 Dietrich Doll et al., published by De Gruyter, Berlin/Boston.)

we present magnetic, mechanical and thermal modeling results for a 3 Tesla actively shielded whole body MRI (Magnetic Resonance Imaging) magnet consisting of coils with a square cross section of their windings. The magnet design was a segmented coil type optimized to minimize conductor length while hitting the standard field quality and DSV (Diameter of Spherical Volume) specifications as well as a standard, compact size 3 T system. It had an overall magnet length and conductor length which can lead to conduction cooled designs comparable to NbTi helium bath cooled 3 T MRI magnets. The design had a magnetic field homogeneity better than 10 ppm (part-per-million) within a DSV (Diameter of Spherical Volume) of 48 cm and the total magnet winding length of 1.37 m. A new class of MgB 2 strand especially designed for MRI applications was considered as a possible candidate for winding such magnets. This work represents the first magnetic, mechanical and thermal design for a whole-body 3 T MgB 2 short (1.37 m length) MRI magnet based on the performance parameters of existing MgB 2 wire. 3 Tesla MRI magnet can operate at 20 K at 67 % of its critical current.

Background: The present German National Guideline is an updated version of previous Guideline published in 2014. It aims to compare various treatment methods and to assist physicians with evidence-based recommendations., Methods: Systemic literature review., Results: Three types of disease manifestation could be differentiated: asymptomatic disease, an acute abscess, and the chronic pilonidal disease. At present, there is no treatment method fulfilling all desired criteria: simple, painless procedure associated with rapid wound healing, and low recurrence rate. Thus, treatment modality should be tailored to disease manifestation and extent., Conclusion: Asymptomatic pilonidal disease should not be treated. A pilonidal abscess should be unroofed. After resolution of the acute inflammation, the disease should be treated definitely. As for today, sinus excision is the standard treatment of the chronic pilonidal disease. Wide excision and open treatment of chronic disease is a safe procedure which, however, leads to prolonged secondary healing and time off-work, as well as to considerable recurrence rate. The extent of excision should be as limited as possible. Excision and midline wound closure is associated with impaired outcomes. Today, it has become obsolete. Minimally invasive procedures (e.g., pit picking surgery) represent a treatment option for chronic pilonidal disease. However, the recurrence rate is higher compared to excision procedures. Nevertheless, they may be used for small primary disease. Off-midline procedures should be used for disease not suitable for minimally invasive treatments. The Limberg flap and the Karydakis procedure are two best described methods which are associated with similar short- and long-term results., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Glioblastoma (GBM), the most common primary brain tumor, is a highly aggressive malignancy for which the median survival is about 13 months, and 5-year survival is well under 5%. These tumors usually occur in the brain and enlarge and infiltrate through white matter, including crossing through the corpus callosum to the opposite cerebral hemisphere. They may spread to distant parts of the central nervous system (CNS) via cerebrospinal fluid pathways. Extraneural metastases from primary brain tumors are quite rare, for 2 probable reasons: because most patients survive less than 2 years, and because of the absence of true lymphatics in the CNS. Typical sites for distant extraneural metastasis of GBM are lungs and pleura, followed by lymph nodes and bones; spread to the liver is exceptional. Most of the reported cases with liver metastases had either single or only a few such metastatic lesions. We report a probably unique case of GBM with extensive liver metastases along with a review of previous cases of liver metastasis from GBM, and we discuss the possible mechanisms of metastasis.

Anemia, iron deficiency and other hematinic deficiencies are a major cause of perioperative transfusion needs and are associated with increased morbidity and mortality. Anemia can be caused either by decreased production of hemoglobin or red blood cells or by increased consumption and blood loss. Decreased production can involve anything from erythropoietin or vitamin B12 insufficiency to absolute or functional lack of iron. Thus, to achieve the goal of patient blood management, anemia must be addressed by addressing its causes. The traditional parameters to diagnose anemia, despite offering elaborate options, are not ideally suited to giving a simple overview of the causes of anemia, e.g., iron status for erythropoiesis, especially during the acute phase of inflammation, acute blood loss or iron deficiency. Reticulocyte hemoglobin can thus help to uncover the cause of the anemia and to identify the main factors inhibiting erythropoiesis. Regardless of the cause of anemia, reticulocyte hemoglobin can also quickly track the success of therapy and, together with the regular full blood count it is measured alongside, help in clearing the patient for surgery.

Introduction: Pilonidalis sinus disease is a mostly chronic selective infection of the hairy skin in the area of skin wrinkles, mainly in the area of the natal cleft. Open treatment is still the most common recommended therapy. Nevertheless, there may be healing disorders within the framework of open wound treatment, which can significantly complicate the course., Methods: The following is an overview of wound healing disorders after excision of pilonidalis sinus. Healing time and frequency are determined on the basis of current data and the causes of the healing disorder are evaluated. In addition, possible treatment options are presented and treatment recommendations are made., Results: The evaluation of published data on wound healing period showed that the wound usually heals after a mean of two months. The results of the German forces cohort study show by way of example that almost all wounds have healed in the period up to three months. However, a small percentage of non-healing wounds remain. The frequency of significantly delayed wound healing is given in the literature as 2 - 5%. The influencing factors for wound healing after sinus pilonidalis excision are not only the size and symmetry of the excision wound but also other details of open wound treatment. In addition to intensification of the previous open wound treatment, the new excision and refreshment of the wound are mentioned as treatment options in the event of a lack of wound healing. Furthermore, changes in strategy for plastic-reconstructive procedures or other surface treatment are also recommended., Conclusion: The excision wound of pilonidalis sinus should be healed after three to four months at the latest, after which the wound can be regarded as a wound with significantly delayed healing or as a wound healing disorder. Around this time, the findings should be re-evaluated and, if necessary, a change in the treatment concept should be made., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Gender-specific risk factors have been suggested to promote a fourfold higher incidence of pilonidal sinus disease (PSD) in male as compared to female patients. However, in recent decades there has been an apparent shift towards an increasing prevalence of PSD in women, as body weight and other risk factors influence the disease. We aimed at determining whether PSD prevalence actually changed in men and women over time., Methods: Following PRISMA guidelines (PROSPERO ID: 42016051588), databases were systematically searched. Papers reporting on PSD published between 1833 and 2018 in English, French, German, Italian and Spanish containing precise numbers of male and female participants were selected for analysis. Gender-specific prevalence of PSD over several decades was the main outcome measure., Results: We screened 679 studies reporting on 104 055 patients and found that the male/female ratio in patients with PSD has remained constant over time, with women being affected in about 20% of all PSD cases (I 2  = 96.18%; meta-regression p < 0.001)., Conclusion: While the prevalence of PSD has risen over the past decades, the ratio between affected males and affected females has remained constant, with women invariably representing about 20% of patients despite wide ranging socioeconomic and behavioural changes., (© 2021 The Authors. ANZ Journal of Surgery published by John Wiley & Sons Australia, Ltd on behalf of Royal Australasian College of Surgeons.)

Our understanding of pilonidal sinus disease (PSD) is based on a paper published 29 years ago by Karydakis. Since then, surgeons have been taught that hair more easily penetrates wet skin, leading to the assumption that sweating promotes PSD. This postulate, however, has never been proven. Thus we used pilocarpine iontophoresis to assess sweating in the glabella sacralis. 100 patients treated for PSD and 100 controls were matched for sex, age and body mass index (BMI). Pilocarpine iontophoresis was performed for 5 min, followed by 15 min of sweat collection. PSD patients sweated less than their matched pairs (18.4 ± 1.6 µl vs. 24.2 ± 2.1 µl, p = 0.03). Men sweated more than women (22.2 ± 1.2 µl vs. 15.0 ± 1.0 µl in non-PSD patients (p < 0.0001) and 20.0 ± 1.9 µl vs. 11.9 ± 2.0 µl in PSD patients (p = 0.051)). And regular exercisers sweated more than non-exercisers (29.1 ± 2.9 µl vs. 18.5 ± 1.6 µl, p = 0.0006 for men and 20.7 ± 2.3 µl vs. 11.4 ± 1.4 µl, p = 0.0005 for women). PSD patients sweat less than matched controls. Thus sweating may have a protective effect in PSD rather than being a risk factor.

Background: Postoperative pain management is key for patient satisfaction. Pressure pain threshold (PPT) has been studied in some surgical cohorts but has not been studied in relationship to acute postoperative pain in short-stay patients undergoing anorectal surgery. We hypothesized that preoperative finger PPT measurements can identify respective patients with higher postoperative pain. Aiming to understand the relationship with subjective postoperative pain perception, we tested the hypotheses that preoperative PPT is associated with postoperative Visual Analog Scale (VAS) pain scores and correlates with postoperative analgesic consumption in short-stay patients undergoing anorectal surgery., Methods: We prospectively assessed preoperative PPT in a cohort undergoing anorectal surgery, known as a moderately to severely painful procedure. Linear mixed-effects models were used to assess the relationship with postoperative VAS pain scores at 1 and 3 days as well as 4 weeks postoperatively. Logistic regression was used to study the relationship with additional postoperative analgesic consumption., Results: We studied 128 patients and found that preoperative PPT is significantly associated with postoperative pain (P value for interaction = .025). Logistic regression modeling additionally revealed an association between the preoperative PPT and the need for additional postoperative analgesics, with odds of requiring additional analgesia decreasing by about 10% for each 1-point increase in PPT (odds ratio [OR] = 0.90; 95% confidence interval [CI], 00.81-0.98; P = .012)., Conclusions: Preoperative finger PPT is associated with postoperative pain and might help identify patients who are at risk of developing more severe postoperative pain on anorectal surgery. Especially in ambulatory and short-stay settings, this approach can help to address patients' high variability in pain sensitivity to facilitate appropriate postoperative analgesia, timely discharge, and prevent readmission., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society.)

Purpose of Review: We review the relevance of quantitative sensory testing (QST) in light of acute and chronic postoperative pain and associated challenges., Recent Findings: Predicting the occurrence of acute and chronic postoperative pain with QST can help identify patients at risk and allows proactive preventive management. Generally, central QST testing, such as temporal summation of pain (TSP) and conditioned pain modulation (CPM), appear to be the most promising modalities for reliable prediction of postoperative pain by QST. Overall, QST testing has the best predictive value in patients undergoing orthopedic procedures. Current evidence underlines the potential of preoperative QST to predict postoperative pain in patients undergoing elective surgery. Implementing QST in routine preoperative screening can help advancing traditional pain therapy toward personalized perioperative pain medicine.

The reticulocyte hemoglobin equivalent (RET-He) is presented as a biomarker for the diagnostics and monitoring of iron deficiency. The marker is independent of the acute phase and can be determined within a few minutes by a blood count. Due to the approximately 120-day lifetime of erythrocytes, iron deficiency and changes in the iron status of erythropoiesis can first be recognized at a relatively late stage using classical hematological parameters, such as hemoglobin, mean corpuscular volume, mean cellular hemoglobin content and also with determination of hypochromic erythrocytes (% hypo). The RET-He is a cost-effective parameter for the diagnosis and monitoring of the iron supply for erythropoiesis. Reticulocytes, the precursors of mature erythrocytes, are washed out of the bone marrow into the peripheral blood and normally mature within 2 days to mature erythrocytes. The determination of the reticulocyte number therefore enables a timely statement about erythropoiesis. A measurement of the hemoglobin content of reticulocytes therefore reflects the actual iron metabolism of erythropoiesis and enables assessment of the quality of the cells. Changes in the iron status of erythropoiesis can thus be detected much earlier than by determining only the hemoglobin content of mature erythrocytes, i.e. the mean cellular hemoglobin content. It is recommended that the evaluation of RET-He should be carried out as an inexpensive routine preoperative marker of latent anemia in order to identify patients at risk. In the sense of a perioperative prehabilitation and the enhanced recovery after surgery (ERAS) concept, patients with iron deficiency can be treated proactively at an early stage in order to prevent complications and extended hospital stays.

Background: Pilonidal sinus disease (PSD) is traditionally associated with young male patients. While PSD is rare in Asia and Africa, lifestyles are changing considerably throughout the so-called developed world. We question that PSD is an overwhelmingly male disease and that the proportion of women suffering from PSD is worldwide evenly distributed in a homogenous matter., Methods: We analysed the world literature published between 1833 and 2018, expanding on the database created by Stauffer et al. Following correction for gender bias with elimination of men-only and women-only studies, data were processed using random-effects meta-analysis in the technique of DerSimonian and Laird., Results: The share of female pilonidal sinus disease patients analysed from all studies available in the world literature is 21%. There are marked regional differences including South America (39%), North America as well as Australia/New Zealand (29%) and Asia (7%), which are highly significant. These results stand fast even if analysis without gender bias corrections was applied., Conclusion: The share of female patients suffering from PSD is considerable. It is time to think of PSD as a disease of both men and women. Previously unknown, there are significant regional differences worldwide; the reason(s) for the regional differences is still unclear.

Objectives: Pilonidal sinus disease (PSD) has been a recognized pathology for the past 188 years. We studied whether scientific interest in this common disease has grown or declined over time. Our investigation included analysis of the world literature between 1833 and 2018., Material and Methods: A PubMed search was conducted to identify all publications on pilonidal sinus disease, broken down by country, year of publication and number of patients included or described., Results: The number of patients studied has been increasing, with date of more than 10,000 patients published per decade since 1970, and the total number of affected patients exceeding n=40,000 in 2010 and Turkey leads the research, contributing 39% of the Mediterranean patients and 18% of the patients globally, while Italy provides 26% of the Mediterranean patients and 12% of the global total. Flap studies have increased, whereas primary open treatment studies have decreased from 40% in 1940 to less than 10% at present. Twenty percent of the studies performed today report primary median approaches, and the number of randomized controlled trials has increased., Conclusion: Surgeons in Turkey currently publish the lion´s share of the pilonidal sinus literature., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare., (Copyright © 2020, Turkish Surgical Society.)

Background and objective : No current nationwide consensus exists on pilonidal disease (PD) treatment in Switzerland and Austria. The objective of this study was to assess and compare the spectrum of PD treatment strategies in Switzerland and Austria. Materials and Methods : A survey including 196 certified institutions (Switzerland, N = 99 and Austria, N = 97) was performed. Treatment strategies for both chronic and acute pilonidal disease were investigated, as well as evolution of treatment over the last 20 years. Results : In total, 92 of 196 (47%) hospitals participated in the survey. Recurrence rate (20%) was similar between the two countries. In acute pilonidal disease, a two-stage approach with incision and drainage as the first step was preferred over a one-stage procedure in both countries. In Austria, all patients with chronic pilonidal disease were treated as inpatients, whereas 28% of patients in Switzerland were treated on an outpatient basis ( p = 0.0019). Median length of hospital stay was double in Austria (four days) compared to Switzerland (two days; p < 0.001). Primary resection and off-midline closure ( p = 0.017) and the use of tissue flaps ( p = 0.023) were performed more commonly in Austria than in Switzerland. Minimally invasive techniques were performed more often in Switzerland than in Austria (52% vs. 4%, p < 0.001). Overall, wide excision with secondary wound healing or midline closures declined over the last 20 years. Conclusion : Treatment strategies for chronic PD differ between Austria and Switzerland with more and longer inpatient care in Austria, increasingly minimally invasive approaches in Switzerland, and outdated procedures still being performed in both countries. Overall, heterogeneity of practice dominates in both countries.

Cardiac metastasis from head and neck cancer is an extremely rare and devastating condition with an abysmal prognosis. Most of our knowledge about this condition is from case reports and series. We present a case of squamous cell carcinoma of the tonsils that was complicated by embolic stroke and critical limb ischemia that were found to be secondary to intracardiac metastasis. We believe that this condition is under-reported; hence, we conducted a thorough review of the literature to highlight the characteristics and previous therapeutic experiences with various presentations of cardiac metastasis from head and neck carcinoma. Clinicians are encouraged to report their experience with evaluating and managing this type of metastasis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Limiting the spread of the disease is key to controlling the COVID-19 pandemic. This includes identifying people who have been exposed to COVID-19, minimizing patient contact, and enforcing strict hygiene measures. To prevent healthcare systems from becoming overburdened, elective and non-urgent medical procedures and treatments have been postponed, and primary health care has broadened to include virtual appointments via telemedicine. Although telemedicine precludes the physical examination of a patient, it allows collection of a range of information prior to a patient's admission, and may therefore be used in preoperative assessment. This new tool can be used to evaluate the severity and progression of the main disease, other comorbidities, and the urgency of the surgical treatment as well as preferencing anesthetic procedures. It can also be used for effective screening and triaging of patients with suspected or established COVID-19, thereby protecting other patients, clinicians and communities alike., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

There is an urgent need to develop climate smart agroecosystems capable of mitigating climate change and adapting to its effects. In California, high commodity prices and increased frequency of drought have encouraged orchard turnover, providing an opportunity to recycle tree biomass in situ prior to replanting an orchard. Whole orchard recycling (WOR) has potential as a carbon (C) negative cultural practice to build soil C storage, soil health, and orchard productivity. We tested the potential of this practice for long term C sequestration and hypothesized that associated co-benefits to soil health will enhance sustainability and resiliency of almond orchards to water-deficit conditions. We measured soil health metrics and productivity of an almond orchard following grinding and incorporation of woody biomass vs. burning of old orchard biomass 9 years after implementation. We also conducted a deficit irrigation trial with control and deficit irrigation (-20%) treatments to quantify shifts in tree water status and resilience. Biomass recycling led to higher yields and substantial improvement in soil functioning, including nutrient content, aggregation, porosity, and water retention. This practice also sequestered significantly higher levels of C in the topsoil (+5 t ha-1) compared to burning. We measured a 20% increase in irrigation water use efficiency and improved soil and tree water status under stress, suggesting that in situ biomass recycling can be considered as a climate smart practice in California irrigated almond systems., Competing Interests: The authors have declared that no competing interests exist.

The development of coils that can survive a quench is crucial for demonstrating the viability of MgB 2 -based main magnet coils used in MRI systems. Here we have studied the performance and quench properties of a large (outer diameter: 901 mm; winding pack: 44 mm thick × 50.6 mm high) conduction-cooled, react-and-wind (R&W), MgB 2 superconducting coil. Minimum quench energy (MQE) values were measured at several coil operating currents ( I op ), and distinguished from the minimum energy needed to generate a normal zone (MGE). During these measurements, normal zone propagation velocities (NZPV) were also determined using multiple voltage taps placed around the heater zone. The conduction cooled coil obtained a critical current ( I c ) of 186 A at 15 K. As the operating currents ( I op ) varied from 80 A to 175 A, MQE ranged from 152 J to 10 J, and NZPV increased from 1.3 to 5.5 cm/s. Two kinds of heater were involved in this study: (1) a localized heater ("test heater") used to initiate the quench, and (2) a larger "protection heater" used to protect the coil by distributing the normal zone after a quench was detected. The protection heater was placed on the outside surface of the coil winding. The test heater was also placed on the outside surface of the coil at a small opening made in the protection heater. As part of this work, we also developed and tested an active protection scheme for the coil. Such active protection schemes are of great interest for MgB 2 -based MRIs because they permit exploitation of the relatively large MQE values of MgB 2 to enable the use of higher J e values which in turn lead to competitive MgB 2 MRI designs. Finally, the ability to use a quench detection voltage to fire a protection heater as part of an active protection scheme was also demonstrated.

Pilonidal sinus disease (PSD) is increasing globally. A recent meta-analysis and merged-data analysis showed that recurrence rates in PSD depend essentially on follow-up time and specific surgical procedures. However, the global distribution of surgical approaches and respective recurrence rates have never been studied in PSD. We aimed at studying the impact of geographic distribution of surgical approaches to treat PSD and subsequent geography-specific recurrence rates. We searched relevant databases as described previously. Recurrence rates were then associated with reported follow-up times and geographic origin. We simulated individual patients to enable analogy across data. Globally, recurrence rates range from 0.3% for Limberg/Dufourmentel approaches (95% CI 0.2-0.4) and flaps (95% CI 0.1-0.5) and up to 6.3% for incision (95% CI 3.2-9.3) at 12 months. Recurrence rates range from 0.3% for Karydakis/Bascom approaches (95% CI 0.0-0.8) up to 67.2% for incision (95% CI 7.5-100) in the USA, and 0.0% for primary asymmetric closure in Germany (95% CI 0.0-0.0). Our analysis shows that recurrence rates in PSD not only depend on therapeutic approaches and follow-up time but also on geography. Primary asymmetric closure and various flap techniques remain superior regardless of the geographical region. Some approaches have extraordinarily good outcomes in specific countries.

Leaffooted bugs ( Leptoglossus spp ; Hemiptera: Coreidae) are phytophagous insects native to the Western Hemisphere. In California, Leptoglossus clypealis and Leptoglossus zonatus are occasional pests on almonds. Early season feeding by L. clypealis and L. zonatus leads to almond drop, while late season feeding results in strikes on kernels, kernel necrosis, and shriveled kernels. A field cage study was conducted to assess feeding damage associated with L. clypealis and L. zonatus on four almond varieties, Nonpareil, Fritz, Monterey, and Carmel. The objectives were to determine whether leaffooted bugs caused significant almond drop, to pinpoint when the almond was vulnerable, and to determine the final damage at harvest. Branches with ~20 almonds were caged and used to compare almond drop and final damage in four treatments: (1) control branches, (2) mechanically punctured almonds, (3) adult Leptoglossus clypealis , and (4) adult Leptoglossus zonatus . Replicates were set up for eight weeks during two seasons. Early season feeding resulted in higher almond drop than late season, and L. zonatus resulted in greater drop than L. clypealis . The almond hull width of the four varieties in the study did not influence susceptibility to feeding damage. The final damage assessment at harvest found significant levels of kernel strikes, kernel necrosis, and shriveled almonds in bug feeding cages, with higher levels attributed to L. zonatus than L. clypealis . Further research is warranted to develop an Integrated Pest Management program with reduced risk controls for L. zonatus .

The US FDA has recently approved an updated nivolumab dosing schedule, a single 480 mg iv. dose every 4 weeks [1], across all its previously approved indications, including second-line therapy for metastatic renal cell carcinoma. As this regimen is still in its infancy, we have not yet observed significant differences in immune-related toxicities and have not yet identified clinical characteristics which would predict intolerance and increased risk for complications. Herein, we present a patient with metastatic renal cell carcinoma who developed bullous pemphigoid after a single 480 mg iv. dose of nivolumab after previously tolerating a 240 mg biweekly dose for 2 years.