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Objectives: The objective was to provide evidence for age-dependent use of neoadjuvant treatment by clinical comparisons of young (lower quartile, <56.6 years) versus old (upper quartile, >71.3 years) patients with esophageal and esophagogastric-junction adenocarcinoma., Background: Neoadjuvant treatment is the standard of care for locally advanced and node-positive EAC. However, the effect of age on oncological outcomes is disputable as they are underrepresented in treatment defining randomized controlled trials., Methods: Patients with EAC undergoing esophagectomy between 2001 and 2022 were retrospectively analyzed from three centers. Patients having distant metastases or clinical UICC-stage I were excluded. Cox proportional hazards regression was used to identify the variables associated with survival benefit., Results: Neoadjuvant treatment was administered to 185/248 (74.2%) young and 151 out of 248 (60.9%) elderly patients ( P =0.001). Young age was associated with a significant overall survival (OS) benefit (median OS: 85.6 vs. 29.9 months, hazard ratio 0.62, 95% CI: 0.42-0.92) after neoadjuvant treatment versus surgery alone. In contrast, elderly patients did only experience a survival benefit equaling the length of neoadjuvant treatment itself (median OS: neoadjuvant 32.8 vs. surgery alone 29.3 months, hazard ratio 0.89, 95% CI: 0.63-1.27). Despite the clear difference in median OS benefit, histopathological regression was similar ((Mandard-TRG-1/2: young 30.7 vs. old 36.4%, P= 0.286). More elderly patients had a dose reduction or termination of neoadjuvant treatment (12.4 vs. 40.4%, P <0.001)., Conclusion: Old patients benefit less from neoadjuvant treatment compared to younger patients in terms of gain in OS. Since they also experience more side effects requiring dose reduction, upfront surgery should be considered as the primary treatment option in elderly patients., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Problem: Failure is a powerful teacher but an emotionally stressful experience. Before residency, when failure in clinical training is inevitable, medical students should learn to talk about and cope with failure. However, medical school curricula rarely include this topic, and physicians seldom share their mistakes and failures with trainees. This report describes and evaluates a workshop on dealing with failure in medicine., Approach: Two attending surgical consultants and a life coach facilitated the workshop between February 2021 and February 2022, which consisted of different educational approaches, such as presentations, small group discussions, and journal clubs. The sessions aimed to enable medical learners to identify and analyze actual and potential failure events in everyday clinical practice and learn from them, disclose and communicate medical failures and "speak up," reflect on failure and develop coping strategies, and understand the moderating role of fear of failure., Outcomes: Thirty medical students participated in the workshop. Dealing with failure in a productive manner was the medical learners' key learning objective and anticipated takeaway from the workshop. After the workshop, 19 of the 30 participants anonymously completed the standard university evaluation form. The medical students gave the workshop a mean (SD) rating of 8.59 (0.98) on a Likert scale ranging from 1 to 10. They felt better prepared to approach future challenges in a constructive manner after being equipped with strategies to deal with failure. Listening to the failure experiences of faculty and peers in a safe environment helped them accept that failure is inevitable., Next Steps: The findings suggest that medical students appreciated a safe environment to discuss failure. By promoting a safe learning environment early in the medical career, medical schools could make an important contribution to reducing the stigma of failure and eliminating the shame and blame culture, thus contributing to students' well-being., (Copyright © 2023 the Association of American Medical Colleges.)

Background: New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations., Objective: To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders., Methods: We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey., Results: The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn ., Conclusion: An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process., Guideline Registration Number: PREPARE-2023CN018., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: COVID-19 precipitated a plethora of mental health difficulties, particularly for those with pre-existing mental health concerns such as depression or addictive tendencies. For some, the distress that emanated from the experience of the pandemic prompted excessive engagement in the safety of online interactions on social media. The present study examined whether variation in individuals' sense of control explained the association between depression and addictive social media use., Method: A sample of 1322 participants from two Middle Eastern nations provided data collected during the peak of the pandemic from February to May 2021. A combination of convenience and snowball sampling were used to recruit and collect data from college-aged students enrolled at two universities in Egypt and the United Arab Emirates, respectively. This study adopted a cross-sectional design in which participants completed a self-administered survey that consisted of measures that assessed depressive affect, sense of control, and addictive social media use., Results: Depression was significantly and positively associated with addictive SMU. Sense of control was negatively related to both depression and SMU and significantly mediated the association between these two variables (β = .62, SE = .03, 95%CI .56, .68)., Conclusion: This study identified a potential protective variable that could be targeted by psychological treatment to ameliorate the potential onset of addictive SMU in individuals with depressive symptoms under conditions of immense psychological distress such as a worldwide pandemic., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Vally et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background/aim: Esophagectomy for esophageal cancer is a complex surgical procedure with predefined surgical steps. Anatomical anomalies can offer additional challenges in case of surgical treatment. We present three cases of esophageal carcinoma with thoracic anatomical anomalies affecting the treatment strategy. The aim was to address the anatomical challenges of the anomalies and their impact on surgery as well as elaborate on possible solutions., Case Report: We present three patient cases with anomalies of the thoracic anatomy. The first patient had a tumor with suspected ingrowth in an arteria lusoria. Restaging after definitive chemoradiotherapy showed progression of disease but without previously noted signs of vascular wall invasion and salvage robot-assisted minimally invasive esophagectomy (RAMIE) was performed. The second patient had an azygos lobe of the lung and underwent RAMIE after neoadjuvant chemoradiotherapy. The azygos vein was clipped, and paratracheal lymph node dissection was performed, however with limited extent at the right side due to the anatomical situation. The third patient was diagnosed with a right aortic arch, where the aortic arch transverses over the right bronchus instead of the left and descends to the right of and posterior to the esophagus and trachea. Treatment included definitive chemoradiotherapy (dCRT) without surgery, given the anatomical situation and a complete clinical response to dCRT of a squamous cell carcinoma., Conclusion: Thoracic anatomical anomalies are rare entities, which can be asymptomatic. Clinical implications can arise in combination with diagnosis of esophageal cancer and the need for surgical treatment. Therefore, detailed information regarding possible anomalies must be obtained prior to surgery and potential challenges have to be taken into consideration. Resection of related structures with tumor ingrowth can be considered in selected cases to achieve a radical resection., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Point-of-care ultrasound (POCUS) improves patient outcomes. The current POCUS curriculum of the Emergency Medicine Society of South Africa is based on guidelines from the United Kingdom with a different burden of disease (BoD) and available resources than encountered locally., Aim: To determine which modules of the POCUS curriculum should be implemented to better equip doctors working at a district hospital in the West Coast District (WCD), South Africa., Setting: Six district hospitals within the WCD., Methods: A descriptive cross-sectional survey with questionnaires for medical managers (MMs) and medical practitioners (MPs)., Results: A response rate of 78.9% for MPs and 100% for MMs was obtained. MPs rated the following modules of POCUS most relevant to their daily practice: (1) first trimester pregnancy; (2) deep vein thrombosis; (3) extended focused assessment with sonography in trauma; (4) central vascular access; and (5) focused assessment with sonography for human immunodeficiency virus (HIV) and tuberculosis (TB) (FASH)., Conclusion: There is a need for a POCUS curriculum informed by the local pattern of disease. Priority modules were identified based on the local BoD and reported relevance to practice. Despite the availability of ultrasound machines within the WCD, few MPs were accredited and able to perform POCUS independently. There is a need to implement training programmes for medical interns, MPs, family medicine registrars and family physicians working in district hospitals. A relevant curriculum for POCUS training based on the local needs within communities has to be developed.Contribution: This study emphasises the need for a locally informed POCUS curriculum and training programmes.

Noma is an infectious disease affecting mostly children aged 0-10. Although it has almost completely disappeared from the Western world, it is still prevalent in many developing regions, mainly Africa's Sahel region. The infection behaves like a necrotizing fasciitis of the face, originating from the gums and progressively expanding into the cheek, nose, or eye regions. In an estimated 90% of cases, the disease is lethal as a result of systemic sepsis. For survivors, typical results are extensive defects of the cheek, nose, and periorbital and perioral regions. Due to the defects, extensive scarring is common, which leads to secondary problems such as growth alterations in an infant's skeleton due to inhibition and restraint of growth resulting typically in cicatricial skeletal hypoplasia. Other sequelae include trismus, partially caused by scarring or complete fusion between maxilla/zygomatic arch and mandible. The resulting overall disfiguring facial appearance results in patients being disabled and socially isolated., Methods: Facing Africa is a UK-based non-governmental organization that treats the secondary problems of Ethiopian noma survivors. Operations are performed in Addis Ababa by a visiting expert team. Postoperatively, patients are seen annually for years after the surgery., Results: This article discusses basic principles, goals, and a practical surgical algorithm for operating on lip, cheek, and oral defects, based on 210 noma patients who were operated on in Ethiopia over a period of 11 years., Conclusions: The suggested algorithm has proven to work for the Facing Africa team members and is considered shareware for all surgeons to use and benefit from., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Esophageal cancer surgery is technically highly demanding. During the past decade robot-assisted surgery has successfully been introduced in esophageal cancer treatment. Various techniques are being evaluated in different centers. In particular, advantages and disadvantages of continuously sutured (COSU) or linear-stapled (LIST) gastroesophageal anastomoses are debated. Here, we comparatively analyzed perioperative morbidities and short-term outcomes in patients undergoing hybrid robot-assisted esophageal surgery following neoadjuvant chemoradiotherapy (nCRT), with COSU or LIST anastomoses in a single center., Methods: Following standardized, effective, nCRT, 53 patients underwent a hybrid Ivor Lewis robot-assisted esophagectomy with COSU (n = 32) or LIST (n = 21) gastroesophageal anastomoses. Study endpoints were intra- and postoperative complications, in-hospital morbidity and mortality. Duration of operation, intensive care unit (ICU) and overall hospital stay were also evaluated. Furthermore, rates of rehospitalization, endoscopies, anastomotic stenosis and recurrence were assessed in a 90-day follow-up., Results: Demographics, ASA scores and tumor characteristics were comparable in the two groups. Median duration of operation was similar in patients with COSU and LIST anastomosis (467 vs. 453 min, IQR 420-521 vs. 416-469, p = 0.0611). Major complications were observed in 4/32 (12.5%) and 4/21 (19%) patients with COSU or LIST anastomosis, respectively (p = 0.697). Anastomotic leakage was observed in 3/32 (9.3%) and 2/21 (9.5%) (p = 1.0) patients with COSU or LIST anastomosis, respectively. Pleural empyema occurred in 1/32 (3.1%) and 2/21 (9.5%) (p = 0.555) patients, respectively. Mortality was similar in the two groups (1/32, 3.1% and 1/21, 4.7%, p = 1.0). Median ICU stay did not differ in patients with COSU or LIST anastomosis (p = 0.255), whereas a slightly, but significantly (p = 0.0393) shorter overall hospital stay was observed for COSU, as compared to LIST cohort (median: 20 vs. 21 days, IQR 17-22 vs. 18-28)., Conclusions: COSU is not inferior to LIST in the performance of gastroesophageal anastomosis in hybrid Ivor Lewis operations following nCRT., (© 2022. The Author(s).)

Background: Laparoscopic (LSC) Heller myotomy (HM) is considered the standard procedure for the treatment of achalasia. Robotic platforms, established over the last years, provide important advantages to surgeons, such as binocular 3-dimensional vision and improvement of fine motor control. However, whether perioperative outcomes and long-term results of robotic-assisted laparoscopic (RAL) HM are similar or even superior to LSC technique, especially concerning long-term follow-up, is still debated. Therefore, the aim of the present study was to evaluate intra- and postoperative results as well as long-term quality of life after RAL compared to LSC surgery for achalasia in a single high-volume visceral surgery center., Methods: Between August 2007 and April 2020, 43 patients undergoing minimally invasive HM for achalasia in a single high-volume Swiss visceral surgery center, were included in the present study. Intra- and postoperative outcome parameters were collected and evaluated, and a long-term follow-up was performed using the gastroesophageal-reflux disease health-related quality of life (GERD-Hr-QuoL) questionnaire., Results: A total of 11 patients undergoing RAL and 32 undergoing LSC HM were analyzed. Baseline demographics and clinical characteristics were similar. A trend (p = 0.052) towards a higher number of patients with ASA III score treated with RAL was detectable. Operation time was marginally, but significantly, shorter in LSC (140 min, IQR: 136-150) than in RAL (150 min, IQR: 150-187, p = 0.047). Postoperative complications graded Clavien-Dindo ≥ 3 were only observed in one patient in each group. Length of hospital stay was similar in both groups (LSC: 11 days, IQR: 10-13 vs. RAL: 11 days, IQR: 10-14, p = 0.712). Long-term follow-up (LSC: median 89 months, vs. RAL: median 28 months, p = 0.001) showed comparable results and patients from both groups expressed similar levels of satisfaction (p = 0.181)., Conclusions: LSC and RAL HM show similar peri- and postoperative results and a high quality of life, even in long-term (> 24 months) follow-up. Prospective, randomized, controlled multicenter trials are needed to overcome difficulties associated to small sample sizes in a rare condition and to confirm the equality or demonstrate the superiority of robotic-assisted procedures for achalasia. Meanwhile, the choice of the treatment technique could be left to the operating surgeon's preferences., (© 2022. The Author(s).)

Neoadjuvant chemo-radiotherapy (nCRT) of locally advanced rectal cancer is associated with challenging surgical treatment and increased postoperative morbidity. Robotic technology overcomes laparoscopy limitations by enlarged 3D view, improved anatomical transection accuracy, and physiologic tremor reduction. Patients with UICC stage II-III rectal cancer, consecutively referred to our institution between March 2015 and June 2020 (n = 102) were treated with robotic (Rob-G, n = 38) or laparoscopic (Lap-G, n = 64) low anterior resection (LAR) for total meso-rectal excision (TME) following highly standardized and successful nCRT treatment. Feasibility, conversion rates, stoma creation, morbidity and clinical/pathological outcome were comparatively analysed. Sex, age, BMI, ASA scores, cTN stages and tumour distance from dentate line were comparable in the two groups. Robotic resection was always feasible without conversion to open surgery, which was necessary in 11/64 (17%) Lap-G operations (p = 0.006). Primary or secondary stomata were created in 17/38 (45%) Rob-G and 52/64 (81%) Lap-G patients (p < 0.001). Major morbidity occurred in 7/38 (18.4%) Rob-G and 6/64 (9.3%) Lap-G patients (p = 0.225). Although median operation time was longer in Rob-G compared with Lap-G (376; IQR: 330-417 min vs. 300; IQR: 270-358 min; p < 0.001), the difference was not significant in patients (Rob-G, n = 6; Lap-G, n = 10) with ≥30 BMI (p = 0.106). Number of resected lymph nodes, ypTN staging and circumferential resection margins (CRM) were comparable. Resection was complete in 87% of Rob-G and 89% of Lap-G patients (p = 0.750). Robotic LAR is not inferior to laparoscopic LAR following nCRT. Larger, randomized studies are needed to confirm lower conversion in robotic, compared to laparoscopic resection., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Robotic-assisted colorectal surgery has gained more and more popularity over the last years. It seems to be advantageous to laparoscopic surgery in selected situations, especially in confined regions like a narrow male pelvis in rectal surgery. Whether robotic-assisted, left-sided colectomies can serve as safe training operations for less frequent, low anterior resections for rectal cancer is still under debate. Therefore, the aim of this study was to evaluate intra- and postoperative results of robotic-assisted laparoscopy (RAL) compared to laparoscopic (LSC) surgery in left-sided colectomies., Methods: Between June 2015 and December 2019, 683 patients undergoing minimally invasive left-sided colectomies in two Swiss, high-volume colorectal centers were included. Intra- and postoperative outcome parameters were collected and analyzed., Results: A total of 179 patients undergoing RAL and 504 patients undergoing LSC were analyzed. Baseline characteristics showed similar results. Intraoperative complications occurred in 0.6% of RAL and 2.0% of LSC patients (p = 0.193). Differences in postoperative complications graded Dindo ≥ 3 were not statistically significant (RAL 3.9% vs. LSC 6.3%, p = 0.227). Occurrence of anastomotic leakages showed no statistically significant difference [RAL n = 2 (1.1%), LSC n = 8 (1.6%), p = 0.653]. Length of hospital stay was similar in both groups. Conversions to open surgery were significantly higher in the LSC group (6.2% vs.1.7%, p = 0.018), while stoma formation was similar in both groups [RAL n = 1 (0.6%), LSC n = 5 (1.0%), p = 0.594]. Operative time was longer in the RAL group (300 vs. 210.0 min, p < 0.001)., Conclusion: Robotic-assisted, left-sided colectomies are safe and feasible compared to laparoscopic resections. Intra- and postoperative complications are similar in both groups. Most notably, the rate of anastomotic leakages is similar. Compared to laparoscopic resections, the analyzed robotic-assisted resections have longer operative times but less conversion rates. Further prospective studies are needed to confirm the safety of robotic-assisted, left-sided colectomies as training procedures for low anterior resections., (© 2022. The Author(s).)

Purpose: Robotic-assisted procedures are increasingly used in esophageal cancer surgery. We compared postoperative complications and early oncological outcomes following hybrid robotic-assisted thoracoscopic esophagectomy (Rob-E) and open Ivor Lewis esophagectomy (Open-E), performed in a single mid-volume center, in the context of evolving preoperative patient and tumor characteristics over two decades., Methods: We evaluated prospectively collected data from a single center from 1999 to 2020 including 321 patients that underwent Ivor Lewis esophagectomy, 76 underwent Rob-E, and 245 Open-E. To compare perioperative outcomes, a 1:1 case-matched analysis was performed. Endpoints included postoperative morbidity and 30-day mortality., Results: Preoperative characteristics revealed increased rates of adenocarcinomas and wider use of neoadjuvant treatment over time. A larger number of patients with higher ASA grades were operated with Rob-E. In case-matched cohorts, there were no differences in the overall morbidity (69.7% in Rob-E, 60.5% in Open-E, p value 0.307), highest Clavien-Dindo grade per patient (43.4% vs. 38.2% grade I or II, p value 0.321), comprehensive complication index (median 20.9 in both groups, p value 0.401), and 30-day mortality (2.6% in Rob-E, 3.9% in Open-E, p value 1.000). Similar median numbers of lymph nodes were harvested (24.5 in Rob-E, 23 in Open-E, p value 0.204), and comparable rates of R0-status (96.1% vs. 93.4%, p value 0.463) and distribution of postoperative UICC stages (overall p value 0.616) were observed., Conclusions: Our study demonstrates similar postoperative complications and early oncological outcomes after Rob-E and Open-E. However, the selection criteria for Rob-E appeared to be less restrictive than those of Open-E surgery., (© 2022. The Author(s).)

Background: Focal nodular hyperplasia (FNH) is typically considered a benign tumor of the liver without malignant potential. The co-occurrence of FNH and hepatocellular carcinoma (HCC) has been reported in rare cases. In this study we sought to investigate the clonal relationship between these lesions in a patient with FNH-HCC co-occurrence., Methods: A 74-year-old female patient underwent liver tumor resection. The resected nodule was subjected to histologic analyses using hematoxylin and eosin stain and immunohistochemistry. DNA extracted from microdissected FNH and HCC regions was subjected to whole exome sequencing. Clonality analysis were performed using PyClone., Results: Histologic analysis reveals that the nodule consists of an FNH and two adjoining HCC components with distinct histopathological features. Immunophenotypic characterization and genomic analyses suggest that the FNH is clonally related to the HCC components, and is composed of multiple clones at diagnosis, that are likely to have progressed to HCC through clonal selection and/or the acquisition of additional genetic events., Conclusion: To the best of our knowledge, our work is the first study showing a clonal relationship between FNH and HCC. We show that FNH may possess the capability to undergo malignant transformation and to progress to HCC in very rare cases., Competing Interests: Competing interestsM.S.M. has received speaker’s honoraria from Thermo Fisher and honoraria as an advisory board member from Novartis. The other authors declare no competing interests., (© The Author(s) 2022.)

The use of patient-derived organoids (PDO) as a valuable alternative to in vivo models significantly increased over the last years in cancer research. The ability of PDOs to genetically resemble tumor heterogeneity makes them a powerful tool for personalized drug screening. Despite the extensive optimization of protocols for the generation of PDOs from colorectal tissue, there is still a lack of standardization of tissue handling prior to processing, leading to microbial contamination of the organoid culture. Here, using a cohort of 16 patients diagnosed with colorectal carcinoma (CRC), we aimed to test the efficacy of phosphate-buffered saline (PBS), penicillin/streptomycin (P/S), and Primocin, alone or in combination, in preventing organoid cultures contamination when used in washing steps prior to tissue processing. Each CRC tissue was divided into 5 tissue pieces, and treated with each different washing solution, or none. After the washing steps, all samples were processed for organoid generation following the same standard protocol. We detected contamination in 62.5% of the non-washed samples, while the use of PBS or P/S-containing PBS reduced the contamination rate to 50% and 25%, respectively. Notably, none of the organoid cultures washed with PBS/Primocin-containing solution were contaminated. Interestingly, addition of P/S to the washing solution reduced the percentage of living cells compared to Primocin. Taken together, our results demonstrate that, prior to tissue processing, adding Primocin to the tissue washing solution is able to eliminate the risk of microbial contamination in PDO cultures, and that the use of P/S negatively impacts organoids growth. We believe that our easy-to-apply protocol might help increase the success rate of organoid generation from CRC patients., Competing Interests: Authors AZ and SR were employed by Viollier AG. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Marinucci, Ercan, Taha-Mehlitz, Fourie, Panebianco, Bianco, Gallon, Staubli, Soysal, Zettl, Rauthe, Vosbeck, Droeser, Bolli, Peterli, von Flüe, Ng, Kollmar, Coto-Llerena and Piscuoglio.)

Background: Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study)., Methods: All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8-53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire., Results: A total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p < 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores., Conclusion: While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Background: Surgical site infections (SSIs) remain a relevant problem in colorectal surgery. The aim of this study is to implement a bundle of care in order to reduce SSIs in colorectal surgery., Methods: All patients undergoing colorectal surgery between October 2018 and December 2021 will be included in a prospective observational study. Since our colorectal bundle has been established gradually, patients will be grouped in a pre-implementation (2018-2019), implementation (2019-2020) and post implementation phase (2021), in order to assess the effectiveness of the actions undertaken. Primary endpoint of this study will be surgical site infection (SSI) rate, while secondary endpoints encompass potential risk factors for SSIs. We assume that obesity, age, diabetes, alcoholism and smoking may lead to a higher risk for SSIs., Discussion: This study aims to determine whether the colorectal bundle designed and implemented at Cantonal Hospital Lucerne, will lead to a significant reduction of SSIs. The impact of potential risk factors for SSIs will additionally be evaluated., Trial Registration: ClinicalTrials.gov, ID: NCT04677686. Registered retrospectively 18 December 2020., Highlights: A bundle of care might reduce the occurence of surgical site infections after colorectal surgery.Analysis of risk factors may detect patient's with high probability of developing surgical site infections., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background: Disease recurrence in colorectal cancer constitutes a major cause of significant cancer-associated morbidity and mortality. MAP17 is a small protein, and its overexpression in malignant tumors has been correlated with aggressive tumor phenotypes. The aim of the present study was to investigate the expression patterns of MAP17 in colorectal cancer specimens and to assess its clinical significance., Patients and Methods: Surgical specimens of 111 patients with primary resectable colorectal cancer constituted the study population. Expression of MAP17 was assessed by immunohistochemistry, and the results were correlated with clinical and survival data., Results: MAP17 was expressed in cancer cells and endothelial cells of tumor blood vessels. Expression of MAP17 more than 10% was correlated with advanced disease stage (p < 0.001), higher T classification (p = 0.007), the presence of lymph node metastasis (p < 0.001), vascular (p = 0.013) and perineural invasion (p = 0.012). Patients exhibiting MAP17 expression of more than 30% in cancer cells compared to those expressing MAP17 less than 10% demonstrated a significantly worse 3-year progression-free survival (35.2 vs. 91%, p < 0.001) and 5-year overall survival (40.8 vs. 91%, p < 0.001). Cox regression analysis confirmed MAP17 expression of more than 30% as a prognostic marker of progression free survival (HR 0.136, 95% CI = 0.056-0.329, p < 0.001) and overall survival (HR 0.144 [95% CI) = 0.049-0.419, p < 0.001) independent of other clinicopathological characteristics. Statistically significantly worse 3-year progression-free survival and 5-year overall survival was demonstrated in the subgroup analysis of patients with early stage cancer only and high expression of MAP17., Conclusions: High MAP17 expression in patients with colorectal cancer is a significant risk factor for cancer-associated morbidity and mortality already in early stage disease., (© 2021 S. Karger AG, Basel.)

Background: To date, limited evidence exists regarding follow-up imaging during the non-operative management (NOM) of blunt splenic injury (BSI), especially concerning ultrasound as first-line imaging modality. The aim of this study was to investigate the incidence and time to failure of NOM as well as to evaluate the relevance of follow-up imaging., Methods: All adult patients with BSI admitted to our level I trauma center, including two associated hospitals, between 01/01/2010 and 31/12/2017 were retrospectively analyzed. Demographic data, comorbidities, injury pattern, trauma mechanism, Injury Severity Score, splenic injury grade and free intra-abdominal fluid were reviewed. Additional analysis of indication, frequency, modality, results and consequences of follow-up imaging was performed. Risk factors for failure of NOM were evaluated using fisher's exact test., Results: A total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. Twenty patients (16.4%) underwent immediate intervention. One-hundred-and-two patients (83.6%) were treated by NOM. Failure of NOM occurred in 4 patients (3.9%). Failure was significantly associated with active bleeding (3 of 4 [75%] failures vs. 8 of 98 [8.2%] non-failures, OR 33.75, 95% CI 3.1, 363.2, p = 0.004), and liver cirrhosis (2 of 4 [50%] failures vs. 0 of 98 [0%] non-failures, OR 197, 95% CI 7.4, 5265.1, p = 0.001). Eighty patients (78.4%) in the NOM-Group received follow-up imaging by ultrasound (US, n = 51) or computed tomography (CT, n = 29). In 57 cases, routine imaging examinations were conducted (43 US and 14 CT scans) without prior clinical deterioration. Fifty-fife (96.4%) of these imaging results revealed no new significant findings. Every failure of NOM was detected following clinical deterioration in the first 48 h., Conclusion: To our knowledge this study includes the largest single centric patient cohort undergoing ultrasound as first-line follow-up imaging modality in the NOM setting of BSI in adult patients. The results indicate that a routine follow-up imaging, regardless of the modality, has limited therapeutic advantage. Indication for radiological follow-up should be based on clinical findings. If indicated, a CT scan should be used as preferred imaging modality., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Unexpected Postoperative Diagnosis of Parathyroid Carcinoma Abstract. Parathyroid carcinoma is a rare endocrine malignancy. It typically presents itself with similar clinical features as seen in patients with primary hyperparathyroidism caused by a parathyroid adenoma. Due to overlapping clinical manifestations, imaging findings and pathological characteristics, the differentiation between benign and malignant parathyroid disease poses a diagnostic challenge, especially prior to surgery. We report the case of a 67-year-old male who presented with symptomatic hypercalcemia and primary hyperparathyroidism. During resection of the enlarged parathyroid gland, suspicious macroscopic features were noticed and the histopathology finding confirmed the malignancy. Parathyroid carcinoma is rarely diagnosed preoperatively, which is mainly due to the lack of distinctive symptoms or morphological features suggesting a malignant disease. As parathyroid carcinoma often has a genetic background, knowledge of mutation status and family history is of high relevance. Surgery with complete resection of the parathyroid carcinoma is the mainstay for a successful treatment and a good prognosis.

Introduction: Polymerase chain reaction testing at birth ("birth-testing") is suggested by new World Health Organization guidelines for rapid diagnosis of infants infected with HIV in utero. However, there are few data on the implementation of this approach in sub-Saharan Africa, and whether birth testing affects uptake of subsequent routine early infant diagnosis (EID) testing at 6-10 weeks of age is unknown., Methods: We reviewed 575 consecutive infants undergoing targeted high-risk birth testing in Cape Town, South Africa, and matched those testing HIV negative at birth (n = 551) to HIV-exposed infants who did not receive birth testing (n = 551). Maternal and infant clinical and demographic data, including EID testing uptake, were abstracted from routine records., Results: Overall, 3.8% of all birth tests conducted were positive while later EID testing positivity rates were 0.5% for those infants testing HIV negative at birth and 0.4% for those without birth testing. Infants who underwent birth testing were less likely to present for later EID compared with those without a birth test (73% vs. 85%; P < 0.001). This difference persisted after adjusting for maternal and infant characteristics (adjusted odds ratio, 0.60; 95% confidence interval: 0.41-0.86) and across demographic and clinical subgroups. Infants undergoing birth testing also presented for later EID at a significantly older age (mean age, 60 vs. 50 days; P < 0.001)., Conclusions: While the yield of targeted high-risk birth testing in this setting appears high, neonates testing HIV negative at birth may be less likely to present for subsequent EID testing. For birth testing implementation to contribute to overall EID program goals, structured interventions are required to support follow-up EID services after negative birth test results.

We present a simple microfluidic system for rapid screening of Escherichia coli (E. coli) O157:H7 employing the specificity of immunomagnetic separation (IMS) via immiscible filtration assisted by surface tension (IFAST), and the sensitivity of the subsequent adenosine triphosphate (ATP) assay by the bioluminescence luciferin/luciferase reaction. The developed device was capable of detecting E. coli O157:H7 from just 6 colony forming units (CFU) in 1 mL spiked buffer within 20 min. When tested with wastewater discharged effluent samples, without pre-concentration, the device demonstrated the ability to detect 10 4  CFU per mL seeded; suggesting great potential for point-of-need microbiological water quality monitoring., (© 2017 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Background: Distal radius and ankle fractures are one of the most common operatively treated fractures. To date, there is no consensus concerning the need for a standard postoperative radiograph. This leads to undesirable practice variations. A standardized radiograph in the department of radiology would theoretically be more reproducible and operator independent than an intraoperatively obtained fluoroscopic image. However, if adequate intraoperative radiographs have been obtained, it is questionable if these postoperative radiographs are necessary and will lead to changes in the treatment strategy. If standard postoperative radiographs are no longer required, this would lead to a reduction in radiation exposure and health care costs. The hypothesis is that routine standardized postoperative radiographs do not influence the quality of care for patients operated on for either a distal radius or an ankle fracture if adequate intraoperative standardized radiographs have been obtained., Objective: The primary aim of this study is to evaluate if there is a need for routine postoperative radiographs after an osteosynthesis of a distal radius or ankle fracture., Methods: In a prospective, randomized controlled, open label trial based on a noninferiority design, we will enroll 332 patients. Patients will be randomized either in the control or the intervention group. The control group will be treated according to our current, standard protocol in which all patients receive a standard anterior-posterior and lateral radiograph on the first postoperative day. Patients randomized to the intervention group will be treated without a standard postoperative radiograph. All patients (N=332) will have a routine clinical and radiographic control after 6 weeks in the outpatient clinic. Primary outcome is a change in treatment plan, defined as either additional imaging or a reoperation based on the postoperative imaging. Secondary outcome measures include a 36-Item Short Form Survey, Patient-Rated Wrist Hand Evaluation, Foot and Ankle Outcome Score, Visual Analogue Scale, and the range of motion. Those questionnaires will be filled out at the 6-week outpatient control., Results: The trial was started in August 2016, and 104 patients have been enrolled up to this point., Conclusions: Our findings will be reported in peer-reviewed publications and may lead to a strong reduction in radiation exposure and health care costs. A preliminary, conservative estimation suggests a yearly cost saving of CHF 1.3 million in Switzerland., (©Florian Oehme, Annika Rühle, Julia Mühlhäusser, Lana Fourie, Björn-Christian Link, Reto Babst, Frank JP Beeres. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 16.08.2017.)

Medicines have evolved over time and so has the realisation of the importance of quality control and regulatory processes. The regulatory practices include all the steps from the development and manufacture of the active ingredients until the medicines reach the consumer. The Medicines Control Council (MCC) is mandated to regulate medicines in South Africa. Complementary medicines were previously perceived to be unregulated, although the Medicines Act does not distinguish between allopathic and complementary medicine. As the era of unregulated complementary medicine ended, the requirements in terms of dossier content left many role-players at odds. However, the MCC has a mandate to ensure that the registration of a medicine is in the interest of the public and that complementary medicine is manufactured in a facility adhering to good manufacturing practice, according to which efficacy and safety are supported by reliable data with a known shelf-life.

Background: Skin abscesses are a frequent encountered health care problem and lead to a significant source of morbidity. They consequently have an essential impact on the quality of life and work. To date, the type of aftercare for surgically drained abscesses remains under debate. This leads to undesirable practice variations. Many clinical standard protocols include sterile wound dressings twice a day by a home-care service to reduce the chance of a recurrent wound infection. It is unknown, however, whether reinfection rates are comparable to adequate wound irrigation with a nonsterile solution performed by the patient. Our hypothesis is that simple wound irrigation with nonsterile water for postoperative wound care after an abscess is surgically drained is feasible. We assume that in terms of reinfection and reintervention rates unsterile wound irrigation is equal to sterile wound irrigation., Objective: The primary aim of this study is therefore to investigate if there is a need for sterile wound irrigation after surgically drained spontaneous skin abscesses., Methods: In a prospective, randomized controlled, single-blinded, single-center trial based on a noninferiority design, we will enroll 128 patients randomized to either the control or the intervention group. The control group will be treated according to our current, standard protocol in which all patients receive a sterile wound irrigation performed by a home-care service twice a day. Patients randomized to the intervention group will be treated with a nonsterile wound irrigation (shower) twice a day. All patients will have a routine clinical control visit after 1, 3, 6, and 12 weeks in the outpatient clinic. Primary outcome is the reinfection and reoperation rate due to insufficient wound healing diagnosed either at the outpatient control visit or during general practitioner visits. Secondary outcome measures include a Short Form Health Survey, Visual Analog Scale, Patient and Observer Scar Assessment Scale, Vancouver Scar Scale, and the EurolQol 5-Dimension Questionnaire. Those questionnaires will be completed at the outpatient control visits., Results: The trial was started in June 2016 and enrolled 50 patients by article publication. Regarding the adherence to our protocol, we found 10% of loss to follow-up until now. Only 2 patients needed reoperation and only 1 patient needed a change of treatment (antiseptic therapy). Most patients are happy with their randomized treatment but as expected some patients in the sterile group complained about timing problems with their working hours and home-care service appointments. Most patients in the nonsterile group are satisfied being able to take care of their wounds independently although some patients still depend on the home-care service for the wound dressing. We are hoping to have enrolled enough patients by summer 2017. The follow-up will take until autumn 2017, and study results are expected to be published by the end of 2017. This trial is solely supported by the cantonal hospital of Lucerne., Conclusions: Nonsterile wound irrigation is more likely to be carried out independently by the patient than sterile wound irrigation. Therefore, if nonsterile wound care shows comparable results in terms of reinfection and reintervention rates, patient independence in the aftercare of surgically drained abscesses will increase, patients can return to work earlier, and health care costs can be reduced. In a preliminary, conservative estimation of health care costs, an annual savings of 300,000 CHF will be achieved in our hospital., Trial Registration: German Clinical Trials Register DRKS00010418; https://drks-neu.uniklinik-freiburg.de/ drks&#95;web/navigate.do?navigationId=trial.HTML&TRIAL&#95;ID=DRKS00010418 (Archived by WebCite at http://www.webcitation.org/6q0AXp5EX)., (©Annika Rühle, Florian Oehme, Katja Börnert, Lana Fourie, Reto Babst, Björn-Christian Link, Jürg Metzger, Frank JP Beeres. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 01.05.2017.)

Introduction: The sexual behaviour and development of children with autism spectrum disorders (ASDs) have been mostly overlooked in research and practice. This study aimed to determine the association between certain clinical and demographic factors found in a sample of children with ASDs, and their reported sexual behaviour (RSB)., Methods: The study was conducted at a school in Gauteng, South Africa, for learners with ASDs. Two questionnaires completed by caregivers/parents enquired about family stability, clinical profile and RSB (if any) in their child. RSB was analysed via three domains: self-care, socio-sexual skills and actual RSB, with additional information from school records., Results: Of the 107 questionnaires distributed, only 31 parents responded and 24 agreed to participate. The 24 (100%) children included 10 pubertal and 14 pre-pubertal children, of which 18 ( n = 18) had more stable primary caregiver statuses as well as more stable socioeconomic and family environments. Two of the 14 pre-pubertal children had abnormal self-care, whereas none of the 10 pubertal children had any abnormal self-care. Eight of the 18 children from more stable environments displayed abnormal sexual behaviours. Of the 6 children from less stable environments, two displayed more abnormal socio-sexual skills, whereas 9 of the 18 children from more stable environments displayed more abnormal sexual behaviour. In contrast with the postulated hypothesis that children from less stable socioeconomic and family environments would exhibit more abnormal sexual behaviours, this study did not find any evidence of such a relationship or association., Conclusion: ASDs are characterised by deficits in communication and social skills. These may lead to an affected individual struggling to develop appropriate sexual behaviour. If specific risk factors that contribute to the development of abnormal sexual behaviour can be identified, one can try to modify/prevent these where some degree of prevention or alleviation may be possible., Competing Interests: The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.

Background: On 5 June 2012 several enterohemorrhagic Escherichia coli, EHEC, O157:H7 infections were reported to the public health authorities of Limburg., Methods: We performed a case-control study, a trace back/forward investigation and compared strains isolated from human cases and food samples. A case was defined as anyone with a laboratory-confirmed E. coli O157:H7-infection in North-East Limburg from May 30 2012 till July 15 2012. Family members with bloody diarrhea were also included as cases. E. coli O157 was isolated by culture and the presence of the virulence genes was verified using (q)PCR. Isolates were genotyped and compared by Pulsed Field Gel Electrophoresis (PFGE) and insertion sequence 629-printing (IS629-printing)., Results: The outbreak involved 24 cases, of which 17 were laboratory-confirmed. Five cases developed Hemolytic Uremic Syndrome (HUS) and fifteen were hospitalized. Cases reported a significantly higher consumption of "steak tartare", a raw meat product (OR 48.12; 95% CI; 5.62- 416.01). Cases were also more likely to buy meat-products at certain butcheries (OR 11.67; 95% CI; 1.41 - 96.49). PFGE and IS629-printing demonstrated that the vtx1a vtx2a eae ehxA positive EHEC O157:H7 strains isolated from three meat products and all seventeen human stool samples were identical. In a slaughterhouse, identified by the trace-back investigation, a carcass infected with a different EHEC strain was found and confiscated., Conclusion: We present a well described and effectively investigated foodborne outbreak associated with meat products. Our main recommendations are the facilitation and acceleration of the outbreak detection and the development of a communication plan to reaches all persons at risk., Mesh: Foodborne diseases, Shiga-toxigenic Escherichia coli, Enterohemorrhagic Escherichia coli, Meat products, Case control studies, Electrophoresis, Gel, Pulsed-Field.

These second edition guidelines, updated from the 2007 version (Marchiondo et al., 2007), are intended to assist the planning and conduct of laboratory and clinical studies to assess the efficacy of ectoparasiticides applied to dogs or cats for the purpose of treating, preventing and controlling flea and tick infestations. Major revisions to this second edition include guidelines on the assessment of systemic flea and tick products, an update of the geographical distribution of the common fleas and ticks species on dogs and cats, determination of flea and tick efficacy based on geometric versus arithmetic means with respect to geographic regulatory agencies, modification of tick categorization in the assessment of efficacy, expanded guidelines on repellency and anti-feeding effects, enhanced practical field study guidance, and considerations on the ranges of flea and ticks for infestations in laboratory studies. The term ectoparasiticide includes insecticidal and acaricidal compounds, as well as insect growth regulators. The range of biological activities from animal treatment that are considered include: repellency and anti-feeding effects, knockdown, speed of kill, immediate and persistent lethal effects, and interference with egg fertility and subsequent development of off-host life cycle stages. Information is provided on the selection of animals, dose determination, dose confirmation and field studies, record keeping, interpretation of results and animal welfare. These guidelines are also intended to assist regulatory authorities involved in the approval and registration of new topical or systemic ectoparasiticides, and to facilitate the worldwide adoption of harmonized procedures.

Around the world there is a small industry of non-governmental organisations that provide health care in niche areas that cannot be met by national health care provision. One topic is facial deformity that can have a dramatic effect on quality of life. In this study we investigate the morbidity and outcome of a British surgical team working for a 2-week period in Ethiopia. Thirty-five patients who presented with facial deformities had 47 operations during a 2-week period. Data were recorded for a minimum of 3 weeks postoperatively. Operative techniques were classified as simple or complex. Postoperative complications were assessed and classified as major, intermediate, and minor. In addition, the character of each complication was recorded and the cause elucidated. After 3 weeks the clinical objectives had been achieved in 14/17 who had simple procedures but in only 5/18 who had complex operations (p=0.004). We conclude that complex procedures are technically possible within an under-privileged health care system but successful outcome depends on paying attention to multiple factors in patients' care and wound management. Early outcome studies may be a useful way to measure the quality of humanitarian surgical missions., (Copyright © 2010 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

The objective of this study was to determine the therapeutic and residual efficacy of a topically applied combination of cyphenothrin (40%) and pyriproxyfen (2%) against the tick Haemaphysalis elliptica and the flea Ctenocephalides felis on dogs. Twelve dogs were infested with 50 ticks 2 days before they were treated and with approximately 100 fleas 6 days before treatment and again 2 days before treatment and with 50 ticks and approximately 100 fleas at weekly intervals thereafter. They were ranked according to their flea counts and sex 5 days before treatment and randomly allocated to an untreated control group of 6 dogs and a treated group of 6 dogs. Ticks and fleas were collected from the dogs 48 h after treatment and 48 h after each infestation and live and dead ticks and live fleas were counted. The counts of ticks and fleas were transformed to geometric means, and efficacy was calculated by comparing these means. The product had a therapeutic efficacy of 83.1% against H. elliptica and 97.5% against C. felis 2 days after treatment. The residual period of protection during which efficacy was > or = 90% was 5 weeks for both H. elliptica and C. felis.

A novel spot-on formulation containing metaflumizone plus amitraz (ProMeris/ProMeris Duo for Dogs, Fort Dodge Animal Health, Overland Park, KS) was evaluated for efficacy against sarcoptic mange mites in naturally infested dogs. Sixteen dogs were allocated to two equal groups and were housed individually. Eight of the dogs were treated topically with metaflumizone plus amitraz at the proposed minimum dose rate (20mg/kg of each of metaflumizone and amitraz, at a dose volume of 0.133ml/kg) on Days 0 and 28. The other eight were treated with metaflumizone plus amitraz at the proposed minimum dose rate on Days 0, 14, 28 and 42. To enumerate Sarcoptes scabiei mites, skin scrapings were taken on each of Days 2, 14, 28, 42 and 56. Clinical signs of mange and the extent of sarcoptic lesions were evaluated on each dog when scrapings were made. Evaluation of the efficacy of the treatment was based on the absence of mites supported by the absence of clinical signs associated with canine sarcoptic mange. Treatment with metaflumizone plus amitraz at the minimum proposed dose rate at monthly (two treatments) or two-weekly (four treatments) intervals resulted in a rapid reduction of mites and improved clinical signs. The overall cure rates at Day 56, based on zero mite counts and/or resolution of clinical signs were 75% and 83% of dogs for the monthly and two-weekly regimens, respectively.

A novel spot-on formulation containing metaflumizone plus amitraz (ProMeris/ProMeris Duo for Dogs, Fort Dodge Animal Health, Overland Park, KS) was evaluated for efficacy against demodectic mange mites in naturally infested dogs. Sixteen dogs were allocated to two equal groups and individually housed. Eight of the dogs were treated topically with metaflumizone plus amitraz at the proposed minimum dose rate (20mg/kg of each of metaflumizone and amitraz, 0.133ml/kg) on Days 0, 28, and 56. The other eight were treated with metaflumizone plus amitraz at the proposed minimum dose rate on Days 0, 14, 28, 42, 56, and 70. Mite numbers were estimated from skin scrapings taken on Days -3 to -1, 28, 56, and 84. Clinical signs of mange and the extent of demodectic lesions on each dog were evaluated when skin scrapings were conducted. Efficacy of the treatment was based on a reduction in mite numbers and an assessment of the clinical signs associated with canine demodectic mange. Treatment at monthly or two-weekly intervals for 3 months resulted in a rapid reduction in mite numbers (>94 and >99% for the monthly and two-weekly treatments, respectively) and an improvement in clinical signs. Success rates, based on zero mite counts in skin scrapings at Day 84 were 42.9 and 62.5% of dogs for the monthly and two-weekly regimens, respectively.

Background: Creating a youthful appearing umbilicus as part of an abdominoplasty enhances the overall result. Various different methods have been reported as producing equally good results., Methods: Twenty-five patients undergoing abdominoplasty were divided into two groups: 12 patients had round umbilicoplasty and 13 had an inverted U flap inset. Three independent surgeons assessed the aesthetic outcome of the two different techniques in specially designed clinics by using four-point ordinal scales, which were also used by the patients for subjective self-assessment., Results: Surgical assessment demonstrated equally good results with both methods, whereas the inverted U flap was the favorite method for reconstruction among patients (p < 0.029). Fifty-eight percent of patients in the round method group were conscious that they had umbilicoplasty, as opposed to only 15 percent in the inverted U flap group. Twenty-five percent of patients in the round group preferred their old umbilicus compared with this new one. None of the patients in the inverted U flap group preferred their old umbilicus., Conclusions: The authors discuss the surgical technique of the inverted U flap. This is currently the method of choice in recreating the umbilicus at the time of abdominoplasty.

The objective of this study was to determine the species spectrum of ixodid ticks infesting birds in Free State Province, South Africa. To this end a large number of birds belonging to several species were examined for ticks and a total of 180 birds belonging to 39 species at 17 localities were infested, and ticks belonging to eight species were recovered. The immature stages of only two, namely Amblyomma marmoreum and Hyalomma marginatum rufipes, were sufficiently prevalent and numerous to safely assume that they regularly use birds as hosts. Helmeted guineafowls, Numida meleagris, were the most heavily infested and one harboured a total of 319 larvae and four nymphs. Amongst the other species an eastern clapper lark, Mirafra fasciolata, was infested with 69 larvae and a nymph, but no other bird harboured more than 40 ticks. The larvae and nymphs of H. m. rufipes were most numerous on birds from April to August.

The study was undertaken to evaluate and compare the efficacy of an imidacloprid (10% w/v)/moxidectin (2.5% w/v) combination (Advocate Bayer HealthCare, Animal Health) with that of selamectin for the treatment of Sarcoptes scabiei on dogs. Thirty naturally infested dogs, of which one was later withdrawn because of distemper, were allocated to two equal groups and individually housed. The dogs in each group were treated twice, four weeks apart, with either the combination product (0.1 mL/kg body weight) or with selamectin (0.05 mL/kg body weight) administered topically. Skin scrapings were made every 14 days over a period of 50 to 64 days after the first treatment to quantify mite numbers. Clinical signs and the extent of sarcoptic lesions were assessed on each dog when skin scrapings were made. Efficacy was based on the presence or absence of mites, supported by clinical signs associated with canine sarcoptic mange. From Day 22 and onwards no Sarcoptes mites were found in the skin scrapings of any of the treated dogs. Treatment with the imidacloprid/moxidectin formulation or with selamectin was highly effective against Sarcoptes scabiei and resulted in an almost complete resolution of clinical signs within 50 to 64 days after the initial treatment.

The efficacy of orally administered powdered aloe juice (Aloe ferox) was evaluated against ticks on cattle and against ticks and fleas on dogs. Twelve calves were each infested over a 25-day period with approximately 4000 larvae of Rhipicephalus (Boophilus) decoloratus and allocated to 3 groups of 4 calves each. Three days after the last larval infestation and daily for 22 days thereafter, the calves in 1 group were fed 5 mg/kg body weight and those in another 25 mg/kg body weight of powdered aloe juice incorporated in game maintenance pellets, while the animals in the 3rd group received only pellets. Detached female ticks were collected daily and counted and the weights and the fertility of groups of 50 engorged female ticks collected from the animals were ascertained. The powdered aloe juice in the game maintenance pellets had no effect on the tick burdens of the calves or on the fertility of the ticks. Six dogs, in each of 2 groups, were treated daily for 15 consecutive days, commencing on Day -5 before the 1st tick infestation, with either 0.39 g or 0.74 g of powdered aloe juice, administered orally in gelatin capsules, while a 3rd group of 6 dogs served as untreated controls. All the dogs were challenged with Haemaphysalis leachi on Days 0 and + 7, and with Ctenocephalides felis on Days + 1 and + 8, and efficacy assessments were made 1 day after flea and 2 days after tick challenge, respectively. Treatment was not effective against ticks or fleas on the dogs.

Two hundred and seventy-three elephant shrews, consisting of 193 Elephantulus myurus, 67 Elephantulus edwardii and 13 animals belonging to other species, were examined for ixodid ticks at 18 localities in South Africa and Namibia. The immature stages of Ixodes rubicundus, Rhipicentor nuttalli, Rhipicephalus warburtoni and a Rhipicephalus pravus-like tick were the most numerous of the 18 tick species recovered. Substantial numbers of immature Rhipicephalus arnoldi, Rhipicephalus distinctus and Rhipicephalus exophthalmos were also collected from elephant shrews at particular localities. Larvae of I. rubicundus were most numerous on E. myurus in Free State Province from April to July and nymphs from June to October. Larvae of R. nuttalli were most numerous on these animals during April, May, August and September, and nymphs in February and from April to August. The immature stages of R. warburtoni were collected from E. myurus only in Free State Province, and larvae were generally most numerous from December to August and nymphs from April to October.

This study was done to compare the collection of cat urine, for phosphate concentration determination, by catheterisation with that via a proprietary cat litter (Katkor). The passage of urine through the litter or its retention in the litter for a period of 2 hours did not affect the concentration of phosphates compared with that of the original sample. Apart from a small volume of urine trapped in the litter by capillary action, and some urine adhering to the funnel in which the litter was placed, the litter proved to be an excellent medium for routine urine collection from cats, and more especially as an alternative to catheterisation when regular collection from a particular cat is required.

Two hundred and twenty-five small mammals belonging to 16 species were examined for ticks in Free State, Mpumalanga and Limpopo Provinces, South Africa, and 18 ixodid tick species, of which two could only be identified to genus level, were recovered. Scrub hares, Lepus saxatilis, and Cape hares, Lepus capensis, harboured the largest number of tick species. In Free State Province Namaqua rock mice, Aethomys namaquensis, and four-striped grass mice, Rhabdomys pumilio, were good hosts of the immature stages of Haemaphysalis leachi and Rhipicephalus gertrudae, while in Mpumalanga and Limpopo Provinces red veld rats, Aethomys chrysophilus, Namaqua rock mice and Natal multimammate mice, Mastomys natalensis were good hosts of H. leachi and Rhipicephalus simus. Haemaphysalis leachi was the only tick recovered from animals in all three provinces.

Bacillus cereus is a well-known cause of food-borne illness, but infection with this organism is not commonly reported because of its usually mild symptoms. A fatal case due to liver failure after the consumption of pasta salad is described and demonstrates the possible severity of the emetic syndrome.

Adult biting lice Damalinia limbata (Gervais 1844) were most numerous on Angora goats in southwestern Free State Province from November to May with the smallest numbers present during August. Nymphs were most numerous from January to March with the smallest numbers present during July. The largest proportion of adult lice was present on the ventral surface of goats during winter, when population numbers were lowest, and the largest proportion of nymphs during summer, when population numbers were highest. Infestation did not affect the body weight of goats, but adversely affected both the quantity and quality of mohair produced. A single treatment with deltamethrin, applied as a pour-on along the mid-line of the backs of the goats, effectively controlled infestation and resulted in a significant increase in mohair production compared with untreated goats. Deltamethrin sprayed along the sides of the animals was equally effective in controlling infestation.

The objective of this study was to determine certain aspects of the biology of Rhipicephalus (Boophilus) decoloratus larvae under laboratory and field conditions. Larvae allowed 48 h to select a vertical questing substrate preferred 90 cm rods in length to those of 60 or 30 cm, while in a separate experiment migration from rods 5 cm or 25 cm in length to rods 45 cm in length continued between 48 h and 72 h after larval release. Hatching of the larval progeny of engorged female ticks exposed to ambient field temperatures during the period June to August, occurred synchronously during the third or fourth week of November. With a single exception, larvae that hatched during November and between April and July survived for 38 days or longer, while those that hatched from December to March survived for 31 days or less. Questing larvae were present on vegetation throughout the year, with most being recovered during January and February. Parasitic larvae were present on cattle from October to May with most being collected during January and February.

Advantages associated with the transdermal delivery route are well documented, but in the past scientists have concentrated primarily on means of decreasing the barrier function of the skin for improved permeability. Pro-drugs, which possess more favourable physicochemical properties for improved transdermal permeability may have considerable potential. These have been considered in the past but recent information concerning structure activity relationships in dermal penetration has prompted increased interest. During this study, N-methyl (2), N-ethyl (3) and N-(2-hydroxyethyl) carbamazepine (4) analogues were synthesised for transdermal evaluation.

The syntheses of a novel trishomocubane hydantoin and its mono- and bis-protected t-Boc derivatives are described. The less nucleophilic N-3' nitrogen of the hydantoin ring is protected first when treated with di-tert-butyl dicarbonate (t-Boc anhydride), possibly owing to steric hindrance by the bulky trishomocubane cage skeleton. More basic conditions were required to form the bis-protected t-Boc hydantoin with the same reagent. The structures of these novel compounds were elucidated with 2D NMR techniques. The proton spectrum of the trishomocubane skeleton is complex owing to major overlap of proton signals. A high-level DFT calculation was used to determine some of the crucial interatomic positions, which assisted with the elucidation of the structures. The assignment of proton and carbon signals of the three structures is described and it differs significantly from each other and also from the trishomocubanol precursor. The bis-Boc hydantoin is required for a more facile hydrolysis to the corresponding trishomocubane amino acid at room temperature., (Copyright 2004 John Wiley & Sons, Ltd.)